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Death Certificate - Davis, Ralph C_11/8/2017 Ire C�i xr., C% 2a '7 �rn�, i•h.1 o . H 1 '� ' r��'eS:�':T ri' `Fatal._% e n 'S1�T`.-�\ , \ r\ ' : a v-e„.,_N v-,�� w -s�.- '-,5.'- 'p" \�" �I."-. r l"'/ a\.c I ,�4\ '\p si. INDIAN A„STATE,DEFARTMENSMHEALTH' �� �� /� t U.\ -._ i' "-'--. ' '00 '5 7`� �EDRFNo 000000589928 iv tat b 0 74� ��` 7- �� �'� /1 b, r US'!/ .1 t 1 I _MACE X03:00 P.M 11.e.:407/22/2017'lit r, v•5 Se"SecurityN bet 6a Age'-Yrs fRUn4�1Year%r--j' s'etjtgt-,4 Jut\\ Ho11 z)`oat of BUN(AW_n�:t?VDaylYear)C;I!BirarralacnelpiryaM State ce Foreign CO,iiy)�`��i It�Y ailt ? llf)a lnt ✓9`.l1,� fljw -I•�,1..���\\\}�vj//�f}{ �l1! 7'l p 1 }v/!R �i.J JtIURiv (J 19 �IOWEN �Ull�'/L.l t ,1_" 1 � ,14316-06-4771_'' a 1570 y ^t??•bs, �,t4i Days ��,����wrs1'��`� Mvnres�a)� p3/23/�19471 51511'OWENSVIL'L"E;INI y i�' i9.-Ever in U s Armed Forces? t .10:If Death°carted N A Hospitals' v U .s 10 _If Death OSmed Some enere Other Than A'Hos .5IM j ■ �. ply ��������n����^l 'a t]�HOery,ce FaaLtyy�(]�'.Dnec�erRS Hone��:NUrs"ug HaneM1a,gt Car F�3ryyy� "�` +� 0r siis O No O,iii ns ®:fia!/ief IL}M /LJt tlIttriF,%LILI c Mk O;a;�l( ,.r uUtr> A A ���� i*d(�t%UJ11 .f �/�W�tU i 11- Facility Name.(If Not!mat: iG eStreet and Number)%// c� {�G .ems 1 `'(/��p�y��//���ry tt{(/ (` ,,�����`�`� +('ty��{r/"/� �'tsu1 EC( DEACONESSHOSPITALIINSr.AN'I I` ltll� l'a�vL �U��a�'�'�IILi%a'S"2 lr1 1��✓ �L1�yyl& %tiCly}lj�/ lily�rr„1.-ll y� `-.Crty ,Tmn,v'%t\1 Cz ` , \\`yV . �'f3'CO'nryol Dealh.,l �V'' \'f4 M ritalsu sAt Tune O'DeaN C I EVANSViLLE IN i 77 /+`4D i 111 /' ` / 'W eai ii�?� '©Ma dO r.i mee ent a eel ❑D c%' EVANSVILLE.IN'47747�ia t'L i/_'.11Ul�l�/ - �l��j� ✓ VANDERBURGFi?, ��� %g Wsdowaalal7!N �Ma�aap unwP.�•{, 11,r.i 11]5,:SLI- r.r-es Name II f i 11 \'is p 5 La tla tName Before First Mamage 1,l',;;.,., ,l{[/y�f\fi\re:eln[Y�S U�SUal OCCVpa:on v f'). i(iM Of Bosinesstlyd terry 1 .rn. s \, ppp` n .. \ RACHELLE LIDAVISit i1+1l lUtft, HIGDON: ' �../!/1111 P.OLIEEEHEIF.% 2�.L t GOVERNMENtTan,' ,,; INDIANA`�i�--,. �\� i � diBSON_-_ � M PRINCETON\ c. .�\1.\_.eedara -'_I l f i8c%tAfd_Ni tuber, , ��� l ti d!/ �}�' i 'I 3�18d AP['NO. fie.'Zip Cade \13:"InsideCrytmitzo% Il�.�l ti�✓j,I1-- 1;,;,NI a2:2� , r. 1 .� 11Ii1fl4 p 4fl\J16 a �.J//" 1t 'tFnyt`[`i / rNiitit% c.:1 945.SOUTHIDEE R3HAVEN DRIVE°�(�3 1 Ulh�".,I ti.... / �s��` �� '�ri�� 'x'47670 I' U*N c.i.ani 19.Decedent's Edura,on ,M1,. �\ `�1 `Si Oecedeniv°� gvnS., \�•`•(v 21,DDeced�rs Race�v jy(I}��v \;VZ�/'" �\i`",' " 1 i ,, a� ,w/., ,(rti3tr -..0 'L•c -0 �, p/ --2,1s i l0„ .. illl ' L e (y' (pp i�l'i l �' BACHELORS.DEGREEI BA;AB 4BS)I NOT,HISPANIC tint /� White ,t :CIS ell V st_. Ior a./� M +pit.-72'Par CrNyame(FUSt.'Mddt la U 1 ''1� 111 cl,' i?, Cr U - , 23''ParnName(F&;.,`idble!Last)� l ."..�\\���1(j .. Pa"%clian Name Be ti IM mage 0,;\mow\\-\-\ ,. \, /�(�'(f ;75:....) " '".��. ��,5. \\l u �4 t - " � `\� ���It jh/2 RALPH Js•Nape tT f� " /Illltll.�l�fl .. /!\� JOANNlDAVIs:(Sfr�a.�l i MEG LEANliny� .+lf,�:'G 24;1 famla t N me" l L Lr'Y,I 'n �/11 'I4alRNa'vo3IHp TODecedent U I2<blMatng Addr (street Ard Number,Gry State:2iPc.:V r< ) it 1) r i /A J�p w RACHEL EI DAMS i :.L it I UN U / 945:SOOTH.DEER HA 0]NN DRI .'f111.11 ®N�I%�a<3'1� n RACHELLEIL-DAVIS 1'.i^ WIFE. 945:SOUTH DEER%HAVENORIVE,:PRINCETON;lIN.C47670 !1`�r l 0 �5 ',?_rl��3�it,1.,1. -- Y1J13-*.`mss.a otasposi 1f -- -511-\�,151a %111ti1���ii tV7l\ cc t 25a-MetDod O1 Disposr2 n��j1fl[fl c2# I(t 25b:vRJa/Fce Of Dlspostben(name Of Ceme' ry C ma:ory;Oter.Place -:25c Loral o/Ccy Tam And Stare tall 1 � O# , cr I' MI S ®lB,m i d d-reiC 1)}iaDoraaon\0' tlDm�� / ,;yin ,t� / \ ` / A j. I *C.9. !- t a O Re.Lsl.` Sa e ` ,� at\ \\_\ \L-,' .\\ , t O O'omer(sP�eea{'ty7-s- 1 f�. it \ BLVHE•CHAP.ELCEMETE�rR�YS•al1�1� / tOWWEENNNStVIICIIEE IAN •bt,L�t-L1/1R !^J C \� W CI° �O 1l\fll±�� 1 ire0 � 'N And tt.r. Of W 111i/ L .roulusus .o li lh1UF/JsullITC -1](II��} j�;"ra.^.FUrerpa &yr rnyse Number:. W`f � 1 lttt,i ✓ HOLDERS;RUNERALHOME:OFtGIBSONiCOUNTY/INC�i319 SOUTH MAIN'STREET; U� �!' lull i 4 S.- , 2 O.Yes' Na ff ,,,, \ nA 1 EH89000021; 4 �vi.l� a Service Ocensee L••LE�INT47665\1(��`\�1 \� 1� � F C:nb�Sgn3•ua Olma,a F,meal Se Liven -1\`\\�YJ.ita ` ,..„. v ,,,r-w„r*. '0_....... -\ ;n4gu se NUnber(Of Licensee): „ �'��}fit -I RANDALGK!DIKE BY ELECTRONIC_SIGNATURE /- S11 1 F�D010101771.1eUl� �gtaie .-##'ism;' 45 LL t'L''}3y lltklli�/"� �y.vx-..--1.1pir „Ito t Cause ati (Seelnstrucboni .c etzesesilli r ? "'91• '7 1 gppro isle [f S heeD oNot/er-+.,LU �2S:Panl Enter The Chain Of Events 1LD1se-V...ryunes Or Catica Mvbu That Dire Uei bale � ENalh Do NOt�Enterdermmai Events l- V lntervaa 'St SuiiW 1 Card ac Aired Respra•ory Anesl,O..VeiYriclar Flbnilatdn VWJioul Showm-1-fr Et'ola a li Nd'Abhe ate Enter ONy One Cease On _"t. A A kV To`DeaN �V 0 . tiALNenAtld Addtional Lnes If NI- s11,I(p( /li�nV .1i /Ali pA�EPHALOnAtVECONiA\TOCALCMAV k `F. �(DE \ �t ft O G/� {yt+l /�/ {I11t OrrC8nd of p__ ,.<•")11 e << SEPTE?EMIA' AL IUUflL SECONDARY 70&1UUhIt& )aEOMYELfTIS ANUuflt. RLY. {� }///�/ Immedla a Cause(Final Disease Ov Cond twn Resul'ung In Dea:h)!', A a CTEREMI c; .m1.1U811L/1S{ll{rd U11ll15111/� I�till(// CiVilltl/� f I cl�.I`G%� 11 jam\{ 11 L(//,<fJti`6. (N v S v \i{riw.my.,���.�a «,- {:1�1 1� 1�iv lI}Yr,�✓ ] Sesuerualy L1s Condltdns I Any Leafing To The.Cause L steel On _ 1�� e iL,ne"A Enter The Und Cause Disease Orin"_.That Initialed J /� 1}n� (111 t7f�{pY'•$,.�-//,jO1,"` (,«°"°1O1 t"� ��%/�,.,I� A 1"'�i} • r}1( t I"L G The E ents Resulti51n Death)Lastf+c.;j l/C-.,ti �/J��i1U111 111191r�LifAtit ajllt'liltl!✓llf lliftitCl% Oil �il 4,e �CL , -f{ �S ter L six <:, �.r/ � ��G L , .;v rs vow.to'�.ee«. vv ���/ d -U �4nt ten_ �n� I t Pan II Enter OtherSnni:rant GoM:ionsC Duv to But Na Resl5tg In The @werryvg Cause Givenin Pall// t29'Was nW,opsy F,Vr eel } r IIi(e1 l/ 1 i use ' i�xof,f.✓iir a 'S% 1 Z ®N L' 4y yr,, l �ILli�fl�DISEAS ECHRliliil%iiOSItlPRESSIO .ad . -, 1\�31� . 30 We ZZ",,IJr -AaiaEt Ts3 eT Citlse0: 4�is rI • l PERIPHERAL VASCULAR DISEASE'CHRONIC IMMUNOSUPPRESSIONLA tltl�iCi`CLLJJ II �� -..�r�.cw'luracs uv - �� 331itttt ///JJJIIL���••III 9 ,(, Nom </ 31 Did Toe Use Corttnat T De N?`t k . 32 'If Female \`_ 'V I33 M m7 Of De ih h . 1 ,,CI ' y l�o. I''O� P'rtr+ n �wn•al"t ", T.-4w.�nir'.«un I®Naasal❑'isade/O' Acid l .04,,�n.Ig inc4t. LOisllts io�yt'IL%® 't 'k.-�l IO,w KiB.R.9eesDett 111. r.rr&b.niuuI O' ie.s set�{1 /LIUn�L// ❑S Odde 0 CooddN emu,) u 1 ir.r-a slut. II 3111 y�y�Xr�1// 34 Dare Of Injury Won:II/Day/Year) 1 ”‘al-1,--a,. 35 Time Of Niuiy (/ y(/,3B Place Ot MVEG!Decedent's Hare,Cautruaion See;R ta L V.bodeCA da)ly t3) iryuy At Wb'k'+- 1j . `iC V//��Anl / / \ VV tell I, �\ \ \ '. ��• `..vv����•\�,1 ��� 1�� .,�\�U` � \�ii ♦ �i i �`��\/❑Yes;I V No --( 38.��nOf injury State) i ll w y338a%Cdy Or•Tow1 38b"-•Streets Number- L I ._- „-N:Code �, --,t ' . ` i'i t1 (�td�//���� 0/� �� ��//�� �[lO i. �l VGG r.i X1`1117 11. lit<r- ? * - i lll� 11iCFi ' hl ll�i�/ '\' '� ��i' gilt) ` GI SONicOU TYiAUDITO ' 1 L y^-lice i trn,ry orwrred i�y�.3 �v \1 ��° '40. II T w«ta:ai Inn'ry s�eory:Sa\ -�v ?\ 1Y "it� Oa^^>w.^"10°1--c...Pe=ntra Oa,.rs r, 1� '8.1,, ;.�H��t��l aD . �3 f]�rtWai'E -_/r' 01Zinlltn IutnrOthIll are>,C_i IUlti itiitt -� d ft, Ctr 4lssgn]U OI Person Cemyug Cause Of DeaDUli\111 ii"/�Jiiltnt%l/�yti:❑ypr�1yy1'f, i`1111 i,},�' 4z.cnfi (cn xpiy onejl LteeAl�'`i///j !: ifj5'� lJ1 t ) CLIFFORD.LEON DOTSONI,BY.E-LECTRONIG�SIGNATURES��\.Ill) ihl.� �\ill L Ceruyng PMsicia,i:�lO' borml 1',IC,IO Health OSCer- ' 4°:', 43 NameAdb And Do Code Of e�GettMno Cause of\e? '� ''. -- �'\}"- \\\� a4+41:tene Nuiper: 45'Da:eCert5ed "e IP L ei d n1\,-,P-4,- �� � 1 1{tuQ� i' �atd • /"111ft�V/� Vl/'l�Iln�": h1p°g(I 111�1� )fill lam/ e CLIFFORD LEON DOTSON?!i6001N1ARYe Tt•LVANSVII LF INt47d_47 V Vld41ic ii t ��1'L1i4111 . 01059237A'R1UUiUG 1l Iii➢07/27/2017if1/< 1 <s Aadt..,IFuneral Setr, ProMcler,�-•v +,/� LrU �,�* • I d - 1 all���74) .A.as.i y - vll) tY v l- ,c,... �,ts,,k I;�s'^t�\� `�y1\�T�11..-1�11��4V/ ��C�\�\yUi'�l:L Ct.: .cam_-..- � \C. 48 SFlaYre of Local Health O°ceri\et�' ':ltt,U'��)Yni."./✓/.LL1.11n �t [may."��� , lFli' 49�rR Istmcrr nlv..Da;a Fled lM nDayne�ar.)//�'}¶k �i!V}¶nom �( ROBERT KENNETH SPEAR.VIA ELECTRONIC:SIGNATURE!✓11'llllll %lUlif '�4Drl] I1 111111tH 111AUG 01'2017taiii'fI -ud'il 4L ^ 121 ek--.4 it11E-- ft' f'n.-'YC�'rU11W-re_ktr AMENDMENTITO CERTIFICATE OFDEATH(ENTRYLOR ORIGINAL) 161Ua%< 1Urirr M(f�/ .y!?11 f/de fill " .tr0' \\\�` '\ \ Vv, `'t ```` „, mow., ,M \�` `�\ 7, `J \\ L-' 49 03'01)'01)7 1 ,i 2 sue' �� �1Yd ,, �v �. V ��V_ �T. \V ``,��j""1. �{1�f/�% L-, 1 HIGGDO\L /��l�/�lt�'V��l(t�l�i V I�-i': / 'i�K ��� O� O 1-21;�i� ���/ \I// Y '1ll1 / {T ! (t ( {Q� i t 'S ll t i 1 Ll li��Ill ri?a"..tU i✓�I I 1 i , 1 11� d'A' t 2 State Form 53395 ATTENTION ESTAT.The SOaaI Secuniy?rs being requested by pilitate agencydn oiler to pursue fe'onsibdi -Disclosure 1s voWOta and there win be no cal for iefusal. ..: -V,3 11411%/0$11545 / DOCUMENT „uua.riiiiuu.lru�if,m aii'Inri r a,mnniry�i�luuurii„s,1 Lnu�i„fuut�i I .7,1 ')O t,II A� b' y ORIGINAL DOCUMENT-HAS A'MI/LTICOLORED BACKGROUND ON SPECIAL'WHITE SECURITY PAPER'AND THE GREAT.SEAT O,THE STATE.DcINDIANA ON BACK THAT Es.- _ . . N I NG..TURNS FROM ORANGE-TO-YELLOW.WHENRUBBED.rORIGINALIDOCUMENi HAS.A HIDDEN.VOID ON FRONT.THAT APPEARS WHEN PHOTOCOPIED* ..LR16