Death Certificate - Falls, Angela Sue_2/14/2018 •
�� ^. INDIANA STATE DEPA TMENT-OF-HEALTH' / ' �
`"- CERTIFICATE OF DEATH /
• ` LoCaYNo"000053 EDR No 000000619509 . State No.001559' ..'
1.Decedents Legal Name(Re.Middle,Last) la. Maiden Name(If Imam) 2.Sex 3. Time Of Death 4. Date Of Death(MantVDaytlea,)
t
ANGELASUE'FALLS:'-. • HAM. _ • FEMALE` 11:00 PM . • 01/07/2018.•
. 67 - •Waits - Den Hats Minutes `-04/26/1950 ' • : '.OAKLAND CITY, IN • . -.
9. Ever in U.S.Armed Forces? . 10.11 Death°carred N A Hospital: 108. If Death Occurred Sornewtiere OBler Than A Hospital .
'--' 0 Hospice Facility 0 Decedents Home-' 0 Nursing HDrneAmg.term Care Fadery ' -
0
.Yes.0.No"D UNuvwn D Inpatient. O Emergency Department Outpatient 0 Deed on Arrival D Omer(specify)
11.-FarAty Name(I(Not Instate;Give Street and Number)' .
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LINDA•E::WHITE'HOSPICE.HOUSE . . - -
12.City Cr Town.State,AM Zip Code 13.Canty Of Death 14, Mental Status At Time Of Death • _
• _ 0 Named D Married,But Separated-0 OMaced•
• EVANSVILLE, IN 47710 VANDERBURGH ®Wdo.ved .O Never Married ;G.yriknovn
15. Sinting Spouse's Name 15a.Last Name Before First Marriage 18. Decedents Usual Occupation 17.Kid Of Business/Industry
WATIRESS BARTENDER. RESTAURANT,
IS.Resdence-State 18a. Canty 18h. City Or Town
• INDIANA- . GIBSON OAKLAND CITY • • •
18c.Seem AM Number led. APL No. tae, Zip Code tat Inside City Units?
439'5:7GIBSON.ST, • _ - . 0 Yes D-NO
:- - , ems,-";r.� a-c-..," ..`---:• _ 47660
19.Dawm:s Educa5m _• _ 20. Decedents Hispanic Owlcin . - ' -21. Decedents Rau• -ti .;� i� -.�- 'z 't s'
- HIGH SCHOOL GRADUATE iOR GED - ° '
- COMPLETED - NOT HISPANIC • White ••
22 Preen Name(Fret Mida..Last) 23.Parents Name(First.Middle,Last) 23a.Parent's last Nene Before Pint Marriage
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DELBERT WAYNE HAM • WILMA JOAN HAM. e•� TN 5
24.Info/mannn Name 24a.RelatsapNp To Decedent 24b,Ma&g Adtresa(Street AM Nunes,City$tae,Zip Coda) w ��
WAYNE MYERS SON 1592 E. CR 550 SOUTH,WINSLOW, IN 47 2-1 - ' - .,`.-
25.Place a Dispasldon "e-
25a.MedrodOf Dispos9m • 254 Place Of Disposition(Name,OlCemetery,Crematory,Other Race) 25c.Location-C4cTam,And State -FE�E41-4.4018- -
D Buial'E C emetdn 0.0onadon 0 Ems foment - ,
D Removal From State -
❑.Oma.(s;edm: ' . EVANSVILLE CREMATORY EVANSLANDING;-IN i �! - - -^-•_ -
26Wet Coroner Contacted? ' 27. Name AM Complete Address Cl Funeral Fadaty - //fr�2�Qp:_Funeral Home License Number '
LAMB BASHAM MEMORIAL CHAPEL, INC.,226 E.WASHINGTON STREET,OAKLAN�0)j,'9k '•. -
❑ver,®NO - • IN 47660 . H83005312-
27b.Signature Of Indiana Antral Service Licensee: 27c..License Number(Of Licensee):
J ;-.BY LEE-BASHAM;-.BY ELECTRONIC SIGNATURE • • • . FD01016589 -
Cause Of Death (See Instructions And Examples) - APWanunate
28.Part I.Enter The Chain Of Events'-Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events - Intervat Onset •
'Such As Cardiac Ames(Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On - • To Death ".
A Line. Add Additional Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. RESPIRATORY FAILURE - • 'DAYS
oa to As ACerevao04
'Sequentially List Cdlio s, If Any,Leadahg TO The Cause Listed On B. CHRONIC OBSTRUCTIVE PULMONARY DISEASE YEARS. ' - '
Line A. Enter The UMersyng Cause(Disease Or lrnjasy That Initiated °ijor°"casase04 -
TheEventsResultignDeath)Lastb C. . • - -
4a%IaAsArerxi.e 0:1 • -
. D.
Pat II:Enter Othergian`cam Condirons Cantbutlna to Den But Not Resstng In TM UMerhang Cause Given In Pan I 29.Was An Autopsy Perfumed? 0 Yes 0 No
30 Were ALAOpe Fedug Available To Impale The Cause Of Dersn?
. - : �._ , - ....„,et.,......> �-ern^ . ❑-Yes D No-
-_ ^Q
31.Did Tobacco Use Catlbub To Death? •'. : 32. II Female:
y.+ ti 0 ma nyan wr*,Pee Hsi 0 Primes u re.Draw. 0 runywu es n.,sn.s vae 42 Daysap.c 0 Natural 0 Homdde 0 Accident 0 Penang Yn ligation
0 Yea 0 Probably-O.No aUnknoomf•
to 0 van...weew en,.Cowl Tw,wren awe 0te.,v:env..wee,me purr.. O Stride 0 Caw Na Be Daa•rwd •
34. Data Of Injury(Mendmayflea4'.'.,I 35, Time Of Injury 38. Place a Injury(E.G..Decedents Home,Construction Ste.Restaurant.Wooded Area) 37. Injury Al Work?
.O Yes 0No '
•30.Location Of Injury-Saes 38a. City Or Town • 388. Street a Number - 3Bc.Apt.No. Sad. Zp Cade
39.Describe How Iron
- Ocoarw • 40.-If Transportation I w. eo7-•• . DpaP�va OPwe s 0New. ,.0aaiv. • .1.h
. L•.
41.,Signature, a Person cowry Cause Of Death - t- - ' 42:Censer(Check Orgy One) •--
DOUGLAS JAYE HATLER:-BY ELECTRONIC SIGNATURE - - - •. I 0 Certifying Physician 0 Coroner •0 HealthOPrer 1., -
43.Name,Address AM Zip Code Of Person Cenfyi g Cause a Death..' 44. License Number 45. Dam Garbled .
DOUGLAS'3AYE HATLER-,4498 FIRST AVENUE,'EVANSVILLE, IN 47710 • ' 01039937A 01/12/2018
' 49..Adadonal Funeral Service Provider, - - �.- .. .. r 47. 'Naas: -'"�'•'
4a.Signature of Local Haan ORcer '- . 49. For Registrar Only -Dam Feed•(MOntfVDay(Yea) r J.
ROBERT KENNETH SPEAR,VIA"ELECTRONIC SIGNATURE -.- ,.``' - JAN.16'2018' " `
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•- - r AMENDMENT 70 CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) - .
. - 4' - Z..
ant- ILI-jq - 001 - 000 ? 346- �0'7
State Form 53395 ATTENTION ESTATE:The Social Security#is being requested by this state agency n order to pursue responsbaity. Disclosure is votnary and there will be no penalty for refusal.-'t7.
WARNING. ORIGWAL-DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECW:WHRE SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF.INDIANA ON BAs(THAT' .
. TURNS FROM(IRANfP TO YFI I M4 WHFN RI IRRPFI r1FIl:IN4r MY9 WCNi 4ac e.MlnnrM VNn nu ennui T at eoaeme wueu eunrrvw¢n '.L.
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