Death Certificate - Nalley, Ray E_1/14/2019 q
!�`"a INDIANA STATE DEPARTMENT OF HEALTH� , O
i4 1't•.- 't CERTIFICATE`OF•DEATH
{.- \zCir Local No 000239 EDR No 000000675608 State No 055269
li i Decedent's Legal Nate(First Middle.Last) la. Maiden Name(1l lema:e) 2.See 3. Tree 01 Death 4. Dore Of Dead(hoc vDay(Year)
ra
RAY ELWOOD VALLEY MALE 06:05 AM • 11/10/2018
: 5.Soot Security Numt er Se.Age-Yrs 60. Under I Year 6c. Under I Mann 6d. Under I Day (Se. Under 1 Hour 7. Date of Bits(MmdQDayNear) 8.Birthplace(City and Sate or Foreign Canty)
85 Macs Days Hors .Mimes ' GIBSON COUNTY, IN •
j9. Ever n U.S.Armed Forces? 10.1f Death Omxso In A Hospital' 10. I:Dean Occurred Somewhere Omer Than A Hospital
!^r 0 Hospice Faoety 0 Decedent's Hare 0 Nursing Hanelong-term Care Fealty
L� N Yes 0 No 0 U,rewen 0 Irpatent 0 Emergent Department Ouyatem 0 Dead on Arrival a Ober(may)
s"'.. 1I. Fac3y'::ame (II Not W toutan.Give Sweet and Nutter)
(te 910 WEST DRIVE '
12. City O Tow. State,And Zip Code 13. Canty Of Death 14. Manta Stites A:Tare Of Death
od
Psi OAKLAND CITY,IN,47660 GIBSON.r 0 Mdowed MID Nees Separatedrrid0 kstoam
0 Widowed ❑Neves Married 0 UnOttm
_'',,( 15. Surviving Cm.Ns Name 15a.Last Name Bette First Manage' 16. Decedents Usual Occupation 17. Kind Of B sinessendustry
MARLENE SUE NALLEY LEE DRIVER TRUCKING
:8. Resioece-Sate tea. County :Bo. City Or Tam
INDIANA GIBSON OAKLAND CITY
t i :ac. Sheet Ara Number led. Apt No. lee. op Code nett hate City lima?
t 910 WEST DRIVE 47660
u n 0 Yes ❑No
N
19. Dexass Eauam 20. Deader* Hi O Hispanic ngt I. 21. Deceoems.Race
bs� HIGH SCHOOL GRADUATE OR GED
.f� COMPLETED NOT HISPANIC White
cj 22.Parents Name(Fist Mick,Last) 23.Parents Name(First Mote,Last) 23a.Parent's last Name Before First Marriage
C4" GAINES NALLEY ROSA NALLEY USERY
24.Informant's Name 24a.Retaeonsrdp To Decedent 24t.mannaAddress (Street And N Co umoa, y,State,Zip Code)
MARLENE SUE NALLEY WIFE 910 WEST DRIVE,OAKLAND CITY, IN 47660
I 25.Pace OI Disposidm
25a.Memos Of esarm= 250.Place Of Dspceoon(Name O'Cemetery,Crematory.Other Pace) 25c-Locaton-Cy.Tar,A.n State
®Sacral 0 ere:taaw.0 Dortaton 0 Emanoment
0 Removal Fran Sate •
e 0 Ober(SpedhY NEW LIBERTY CEMETERY COE. IN
25.Was Coroner Contacedi 27. Name Are Complete Address Of FVneal Fadry - 27a. Focal:Ha-e Itreree Nu^foc.
❑Yes ®Np CORN-COLVIN FUNERAL HOME, INC.,323 N. MAIN ST. PO BOX 278, OAKLAND CITY,IN
47660-0278 _
27o. Signature Of Mara Flnenl Service Licensee:
RICHARD D HICKROD. BY ELECTRONIC SIGNATURE I FD010121 i (IL J
Cause Of Death (See Instructions And Examples) Appmxvmate
29.Part I.Enter The Chan Of Events -Diseases,Injunes,Or Complications-That Directly Caused The Death.Do No:Enter Terminal Events Interval: Onset
Such As Cardiac Arrest,Respiratory Asreat Or Vettnattar Fibnlatidn Without Showing The Etiology.Do Not Abbreviate Etter Only One Cause Or. JAN .SO�(y To Death
A Line. Add Add:ioral Limes If Necessary. 4 L J
• Immediate Cause(Fatal Disease Or Condcion ResuSig In Death) A METASTATIC MELANOMA
tie fen..v Uses.orr.
Secuentasy Lin Conditions, N My.Leading To The Cause Listed On B• pan tort r an va OA /�7��/I�(._"'
✓ Ire A. Enter The Under/Ong Cause(Disease Or L-gry That Initiated
£ Tne Events Revili Li
gDeaJh)last C. GIRSON COUNTY AUDITOR
o.maid...p^ra.•e Op:
y D.
(c,:, Pad ll.Enter Omer Ssgndnnt fnnd:t4ne ferrna.'nd to Death But Na Res,Sang In The lkmdeRyirq Cause Given L Parr 29. Was An Autopsy Performed? 0 Yes 0 No
® 33.Were Autopsy Finding Available
ble To Coe The Cause Of Deem? Oyes 0 No
,V(
a. 31. DC iota=Use(.atidire To Dean? 32. If Female. 33. Ma:ner C.newt:
VannPont 0 4.a,44 At Pee ter. r 0'e'e,am r.Sie.Pre entvae n an IS Natural 0 Homicide 0 Anders 0 Penang tma om sga:i
'° ❑Yes 0 Probably UnknownNoUnknown ❑Net P,.>..e
.w ny..udon late,,end.teen
Oy. ❑vn.o.e 01e,.snen.Pwwee Me nor r.' 0 Suicide 0 Cart Na Be Determined
4i. 34. Date Of Injury(M.on.YDay(Year) 35. Time Of Injury 36- Place O:Iryvy(E.G.,Decedent rn s Hoe,Coosow,on Ste,Restaurant Wooded Area) 37-Irjsy At Work?
❑Yes 0 No
�44ffS.F
SWLazion Qlf{sy-Sa's 3Ba. City Or Town 38[. Street NumberSec. Apt,No. 3ed. Zip Code
4a
1` eOccurred39. Dezme Hair Lnjury Occurred IN. a-ao taDr-n Speb '❑
re 41. Signature, Of Person Ce^vying Cause Of Deaf 42. (Chet Center(Che Only One)
tr. (ERIC STEED JACKSON , BY ELECTRONIC SIGNATURE I 0 Certifying Physical 0 Coroner ,0 Heads Utter
/r'a 43. Name.Address And Zip Code Of Person Certytt Cane Of Death 44. license Nailer 45. Data Catted
tLI ERIC STEED JACKSON , 1033 MT. PLEASANT RD., EVA.NSVILLE. IN 47725 01047256A 11/13/2018
b 46. Additional Funeral Senice Provider. 47. 'Akers:
Nr 48. Signature of Local Hear Oftcer. 49. For Registrar Only -Date Fgo (MmsvDayfYea):
- BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE NOV 13 2018
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AMENDMENT TO CERTIFICATE OF DEAT.i(ENTRY OR ORIGINAL)
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tey State Fonn 53395 ATTENTION ESTATE:The Social Seamry a is being requested by this state agency in order to pursue reslaalsudlY. Disclosure is voluntary art Mere will bend peaty fcc rehJS.31.
.11"4T WARNING• ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER AND THEE GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT
TURNS FROM ORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCIJ 1ENT HAS A HIDDEN VOID ON FRONT THAT APPEARS WHEN PHOTOCOPIED.
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