Death Certificate - Adams, Roy D_6/20/2017 __ �.-:,,.r__�.:,',�.�TO.rite..;1-.:1..ri.r�i^Le,51ii.?,- 1 ' _ • 1 e tiiv �, V.i_.�-r∎. 1.avr_,:a..�.iv:�r�n;.�.<•
e 40!nA>gq. -- INDIANA STATE DEPARTMENT OF HEALTH
0
• v.' CERTIFICATE'OF DEATH •
Local No 000278. State No •
yl sere .
< I Decedents Legal Nero(Fiat Middle,Last) • la Maiden Nana(t tamale) 2 Ses'. 3 Tare d Death 4 Data d Death(t4aeNDay/Year)
• ROYDADAMS MALE 1 6:12 AM I February/14/1988
s Age-Yd 6b Under 1 Year 6c Under 1 Month 6d Under 1 Day • 6e Under I How 7 Data d BYth(ModdDayfYear)I 8 BirthPlace(City aid State a Foreign Catty)
r i I US May/18/1921 FORT BRANCH INDIANA
9 Ever in U.S.Mred Forces? 10 If Death Owned In A Hospital - 10a 8 Death°owned Somewhere Omer Than A Hospital -
YES DEACONESS HOSPITAL
Ac • Puler tepoxy) .
- 11 Facility Name Of not ibttbrt e Give Street And Nuntr) `
DEACONESS HOSPITAL -
F 12 City Or Town.Slate AM Zip Code 13 Courtly of Dean 14 Mahal Stabn At Tme Of Death
a EVANSVILLE INDIANA ' VANDERBURGH Married
15 Surivig Spouse',Nana Ise(Y Wte)Give Maiden Last Nane 16 Decedents Usual Occupation 17 rind d Business/Industry
_4. BETTY J.WEIST I WEIST • 4 , '- ' RETIRED INSURANCE SALESMAN
18 Residence Sub tab City Or Town '
INDIANA I VANDERBURGH - .` EVANSVILLE
M.
lee Street and Number led APL No 18e Zip Code 1m trsieeCity Limits?
C 510 OLMSTEAD AVENUE 1 47711 I NONE
: 19 Decedent's Educates 20 Decedent Of Hispania Origin - 21 Decedent's Race
HIGH SCHOOL GRADUATE OR GED White e
COMPLETED _
c• 22 Parents Ware(FOa,Middle.Lasl) 23 Paretb Na (Fissf.Midafo.Last) 23e Pamirs Last Name Betore Fist Marriage
VIRGIL ADAMS I ra ANNA F.ADAMS I HICKROD
24 nblmats Name 24a Relationship To Decadent 241,Mang Address(Street And Nurber,Cry,Sub,Zip Coda)
▪ BETTY JO ADAMS I 1 510 OLMSTEAD AVENUE EVANSVILLE, INDIANA 47711
' 25 Place of Disposnien •
25e It of Dscosiion 125b Place d Osposav(Na a Of Cemetery Crematory.Other Place), 25c Location-City,Ton And State .
• BURIAL 4t. I .WALNUT HILL ,. I FORT BRANCH, INDIANA
26 Was Caaur Contacted? 27 Name And Complete Address Of Funeral Fealty • 27e Funeral Home License Number
NOs'�,,.:ol ALEXANDER NORTH CHAFE: ' .
a i ,4200 STRINGTOWN ROAD EVANSVILLE, INDIANA
• 27b Suns°Of Inane Amaral Service Licensee I 27c License Mutter(Of Licensee)
t
Cause of DeaffilSee InstrectIons And Eaenmlea) .
29 Part I Ede c yst' V tr 'Q�4. .'orn Mud query Caused The Not Do Nos Eider Terminal Evans Approximate .
tARAcardiacMatt v___flflpne��leti wabdSaatgThe EbaogyDaNdnmr eEdeanyoremouseon Interval
/w'RAY 'To Death
liffineckate Cause(' Fad Disease Or Condition R22esultng7g(nIn�Death) . A1 ! RUPTURED DESCENDING AORTA ANEURYSM .
• I! evil M lie0Cah�LSted • Due To(Or As A Consequence OO..
i Sequentially List Corot r,If My L o On . B
Lie A Ede The Underyig Caee(Disease Or Wry That Initiated Due To(Or As A Consequence Of) • •
The Events Resitting In Death)Last C
.Due To(Or/u A CaaeQUmnce Of)
rsk GIBSON CODUUN"TTY"^^A""UDITOR D -
k. Pat 1.�,�0r,Sguuat Caudtias Contributing To Death But Not Restmig n The LMdalyitg Case Given hi Pan 1 ' 29 Was An Autopsy Performed? "_-
7> 31 Di:Vobaan Use Cabibte To Death? 32 t Female Were F�Available To Complete The Cane d eath?
• ����3 I NATURAL.
34 Oate of injay(M tsDayfYee) - 35 Time of hjuy I 36 Placed Irjry(E.G.Deserts Homs-Construction Ste.Restaurant.Wooded Area) 37 b ty at Wort?
• 38 Location ahgay-State ( • 38a City Or Teen 310 Sher Muter mber -t r 13ec Apt No 38rZip Code•
t .fi -
_ 39 Describe{ow tipsy Occurred- 40 U Tmspmsbr,jury Specify
4-L-443 .v
,c 41',Strohm Of Person Certifying Case of Death . i 42 Cettha(Check Only One)
IYCHARLES R ALTHAUS,CORONER by electronic signature CORONER
.� 43 Nan..Address AM Zip Code Of Person cawy:g Case Of Death 44 License Numar 45 Date Canted
RM 107 CIVIC CENTER COMPLEX EVANSVILLE,-VANDERBURGH,INDIANA 47708 . ;v,3 J February/17/1988
• 46 Acavmat Foam Se..ce Provider ` -L.-,- - -- —y. tr., 47 uws
•
t �� _ ,
48 Weave
Of Local Heath Officer - � 49 For Registrar Only-Owe• Filed Not/. ey/Yee)
\W.. ". ? _ "� - February/16/1988
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i AMENDMENT TO CERTIFICATE OF DEATt (ENTRY OR ORIGINAL)
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4 o 1 t
•° 4a6 - la -08- A03- -000-01 F::-Da B ` •.< :Y:S„ Acs A
WARNING: T S O " �SECURITY µ THE INDIANA THAT
TURNS ORANGE HAS OW MULTICOLORED ORIGINAL DO TADDE FRON THAT APPEARS W4FNPnTMnFF '.