Death Certificate - Whitehead, Larry_11/7/2019 �,rn•.au -V v- ,c...71., - - ,c.eav _ •rf amr -.7 y: me5w ,' - - e. -WINr- --11P r\S VIVA. �Ti►`!y-111a1Sr-.-. 17c
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,- . INDIANA STATE DEPARTMENT OF HEALTH
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►' 14, - ii= CERTIFICATE OF DEATH
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'' /', Local No 000573 EDR No 000'00'0725768 • state No 041281
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)
LARRY LEE WHITEHEAD MALE 03:35 PM 08/08/2019
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)
4� 72 Months Days Hours Minutes
WASHINGTON, IN
9. Ever in U,S.Armed Forces? 10.If Death Occurred In A Hospital: 10a.'If Death Occurred Somewhere Other Than A Hospital
F���: _ ❑Hospice Facility 0 Decedent's Home ❑Nursing Home/Long-term Care Facility
@� ' ❑Yes.®No ❑Unknown ®Inpatient 0 Emergency Department Outpatient ❑Dead on Arrival' ❑"Other(Specify)- _
11. Facility Name(II Not Institution,Give Street and Number) , ' " ,
,,, DEACONESS GATEWAY •
4 12. City Or Town,State,And Zip Code 13. County Of Death 14. Marital Status At Time Of Death
ElMarred❑Married,But Separated 0 Divorced
tp NEWBURGH, IN,47630 WARRICK ❑Wdowed 0 Never Married 0 Unknown
pc 15. Surviving Spouse's Name 15a.Last Name Before First Marriage 16. Decedent's Usual Occupation 17. Kind Of Business/Industry
,/4 PAULA WHITEHEAD MARVELL TRUCK DRIVER CSX RAILROAD
181I Residence-State . 18a. County 18b. City Or Town '
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INDIANA' PIKE PETERSBURG ' ,
p,418c,Street And Number 18d. Apt No. 18e. Zip Code 18f. Inside City Limits?
►I� 2909 NORTH STATE ROAD 57 47567 El Yes ®No
19. Decedent's Education 20. Decedent Of Hispanic Origin 21, Decedent's Race
� HIGH SCHOOL GRADUATE OR GED
IF COMPLETED NOT HISPANIC White
22.Parent's Name(First,Middle,Last) 23.Parent's Name(First,Middle,Last) 23a.Parent's Last Name Before First Marriage
'tit ORAL RICHARD WHITEHEAD LORRAYNE PERRY WHEATLEY
0 24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address(Street And Number,City,State,Zip Code)
W
U) PAULA WHITEHEAD WIFE 2909 NORTH STATE ROAD 57, PETERSBURG, IN 47567
CC 25.Place Of Disposition V
W 25a.Method Of Disposition 25b.Place Of Disposition (Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State
®Burial 0 Cremation 0 Donation❑Entombment
O0 Removal From State
0 Other(Specify): OAK HILL CEMETERY PATOKA, IN .
0 26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility 27a. Funeral Home License Number
W
EC 0 Yes 0 No
W O.D. HARRIS&SONS FUNERAL HOME,705 E.WALNUT, PETERSBURG, IN 47567 FH83005524
J27b. Signature Of Indiana Funeral Service Licensee: 27c. License Number(Of Licensee):
Q NICHOLAS HARRIS HENSON , BY ELECTRONIC SIGNATURE FD21300061 .-
lL Cause Of Death (See Instructions And Examples) Approximate
- 28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset
0 Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
O A Line. Add Additional Lines If Necessary.
> Immediate Cause(Final Disease Or Condition Resulting In Death) A. ANOXIC BRAIN INJURY WITH DIFFUSE CEREBRAL EDEMA 1 DAY
Due to or M A consequence oil
Sequentially List Conditions, If Any,Leading To The Cause Listed On B. CARDIAC ARREST 1 DAY
iii Line A."Enter The Underlying Cause(Disease Or Injury That Initiated Due to(a A•n cen:eauon«on:
it The Events Resulting In Death)Last C. ACUTE MYOCARDIAL INFARCTION 1 DAY
Due to(Or Ae A Consequence r):
01
0.J D. PROBABLE ACUTE THRO OSIS OF NEW CORONARY S : NT 1 DAY
/�V Part II.Enter Other Significant Conditions Contributing to Death But Not Resulting In The Underlying Cause Given In`art I 29. Was An Autopsy Performed? • yes ®No
rrr ACUTE PULMONARY EDEMA,LACTIC ACIDOSIS,SUBARACHNOID HEMORRHAGE,HYPOTENSIO•,ACUTE �ppp,We • sy red, Available To Compl to The Cause Of Death?
`\� KIDNEY INJURY,TOBACCO USE DISORDERa F
❑Yes ❑No
31. Did Tobacco Use Contribute To Death? 32. If Female: Manner Of Death.
❑Not Pregnant WoNn Past Year ❑Pregnant At Thee Of Deet ❑Nct Pt Pr O wn 4 Da I Natural❑Homi de ❑Accident ❑Pending Investigation
1` ®Yes ❑Probably❑No ❑Unknown
F: ❑Not Pregnant.BW Pregnant 43 Days To 1 year Before Death ❑wwrnan WMm TM Past Year ❑Suicide❑Coul.Not Be Determined
34. Date Of Injury(Month/Day/Year) 35. Time Of Injury 36. -lace Of Injury(E.G.,Decedent's Home,Construction Site,Restaurant, ..ded Area) 37. Injury At Work?cf NOV 0 7 2019 ❑Yes ❑No
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. 38. Location Of Injury-State 38a. City Or Town 38,. Street 8.Number 38c.Apt.No. ' 38d. Zip Code .
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7 39. Describe How Injury Occurred sg A 0 jurp4I a p cation
I jur , ec emn El Other(Specify)
"�� PARSON COUNTY
41, Signature,Of Person Certifying Cause Of Death: 42.Certifier(Ch'.1 Only On
KURT DONALD BOTTLES, BY ELECTRONIC SIGNATURE Ie)Ei Certifying ysician Coroner
fy g' ❑ ❑Health Officer
43. Name,Address And Zip Code Of Person Certifying Cause Of Death: 44. License Number 45. Date Certified
lr KURT,DONALD BOTTLES ,600 MARY STREET, EVANSVILLE, IN 47747 01036958A 08/25/2019
48.Additional Funeral Service Provider. 47. 'Akas:
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48. Signature of Local Health Officer. 49. For Registrar Only -Date Filed (Month/Day/Year):
RICKY B YEAGER,VIA ELECTRONIC SIGNATURE AUG 26 2019
pP?(/d, AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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i 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.. TTURNIS FROMOORANGE TO YELLOW WHEN RUBBED.ORIGINALL DOCUME HATS A HIDDE VO DPON FRONT THAT APPEARS W NE HOTOCO PIIED.ANA ON BACK THAT