Death Certificate - Waite, Nancy_10/16/2019 • v "•.. INDIANA STATE DEPARTMENT OF HEALTH
t, CERTIFICATE OF DEATH
Local No 000157 EDR No 000000736032 State No 049884 ��
,.� 1.Decedents Legal Name(First,Middle,Last) 1a. Maiden Name (If female) 2.Sex 3. Time Of Death 4_ Date Of Death (Month/Day/Year)
rNANCY J WAITE TREVIS FEMALE 03:32 AM 10/10/2019
o5. 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)
1.1 72 Months Days Hours Minutes TOLEDO, OH
9. Ever in U.S.Armed Forces? 10.If Death Occurred In A Hospital. 10a If Death Occurred Somewhere Other Than A Hospital
❑ Hospice Facility ® Decedent's Home 0 Nursing Home/Long-term Care Facility
❑ Yes ® No ❑ Unknown ❑ Inpatient❑ Emergency Department Outpatient ❑ Dead on Arrival ❑ Other(Specify)
s 11. Facility Name (If Not Institution,Give Street and Number)
12917 SOUTH SCOTTSDALE DRIVE
12. City Or Town,State,And Zip Code 13 County Of Death 14 Marital Status At Time Of Death
viV
ril
ri Gil Married Married,But Separated ❑ Divorced
HAUBSTADT, IN,47639 GIBBON ❑ VNdowed El Never Married ❑ unknown
15. Surviving Spouse's Name 15a.LastOrigin Name Before First Marriage 16. Decedents Usual Occupation 17. Kind Of Business/Industry
1 PATRICK Ja WAITE
COSMETOLOGIST BEAUTY CARE
18. Residence-State 18a. County 18b. City Or Town
INDIANA GIBBON HAUBSTADT
18c. Street And Number. 18d. Apt.No. 18e. Zip Code 18f. Inside City Limits?
. 12917 SOUTH SCOTTSDALE DRIVE
❑ Yes ® No
47639
19. Decedents Education 20. Decedent Of Hispanic 21. Decedent's Race
. HIGH SCHOOL GRADUATE OR GED
a COMPLETED NOT HISPANIC White
i( 22.Parents Name(First,Middle,Last) 23.Parents Name(First,Middle,Last) 23a.Parent's Last Name Before First Mamage
GERALD TREVIS MILDRED TREVIS WHITE
f i 24.Informant's Name 24a Relationship To Decedent 24b.Mailing Address (Street And Number,City,State,Zip Code)
CI
W N PATRICK WAITE HUSBAND 12917 SOUTH SCOTTSDALE DRIVE, HAUBSTADT, IN 47639
Q 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
111 0 Burial 0 Cremation 0 Donation 0 Entombment
Cr ® Removal From State OTTAWA HILLS MEMORIAL PARK
O 0 Other(Specify) CEMETERY TOLEDO, OH
Q 26.Was Coroner Contacted'? 27 Name And Complete Address Of Funeral Facility 27a. Funeral Home License Number
ILI
® Yes ❑ No
W WADE FUNERAL HOME INC, 119 S. VINE STREET, HAUBSTADT, IN 47639 FH83002990
27b. Signature Of Indiana Funeral Service Licensee: 27c. License Number(Of Licensee):
J ALAN J. WADE , BY ELECTRONIC SIGNATURE FD01017080
Q Cause Of Death (See Instructions And Examples) Approximate
LL 28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events T T Interval: Onset
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause To Death
A Line. Add Additional Lines If Necessary.
O Immediate Cause(Final Disease Or Condition Resulting In Death) A. MALIGNANT NEOPLASM OF UNSPECIFIED OVARY YEARS
> Due to(Or As A Consequence On
� Sequentially List Conditions, If Any,Leading To The Cause Listed On B O C T 16 2019
i Line A. Enter The Underlying Cause(Disease Or Injury That Initiated Due to AaA censeque oa OQ
The Events Resulting In Death)Last C
Due to(Or As A Consequence Or). l 19-J
D. r r ua
ds>JQ 6 Yes g 1G R
Part II Enter Other$jgnificant Conditions Contributing to Death But Not Resulting In The Underlying Cause Given In Part I 29. Was An Auto CO UN Y AiJ fJ
OLD MYOCARDIAL INFARCTION,TYPE 2 DIABETES MELLITUS,ARTHROPATHY 30.
Were Autopsy Finding Available To Complete The Cause Of Death? ❑ Yes ❑ No
f' 31. Did Tobacco Use Contribute To Death? 32. If Female: 33. Manner Of Death:
•
® Not Pregnant Wallin Pest Year 0 Pregnant Al Tune Of Nett) 0 Not Pregnant,But Pregnant Within 42 Days Of Death ® Natural❑ Homicide ❑ Accident ❑ Pending Investigation
❑ Yes 0 Probably 0 No ® Unknown
O Not Pregnant,But Pregnant A.Days To 1 year Before Death 0 Unknown If Pregnant we,,r The Pest Year ❑ Suicide❑ Could Not Be Determined
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?
❑ Yes ❑ No
r
t 38. Location Of Injury-State 38a. City Or Town 38b. Street 8 Number 38c. Apt.No. 38d. Zip Code
I
41i 39. Describe How Injury Occurred ��yn. If Trans�r�r��'�tg)ion Injury,r�c{pecify.
is,,ll Li Drnarropenror L i Paaanger L i Pebalrun 0 oe.,(SPeci0Y1
'
r 41 Signature, Of Person Certifying Cause Of Death 42 Certifier(Check Only One)
DONALD RUDOLPH BRAKE JR, BY ELECTRONIC SIGNATURE ® Certifying Physiaan ❑ coroner ❑ Health Officer
,, ` 43. Name,Address And Zip Code Of Person Certifying Cause Of Death 144. License Number 45. Date Certified
$f,
1jj DONALD RUDOLPH BRAKE JR, 1146 A WASHINGTON SQUARE, EVANSVILLE, IN 47715 01042288A 10/14/2019
j 46. Additional Funeral Service Provider 47. 'Akan.
r 48 Signature of Local Health Officer. I i 49 For Registrar Only -Date Filed (Month/Day/Year).
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE OCT 15 2019
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
0c_ l co -- Doo . ---1 qq-Ca
State 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.
� , WARNING- OURNS FR M 0 ANGE TO YELLOW WHEON RUBBED.ORIG NDALL DOCUMEN HHAS A H DDEN VOID ON FRONT T ATEAP EARS WH NE HOTOCOOPIIEDIANA ON BACK THAT