Death Certificate - Williamson, William Harold_8/30/2016 INDIANA STATE DEPARTMENT OF HEALTH 7817 3 9
4_"s ` CERTIFICATE OF DEATH
Local No 001843 EDR No 000000222316 State No 043297
I.Decedents Legal Name(First MCde,Last) fa. Madan Name(11 faunae) 2.Sex 1 Tune Of Deem 4. Date Of Dean(MordvOayIYear)
WILLIAM HAROLD WILLIAMSON MALE 06:20 AM 10/02/2011
10.If Death Omnid N A Hcspdal: ID, II Deeds Occ, red Sane'Mere Oea Than A Hospital
0 0 Yes 0 No 0 Unknown 0 hpabera 0 Emergency Department Wpabent 0 Dead on Amval 0 other(( FaaSy ❑Decedents Horne ❑Nursing Home/Long-term Care Fadiry
❑other ISpeoy)
11. Farley Name(II Not InstuYim,Give Street and Number)
DEACONESS HOSPICE CARE CENTER
12.City a,Town,State,And Zip Code 13.Carry Of Dean 14.Manta Stns At Time Of Dear,
0 Manisa 0 Manned,Be Separated 0 Divorced
EVANSVILLE,IN,47747 VANDERBURGH 0'Madre, 0 Never Named 0 Unknown
15. Ssvi*ig Spaces Name 15a. (II Wf)Give Maiden Lan Name 18. Decedents Usual Occupation 17. Kind 01 B,svessAndustry
JUDITH A.WILLIAMSON FREEMAN LABORER APPLIANCE
1e. Residence•State 18a. Cony 18b. Cary Or Tam
INDIANA GIBSON HAUBSTADT
1k Sreet And Number 124. Apt No. fee. Zip Code tea.Inside Csy Limits?
113 SOUTH VINE STREET 47839 O Yes 0 No
19.Decedents Education 20.Decedent Of Hispanic Origin 21. Decedents Rau
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Feelers Name(First Wide,Last) 23.Meters Name(First Midde,Last) 23a.Mothers Owen Last Name
DELMAR WILLIAMSON GRACE WILLIAMSON BRANDENBURG
24,Informant's Name 24e.RNamnsrap To Decedent tab.Mang Address (Steel And Number,City,State.Zip Code)
JUDITH A WILLIAMSON WIFE 113 SOUTH VINE STREET, HAUBSTADT, IN 47639
25.Place Of Cisposrsn
25a Method Of Dtsposdon 250.Place 01 gspieibon(Name Of Cemetery,Crenum•y,Oder Place) 25c,Location-City.Town,And State
0 Build 0 Cremation 0 Daebpn 0 Entanbment
0 Renewal From Sate
0 other(Sperry): MOUNT PLEASANT GRIFFIN, IN
25.Was Coroner ComaCedi 27. Name And Complete Address Of Funeral Fplfy 27a. Ftnaal Mae license Number
Yes ®No HOLDERS FUNERAL HOME OF GIBSON COUNTY, INC., 319 SOUTH MAIN STREET,
OWENSVILLE,IN 47665 FH89000021
27b. Signature 01 Indiana anent Service Licensee: 27c.license Number(Of licenses):
RANDALL K DIKE, BY ELECTRONIC SIGNATURE FD01010177
Cause Of Dads (See Irntrvcdane And Examples) Approximate
28.Part I.Enter The Chain 01 Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events INarvat Onset
Such As Cardiac Arrest Respiratory Arrest,Or Ventricular Fib:Bato)W awut Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Additinal Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resitting In Death) A RESPIRATORY FAILURE DAYS
Pe arcs w ar
MONTHS TO
Sequentially list Cts, If Any,Leading To The Cause Listed On B. LUNG CANCER YEARS
orsd:ior
Line A. Enter The Underlying Cause(Disease Or!nary That Initiated
P.aLd°.v�.s:.°op
The Events Resulting In Death)Last C.
owe or A.A daree.e 04
D.
Pal It.Enter Odes SionASam Cdndaons Cambuavo to Deer But Not Radbng In The Uropyvg Cause Glen In Pan I 29.W83 M Atopsy Performed? 0 Yea 0 No
CHRONIC OBSTRUCTIVE PULMONARY DISEASE.GENERALIZED DEBILITY '30Wen AUtocey FiWiry Available To Complete The Cause Of Death? O Yes 0 No
31.Did Tcbecao Use Cantbu:e To Death? 32.II Female: is 33. Mariner Dl Deane
❑Yes ®PrpOSey❑No ❑UnMtam 0 e.un.wwvs,.,rr ra 0 vote ere . v.Ma Pre.a ono 0 Neural 0 Flom:Oat ❑Accident ❑Pe nd+g Investigation
❑wwe..:AU nee..a Pr.r..,e.wen Pa ^ 0 um..nice.tan rte riw 0 Suicide 0 Cold Na Be DeaminM
34.On Of tipsy(Monti/Day/Year) 35. Tine Of Injury 35. Plac*j)nE0.,Offffp(ds Horne,Osman Site.RemvaR Nboded Area) 37. Irryy Al Work?
/�VU ti Cult) ❑yes 0 N
3B.Loca on Of lryury-Sus 38a. City Or roan 38b. Snot&&Nuns ' 3Bc. Apt No. 38a. Zip Code
39.Desoto How lrpry Oxustes GIBSON COUNTY AUDITOR 40. If T "sury.
, ae-u 00•••Meat)
41.Sgnetse,Of Person Cerulyng Casa Of Dean 42. Gender(ChM Only tie)
DOUGLAS JAYE HATLER , BY ELECTRONIC SIGNATURE 0 Cert.yinp Physidan 0 Coroner 0 Heath Otter
43.Name,Address And Zip Code 01 Person Crayag Case Of Dan u. License NUM* 45. Dabs Cert:.ed
DOUGLAS JAYE HATLER , 4498 FIRST AVENUE, EVANSVILLE, IN 47710 01039937A 10/04/2011
4a. Add:tonal Funeral Service Provider 47. 'Akan.
4$. SgnaLn of Local Heath OTScer 49. For Register Only -Dabs Feed(Mont/Day/Year):
RAYMOND W. NICHOLSON,JR.,VIA ELECTRONIC SIGNATURE OCT 05 2011
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
q - 31 - 303 "OW,;10- 9
'State Form 53395 AqrrE.YT)ON ESTATE:The Social Security r u being requested by this state agency in order to pursue responstbay. Disclosure is vohntary and Mere will be no penalty for refusal.
IVRA 20
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