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Death Certificate_Farris •II ;, INDIANA STATE DEPARTMENT OF HEALTH ;fill }� CERTIFICATE OF DEATH :; Local.No 001883 EDR No 000000664869 State No 044966 -= : I.Daederu's Legal Name(First,Middle,Last) la.Maiden Name(If female) 2.Sex 3. Tune Of Death 4. Date Of Death(MorcvDayflear) FRED ISAAC FARRIS MALE 11:56 PM 09/11/2018 10.II Death Occurred In A Hospital: 10a. If Death Occurred Somewhere Other Than A Hospital ' 0 Hospice Faaty 0 Decedent's Home 0 Mining Home/Long-term Care Facitty ®Yes D No 0 Unknown 0 trcaaent 0 Emergency Depatanent Dutpabem 0 Dead o,Anival 0 other(Speoly) 11. Faddy Name(If Not Instvtan,Give Street and Number) LINDA E.WHITE HOSPICE HOUSE . 12.City Or Town,State,And Z;p Code 13. County Of Death 14. Mental Status At Time Of Death ®Mamed 0 Married,But Separated ❑OivacaC EVANSVILLE, IN,47710 VANDERBURGH 0 W5cowed 0 Never!Mated ❑,Yr41ta.n 15. Swivirq Spouse's Name 15a.Last Name Before First Manage M. Decedent's Usual Occupation 17. Kin Of BusinessAndusq BETTY FARRIS WITT ELECTRONIC LAB TECH MANUFACTURING 18,-Residence-State 18a. County tad-Gty Or Tam - - INDIANA GIBSON PRINCETON 18c. Street And Number _ - - 18d. Apt No. - - 18e.Zip Code - 18f. Inside City Limits?' 704 SOUTH PRINCE STREET 47670 0 Yes•❑No 19. Decedents EOuraton 20, Decedent Of HispartC O^pa 21. Decedents Race SOME COLLEGE CREDIT, BUT NOT A DEGREE NOT HISPANIC White 22.Parents Name(First Middle,Last) 23.Parents Name(First,Middle,Last) 23a.Parent's Last Name Before Fist Manage ' FRANCIS ISAAC FARRIS BEULAH FARRIS CANIFF 24.InkanaNe Name 24a.Relationship To Decedent 24b,Malang Address (Street And Number,City,State,Zlp Code) BETTY FARRIS WIFE 704 SOUTH PRINCE STREET, PRINCETON, IN 47670 25.Place Of Dispoaton 25a.Method Of Disposnm 25b.Place Of Dispositon(Name Of Cemetery,Crematory,Other Place) 25c.Locator-City,Town,AM State 0 Banal 0 Cremation 0 Donation 0 Entombment 0 Removal Fran State ❑Other(Specify): EVANSVILLE CREMATORY EVANSVILLE, IN 26.-Yhs Coroner Contacted? 27. Name AM Complete Address Of Fmnaal Facility - -- - - 27e. Funeral Hane License Number. ❑vas,®No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671-' t.27b.Sid®an Of Indiana Ramat Service Licensee: 27c. License Number(Of licensee): MARK R.WALTER. BY ELECTRONIC SIGNATURE FD01013010 Cause Of Death (See Instructions And Examples) Approximate 29.Pan I.Enter The chat Of Events -Diseases,Iryuies,Or Complications-Thal Directly Caused The Death.Do Not Enter Terming nts Intervat-Onset Such As Cardiac Arrest Respiratory Arrest,Or Ventricular Fibrifation Nathan Shoving The Etiology.Do Not Abbreviate.Enter Only 0 I0rI To Death': •Such A Late- Add Additional Lines If Necessary, 111LLt Immediate Cause(Final Disease Or Condition Resulting g In Death) A SEPSIS P,wtax.xn,..5" N 9 2019 - Sequeritiatiy List Conditions, 11Any.Leading To The Cause Listed On 8. PNEUMONIA Line A. Enter The Underlying Cause(Disease Or Injury That Initiated Dula to As x Cepus°m De _ The Events Resuhirg In Death)Last C. POLYMYOSITIS ' co.co,xi x cu., 0. rlRSON en' AUNTOR Pane.Enter Other Sidascmn Cond3ms CwNiW'ina to Death But Not Restating In The Underlying Cause Given In Pat l 29. Was ttopsy Performed? Yes ®No HYPERTENSION.HYPOTHYROIDISM 30. Were Autopsy Arcing Available To Complete The Cause Of Death] D Yes '0 No 31. Did Tobacco Use Cornbeae To Death] 32. II Female: - 33. Mama Of Death: ❑Yes 0 Probably©No 0 Unknown0 wn.a.esseabearn✓ R.Pae 40 cis see" webq.n ea worse vAbb..x Din PlataNatural 0 Homicide 0 Acddem 0 Pending Insesbgstian� ❑row irnaa d Reprisal u Din T.Is.w s...on) ❑umne nerew metro vie me ❑Suicide D Could Not Be Determined 34.Date Of iyury(Month/Day/Yea/ 35. Tare Of awry 36. Place Of In ry(EG.,Decedent's Home,Consthoon Site,Restaurant Wuaded Area) 3T- Injuy Al Work] ❑yes ❑No 38..t ocaton Of Ilney-State 38a. City Or Tam 38b. Street S Number 38c. Apt No. 380. Zrp Code ' 39. Desalt*How Injury Occurred 40. if Transpmaam Injuy,��yymmry: " Qui..b M.v Don Inalr .Unt .Dawtxm.Y) - 41. Signature,Of Person CerLTying Cause Of Death 42. Certt'ier(Check Only One) ROBERT L. RUSCHE , BY ELECTRONIC SIGNATURE El perching Physician 0 Comer 0 Heath0Dcer 43-Name,Address And Zip Cade Of Person Cenilytg Cause Of Death 44. License Number 45. Date Certified ROBERT L. RUSCHE , 313 WEST IOWA STREET, EVANSVILLE. IN,47710 01033818A 09/13/2018 46. Additional Funeral Service Provider. 47. 'Mat: 43.Spaten of Local HealhOanc - '49. For Registrar Only -Data FliedmW(MDay/Year): ROBERT KENNETH SPEAR,VIA ELECTRONIC SIGNATURE - I- SEP 13 2018 -- ' AMENDMENT TO CERTIFICATE OF DEATH(ENTRY,OR ORIGINAL) . Iiii_j) sv--). .N........._o 7 ___403 cciroo. State Form 53395 ATTENTION ESTATE:The Social Security a is being requested by this state agency in trru to pursue responsibility. Disclosure is voluntary and there will be no penalty for refusal. - WARNING: °RN'CrLQCIOT•119ANllr TTO VFMUOWCWOLONEmDimmcrs ROVN°el°MIEFy NT MAR ASH1f11FN Vt110srN ONT THATEsPra0.0 LW NEP11nTMl1PIFl ON BACK.HAT '