Death Certificate - Catt, James E_10/7/2019 ,> �"` a INDIANA STATE DEPARTMENT OF HEALTH
l � s `t CERTIFICATE OF DEATH
0
\Z.... a' Local No.000348 EDR No 000000731889 ' state No 045079
l-' 1.Decedent's Legal Name(First,Middle,Last) la. Maiden Name(If female) - 2.Sex 3. Time Of Death 4. Date Of Death(Month/Day/Year)
JAMES E CATT MALE 12:12 PM • 09/15/2019
%•, 5.Social Security Number 6a.Age-Yrs 6b. Under 1 Year 6c. Under 1 Month-6d. Under 1 Day 6e. Under 1 Hour '7. Date of Birth (Month/Day/Year) 8.Birthplace (City and State or Foreign Country)
r,t1
-! 82 Months Days Hours Minutes
Hospital
Hospice Facility ID Decedent's Home ❑Nursing Home/Longterm Care Facility,
. ❑Yes E No ❑Unknown E Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival
❑❑Other(Specify) ,
y‘, 11. Facility Name(If Not Institution,Give Street and Number) '
GOOD SAMARITAN HOSPITAL
12. City Or Town,State,And Zip Code 13. CountyDeathTime Of 14. Marital Status At Of Death
6- ®Married 0 Married,But Separated ❑Divorced
lf,,-; VINCENNES, IN,47591 KNOX 0 Wdowed D Never Married ❑Unknown
Frr- 15. Surviving Spouse's Name 15a.Last Name Before First Marriage 16. Decedent's Usual Occupation 17. Kind Of Business/Industry
C.• SUE GATT KIRK FARMER AGRICULTURE
'� 18. Residence-State 18a. County 18b. City Or Town
INDIANA GIBSON . • HAZLETON •
Lt.- 18c. Street And Number 181 ApL No. 18e. Zip Code 18f. Inside City Limits?
IA'
l( 204 KENTUCKY STREET 47640 IDYes 0 No
19. Decedent's Education r 20. Decedent Of Hispanic Origin 21. Decedent's Race
HIGH SCHOOL GRADUATE OR GED
' COMPLETED NOT HISPANIC White
L,. ' 22.Parent's Name First,Middle,Last)( 23.Parent's Name(First,Middle,Last) 23a.Parent's Last Name Before First Marriage
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ON
MAURICE CATT LOUISE CATT ROSS
is24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address (Street And Number,City,State,Zip Code)
SUE CATT WIFE ' 204 KENTUCKY STREET, HAZLETON, IN 47640
25.Place Of Disposition
cc 25a.Method Of Disposition 25b.Place Of Disposition (Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State
UJ 0 Burial E Cremation 0 Donation❑Entombment i
Cc ❑Removal From State
O ❑Other(Specify): EVANSVILLE CREMATORY EVANSVILLE, IN
Q 26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility e. Funeral Home License Number:
III A
0 Yes E No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FF�83095671 %
W 27b. Signature Of Indiana Funeral Service Licensee: 27c. License Numb Of Licensee): .1
J MARK R.WALTER, BY ELECTRONIC SIGNATURE FD01013010 L.\ J\,) COF`
Q Cause Of Death (See Instructions And Examples) O wt.LL 28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events r1Tal: Onset
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On ,c..-Co Death
13 A Line. Add Additional Lines If Necessary.
0 Immediate Cause(Final Disease Or Condition Resulting In Death) A. ACUTE HYPDXIC RESPIRATORY FAILURE �GO 2WEEKS
Due to(Or As A consequence Op: 0
Sequentially List Conditions, If Any,Leading To The Cause Listed On B. RAPID ATRIAL FIBRILLATION \_:, 1 WEEK
Pr Line A. Enter The Underlying Cause(Disease Or Injury That Initiated Dua to(Or AsA Consequence Oq'.
j'+1 The Events Resulting In Death)Last C. URINARY INFECTION WITH SEPSIS 1WEEK
Doe to(Or as A consequence Of):
P?/ D. WORSENING ANEMIA 10DAYS
,e` Part II.Enter Other Significant Conditions Contributing to Death But Not Resulting In The Underlying Cause Given In Part I 29. Was An Autopsy Performed? •❑Yes E No
E.r PROSTATE CANCER WITH DIFFUSE BONE METASTASES 30. Were Autopsy Finding Available To Complete The Cause Of Death? ❑Yes 0 No
)i;�, 31. Did Tobacco Use Contribute To Death? 32. If Female: 33. Manner Of Death:
",.� 0 Not Pregnant vwtivn Past Year ❑Pregnant AlTone Of Death ❑Not Pregnant.But Pregnant Vahan 42 Days Of Death E Natural❑Homicide El Accident 0 Pending Investigation
�.- ❑Yes 0 Probably 0 No ®Unknown
W. ❑Not Pregnant.But Pregnant 43 Days To 1 year Before Death ❑Unknown If Pregnant Wusn Tho Past Year ❑Suicide❑Could Not Be Determined
j[i:.. 34. Date Of Injury(Month/Day/Year) 35.Time Of Injury 36. Place Of Injury(E.G.,Decedent's Home,Construction Site,Restaurant,Wooded Area) 37. Injury At Work?
k ❑Yes ❑No
38. Location Of Injury-State 38a. City Or Town 38b. Street 8 Number 38c.ApL No. 38d. Zip Code
-( I
N39. Describe How Injury Occurred 40. If Transportation Injury,S ecify:
Lt.,' ❑ n DrIverfOpebr ❑ v Paenger DPeoY. san['Ogler(Speedy)
I
tP _ 41.Signature,Of Person Certifying Cause Of Death: 42. Certifier(Check Only One)
ik GERRY M. HIPPENSTEEL,.BY ELECTRONIC SIGNATURE E Certifying Physician 0 Coroner 0 Health Officer
g: 43. Name,Address And Zip Code Of Person Certifying Cause Of Death: 44. License Number 45. Date Certified
,�fGERRY M. HIPPENSTEEL ,406 NORTH FIRST STREET,VINCENNES, IN 47591 01025674A 09/17/2019
f¢¢Er-, 46.Additional Funeral Service Provider. 47. •'Akas:
E) 48. Signature of Lot.al Health Officer: 49. For Registrar Only -Date Filed (Month/Day/Year):
ALAN D. STEWART,VIA ELECTRONIC SIGNATURE SEP 17 2019
LW. AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
6�r 0a �a OOW• alb' 01q
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yState Form 53395 ATTENTION ESTATE:The Social Security#is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary and there will be no penalty for refusal.
fvtiORIGINAL DOCUMENT HAS A i, WARNING. TURNS FROM ORANGE TO YELLOW WHEN RDUBBED.ORIGINAL DOCUMENT AS A H PAPER O INDIANA IDDE VO DON FRONT THAT A PEARS W EN HOTOC PIED ON BACK THAT