Death Certificate - Cleveland, Charles Jr_10/30/2018 I'.n r s a
""s INDIANA STATE DEPARTMENT OF HEALTH '020 2 4 7
T CERTIFICATE OF DEATH
-fir:, ii Local No 000549 EDR No 000000350029 State No
048669
i :.Decedents Legal Name(First.Middle.last) la.Maiden Name(If female) 2.5es I 3. Tune Of Dean 4.Date Of Death(Uorn/Da➢lYear
CHARLES JUNIOR CLEVELAND MALE .1 04:03 PM 10/23/2013
E InpatentT. 0 Hospice FaNny 0 Decedents Home El Nursing Home/Long-tent Care Favary
❑Yes 0 No 0 UninPn
0 Emergency Deranment Outoacent 0 Dead on Arrival
•❑Omer(Specify)
1. Facdty Name(II Not L s tuton.Give Suet aid Number)
DEACONESS GATEWAY
•
Ii-. icy Or Town.State,And Lc Code 13.County Of Dean 14.Maeal Status At lune Cf Death
al M'aMed 0 Married.Curt Separated ❑Divorce
NEWBURGH, IN, 47630 WARRICK ❑vlcowea 0 Never Maned 0 Unitaw-
:5. S:rtnng 5paus s.':acre I I$a (it.:die)Gme Ma loan LastNate :E. Decedents Us'ua-Occu:attn 17. KUG Of Bu s'nessMOlstry
HELEN JANE CLEVELAND I MARVEL FARMER AGRICULTURE
115 Residence-Sate lea. County t6o.C'y Or Tcar.
INDIANA POSEY POSEYVILLE
I&. _uect And Nance lad. Ant No. Ste.Lp Code teat.Irsae City Lcss,
150 NORTH CALE STREET %Yes 0 No
47633
i a. Ce:dreams Eanmum - ie. D.cecenl oaN:caMC Cr:y, ' 2,- ------_..Race
I HIGH SCHOOL GRADUATE OR GED
I COMPLETED NOT HISPANIC White
m.Fames Name(F s:M•..=e.Last) 23.ftcmels Name "vsL Mode.Last)) 23a.e.Y:e's M'a Nm Las:M1ame
- CHARLES NELSON CLEVELAND • BEATRICE OPAL CLEVELAND BRADSHAW
124.1Atdrants fame 24 a.ReatSF+o To Dececent 2:n.:bib„Address (Sleet as Hunter.Cry.State,Lo Cone)
'HELEN J CLEVELAND WIFE 150 NORTH CALE STREET, POSEYVILLE, IN 47633
I 25.Race Of Disoos:ion
Cf, ..s;csc-. 25a Max Of uepcotoc a
(Name Of Cemetery.Crematory,Crier Place) 25c Locator. City.Toss..no StateSr` r: 0 Cremator. 0 Donato. 0 Era-tree:
Removal From Sate
0 on:(Specgt POSEYVILLE CEMETERY POSEYVILLE, IN
2E.Was Coroner Coma-ea? 27.Name And Carriers Address Of Funeral Facity 27a.Funeral Home License WtAe
0Ye, 0 No HOLDERS FUNERAL HOME OF GIBSON COUNTY, INC., 319 SOUTH MAIN STREET,
OWENSVILLE. IN 47665 FH89000021
27o.Signature Ot In:"a-a Funeral ca.Ye Licensee'
27:.D1010177 ear(0:licensee):
RANDALL K DIKE, BY ELECTRONIC SIGNATURE I FD01050177
Cause Of Death (See Instructions And Examples) Approximate
28.Part I.Enterri The ft.R Of atr Events • t.Diseases.OrV In.oufar ibOr Complicationssith ho-ahat Dng The Caused The Abbreviate.
rDoe Not Enter Terminals s ,�, Interval: Onset
Such Line.
. Add Aral li es If Necessary.
Arrest Or Ven:rcWar Fibrillation Without Shosiny The Etiology.Do Not AbCre na;e.Enter Only One Cause Or. To Deals
A Line. Add AdCimlal Lines If Nressary.
Immediate Cause(Final Disease Or Cand•tcc Resul2rg In Dean) A. PNEUMONIA.RESPIRATORY FAILURE
-toe In A..ewo-^e.r, (y p
Secuen5a:ly Lis:Conc.yixs, If My.Lead::-a To The Cause Listed On B. - to- ' �.. I I r T 3 0 20!0
Line A. Enter Inc Underlying Cause(Dsease Or Injury In at Lu ateo '^" -a
Ire Events Resul?rg In Deers)lass C.
...pro-...v......cm
I Par.II.Enter 0uerscntart Condcons Cmmneu:nq to Dean Oct Not Resultng L The Underlying Cause GMn Ir,Pan I 129.Was An Autopsy Gititco LU ALtP1TOR
e
I I so.Were Autopsy%mpn;A:era ve To Cor::ea The Cause Of Dean.
Tara tie Con:ate I:-,;catty - Fe-a:.: n• •anx Dean:
❑Yes ❑No
at :tic mc St
❑',••_•'•• 0 x 0 .r t 5 .r.-..ew..sc.r.o-c..- y Natal 0 Haridde 0 Awe^.: 0 Pending l:vestsaxc.0 Yes 0 Prota y 0 No 0 uni.�..
❑sr m•+•a.Pm.yar..n it I....5“,”:”..-..e .Pe.v,❑:. r .,,�n....,:ece..v.. ❑Suicide 0 Could NNate:ernhr Be Ded
34. Date Of Injury(MbnnuDa,,Ysar) 35. Time Of rely 36. Place Cf L{ury(E.G..Decedents Home,Consul:mon Ste.Resa,:rart.Wooded Area) 37. Injury At Wcr?
❑Yes ❑NO
3E.L000caollnury-Sate 38a. CM Or Toss 3E8. Street b Number 38c.Apt No. 380. Zip Cale
39. Desrnbe How!nasty Occurred Trananon Injury.S
.r0.c-Ifx.e d+.... . . Dor.rs...-ir.
41.Ssrature. Of Person Cerdyurg Case Of Dean: a2. Cer sear(Cnea Only One)
TASHFEEN MAHMOOD,BY ELECTRONIC SIGNATURE I 0 Cerf,Lng Pnys.oan 0 Coroner , 0 Head.Cftcer
43. Name,Andress And Lp Ccce Of Person Cemtieg Care Cf Deab" 44.Iterse Number 45.Date Certtea
TASHFEEN MAHMOOD , 600 MARY ST., EVANSVILLE, IN 47747 01070928A 10/24/2013
46.Ada ponal Funeral Senece Pro-Mar: 42, 'Aids:
.Sgaarre of Local Hears 0:5cec Fired(Mlonth/Day/Year)
RICKY B YEAGER.VIA ELECTRONIC SIGNATURE I 49. Far Registrar Only -Date OCT 25 2013
I AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
a6, -1
1 - 3b - oleo - sod- d8y- G I
Stave Form 53395 ATTENTION ESTATE:The Social Security a is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary and there'sill be no penaly for refusal.
..-A 2.