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Death Certificate - Woods, Eleanor Jane_5/11/2018 ''INDIANA STATE DEPARTMENT OF HEALTH? CERTIFICATE OF,'DEATH t ' ,) g 1 O "% Local No 001485 EDR No 0000.00587218 state No 035690,::::.' • 1.Decedents Legal Name (First Middle,Last) Ia.Maiden Name igf tamae) 2.Se. 3. Time Of Death ;4:`Date Of Death(MOr4NDaylyear) ELEANOR JANE WOODS -'.2r KOLB • FEMALE' 03:09 AM 07/08/2017 .. 81 MOnt1ns . " Dan Hour Mexees 4105/27/1936 WASHINGTON TOWNSHIP, IN 9. Ever in U.S.Armed Forces? 10.11 Death Occurred In A Hospital: 10a. Occurred h II Deatn Occurred Somewhere Other Than A Hospital - , II,r,• :0 Hospice Fealty 0 Decedents Home 0 Nursing Homekapterm Care Faofity 0 Yes 0 No 0 Unknown 0 Inpa em 0 Ernerpmlcy DePanmem Ou:pa:ienl 0 Deadr!m3:•- YMrvel, :0 Other(Specify) 4, 11. Feo+ty Name•Of Not lnsttton,Give Sheet and Number) .' 3 '� •DEACONESS HOSPITAL INC w I+.- '''"' 13.Catty Of Derr\'t. ` 14. Marra State At Time Of Dean ,....f-J. 12.Coy 0r Town Sab,And Zip Cad! ' � `-I; CtI t�- v ❑Named❑.Marred,But Separate]•®Owomed . EVANSVILLE, IN 47747 1'!' • . . VANDERBURGH • - _ 0 Wda'ied 0 Never Matted :0'Unknwwt 4 15. Surviving Spouse's Name 15a.Last Name Before First Mamage T t) • 18. Decedents Usual Occtpaton 17, Kind Of Business/Industry - „- TEACHER -.+, - EDUCATION v.. 13 Residence-Sate 15a. County 1'..2...lbs tsb. CAN Or Town • { F INDIANA GIBSON PRINCETON. it 15c. Street And Number . 180. Apt No. the. Zip Code 181. Impe City Lanus? . '14.J,' .0 Yes.O No 557 MEADOWLARK DRIVE cAiti.'�..ti's 47670 �• ?. 19.Decedents Eduaeon 20. Decedent Of Hispanic ' Stj ' 21. Decedents Race . i " i :C . BACHELOR'S DEGREE(BA,AB, BS) NOT HISPANICt. • White = - ' J " a 23.Patents Nme(Pest Middle,Last) rj 23a.Parents Last Name Before Fest Mamage .22.Parents Nara(Pest Middle.Lest) s{_ ( `7C:A I 1 LEOTIS KOLB MARGARET KOLB3 STEWART =' 9 24.Informant's Name - 245.RelaMmstip To Decedent 240.Meting Address'(Street And Number.City.State.Zip Cafe) e;*,.`1 7- KATHERINE WILLIAMS .• DAUGHTER 2900 EAST450 NORTH, PRINCETON, IN 47670 C's 25.Place Of DIsPOii•.bri'. - K'. 25a.Meead Of Dispossoon 25b.Race Of Disposition(Name Of Cemetery.Crematory.Other Place) 254:Locators-City.Town,And State r,.a t,i- 1�+'t IC" a‘11.11. ®18tnel ❑Gmamn ❑Denton❑Entombment Ly t r `•....,I - ❑Removal From State , fir^: - \4;11 `_i' 0 Omer(sway): DECKER CEMETERY PATOKA, • IN 1'd`Q,ii-,› 2p.Wale Coroner Contacted? 27.Name And Complete Address Of Funeral Fealty 275. Fulani HwM license Number. VA O Yes 0 No INCETw �'• ' N FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671 270. Signs !'I : '' 274. License Number(Of Licensee): JOHN W L T951 SIGNATURE •s.T c' FD01009940 -so 1 Cause 01 Death (See Instructions And Examples) -5.`; Approximate �•wa�D, irnevat Onset 28.Pan L Enter The than Of Events -Diseases,Iryuries,Or Complications-.Yowl Dearly Caused The Death.Do Not Enter Terminal Events To Death Suct As Cardiac Ares R st,Or Vernriw'ar FiMga.pn W ithoul Showing The Etiology,Do Not Abbreviate.Enter Only One Cause On ,, ?'- w . A lie. Add Ad� Ln sI N _Il'> J 1,5,,,,,,,,„II - Immedate Cause(Final Disease Or Condition Resulting In Death) �. A. CARDIOPULMONARY ARREST ..€r 4( IMM.EDIATE'r oeai.7 At.e.ero oe , lei !MLR; B. ACUTE RESPIRATORY FAILURE«.d'e.__'-' MINUTES 9r Sequentially A. Enter s AA. v...4.1••nsp4008 ry Tat Listed .t into lab tees..oe Line A. Enter Th w l J .+ p n e z That Initiated f c.:-‘1"� +T-Fi J The E©I@� •t t. . Tall•UDFIDOI C. ATRIAL FIBRILLATION yy1NA" • •.a. bu etc.As.fw.w.e 04 _ - ..- - �D.1U_ . . _ ._. -- -- - �•+mil'=' _ Part IL Ems Other Si itten'Cap:bml Comobvt no to Dean Bait Not Resulting In The Unda1 big Cause Given L Pat l 29."LVas'nn Ateops)Pertmne0 i 4, -- Q Yea 0 No _- ti\� 3p. 4\ta Auopry Finding A made To Canpla'a The Cause Of Deatn?-ILEUS - _ 0 Yes'7 O No pp 31. Did Tobacco Use Centime To Death? 32. II Female: c S yam-+ 33. Manner Of Deae: . . 0 wnvy.nvea'Gtl v.:,-.0 ProonstIne aoe 0 se mews eu q.P.lwmt 42 My.0111•441 ®'Natural 0 Homicide 0 Acodea 0 PenMa°kwesogaoon ITL7ppi!n ❑Yes ❑Probably®N0 ❑Unkrown` 0 w e. e P �a�re n pi 4.04..am 0 Ova..e er..4v S.rye'le tem . ❑Suade 0 Could Not Be Determined ,rs % . 34.Data Of eyury(MaCNDayrtear) 35,Time Of injury `�) 38.Place Of Miley(ED:Decedent's Home,Casstcton See Reaauent;Wooded Area) 37�riuy At Wok? "�"1..1I3� Dees ONO 38.Locao0n 01lrryry-Sate 3134. City Or Town r: t 38b. Street a Number 7.t-. 38c. Apt No. 380. Zip Code , �.irr 39. Desmee How MOM Occurred .l < 'r� ti'jAA fi 40. if Transportation 0..•a.'LJ°•w7�..Don.nwrt. ` f rt 41.S413tue,Of Person Carolyn;Cause Of Death: •' i ". II k'•' 42.Certifier(Check Only One) ADAM ROSS WADLINGTON(:BY ELECTRONIC SIGNATURE - e.s�t L S Ceram Physician 0 Coroner 0 Health O:.cei- 43. Name,Adores And Zip Cone Of Penal Cestfyir@ Cause Of DeatR- r - -..r.c 4) 44.license Number 45. Dale Cw_Sed ADAM ROSS WADLINGTON ,600-MARYSTREET;EVANSVILLE, IN 47747 02004797A' 07/19/2017 • 48. AddOc al Funeral Service Provider. - r'�,wit _ 47.. AI•as:' 48. Signature of Local Heads Officer. - ' - " , 49. Fa Reyleuar Only--Dab Filed(MonaiDaylvea) ROBERT KENNETH SPEAR"VIA ELECTRONIC SIGNATURE -: .taw JUL r°'' - 20 2017 • 1, - 'AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) - - _ 66- Ds--a3_300-000- Q.5 6 -of./ c � -,-,..y--. .....-t ciSt.J- • (Vb.- 05 -aa" Moo - 000 9: = 011 ., , 'State Form 53395 ATTENTION ESTATE The Social Seemly 0 is being requested by this state agency in order to Wrdue FesponsibLly. Disclosure is otntary and there will be no penally for refusaL a•a• n•Ii•spa- ORIGINACDOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT