Death Certificate - Wallace, Carl_11/20/2019 N,, ,�- . �,-.%i; .r.., , ;�INDiANA;STAT `':D,Et FtTMtNT-OEr'ry(EA�:T`( '' ----r1 I;a:_:: A := : !i1i :t, t,,r1
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L�. , ` 'CERTIFICATE CIF•2DEATH•$•-::.;-<' c; c: : ' .Z�z`.
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_y-, , ;Ta' : •: oc_I,nia;0004.•.- •• ` '• . �`ED�2 No OOOOOO5Z2356 '+�,.. State No 034531:` ,
)l'' 1 AecedentsLegalt)lame(First Middler•L st);ift�:l ,L• ;+." ,i, ta. MaidenNnthe(If female), ff ,i 2''Se i.,1!Sr meOf,Death: 41'DatgCfOeattt. n1h/Da NNear
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r ..r•:` II. A� em ' r f 'F'n-a;I :i �I f % • '''::'
,,, .CA$L OtVIER`V A'U ACE .. - ' "! °^`a' '". MALE _03 010 AM'> =�i 07/'6/2O16 -•
I i 5. Social Security Number 6a.Age Yrg 6b. Under 1;Year 6c. Under 1 Montb 6d Under 1 Day ` 6e Under 1,Hou7„`7.:Date of-Birth (Month/Day/Year): S.Birthplace(City and'State orForeign Couritry)%
, ' ' >' 69 tanners Days Hours Minutes"; . \ , PRINCETON IN
1 .9. Ever in U.S.Armed Forces? 10 If Death Occurred In A Hospital: f: - 10a if Death Occurred Somewhere Other Than A Hospital - •, ,
• � '' ���� :�- •-, ‹,.;. .- 0 Hq;p`ce Faculty 0 Decedents Name ,`❑Nursing Home/Lorig-tern Care Facility ",, �
®Yes 0 No 0 Unknown In atient9 Y P tP 0 Dead o mval, `
�., ® p 0 Emer enc'De artment Ou alien.: R. ❑oth:•C 1'eafy)
• '1 1. Facility Name(If Not Institution'Give Street and Numberr-) '- ,� ,/ _
DEACONESS GATEWAY- ;
.,r . 12.City Or Town,State;And Zip Code , • 13.,Dounty Of Death � 14. Marital Status At Time Of Death -
/ ' .' 0 Married 0 Manied,'But Separated'-❑Divorced
NEWBURGH,'IN,47630 • Widowed
r " "-„ „-''''',,, WARR CK ❑ .Never Married, 0 Unknown
I:• 15. Surviving Spouse's Name 15a. (If Wife)Give.Maiden Last Name , 16. Decedent's Usual Occupation 17.Kind Of Business/Industry ,
k PATSY WALLACE MAHAN - '` RAILROAD WORKER , , RAILROAD",,.. '
+ -. 18.•Residence,=State; - 18a.County
�,.-. •
ty - //•' r 18b.City Or'Town
,it 'INDIANA,, _ GIBSON' , • , ;(,>. PRINCETON •r','' '., , '. • '
s 18c.-Street And Number • , ..- / c e • -'. Inni`
jr� ;' - - 3/ 10d.,A 1.No.' • \'18e.Ti •
ft� `�� �� P p Code 48t Inside City Limits?
1 3857 EAST 100 NORTH ❑Yes ❑No
• , •47670 . .
r 19:Decedent's Education- ;' ' • '• 20. Decedent Of Hispanic Origin.; .' s 2,1. Decedents Race;
l 'HIGH SCHOOL-GRADUATE OR GED ., ,l
' COMPLETED"; • NOT HISPANIC ' �. White
•i 22.Father's Name(First,Middle,Last) ,'" '23,Mother's Name-(First;Middle,Last) 23a.Mother's Maiden Last Name
WI'
`5.4' .: BOB WALLACE: : - f ' BEULAH WALLACE \ , WILLIAM'S / : I
' 24.•Infomtant's Name, 24a.Relationship To Decedent ' ,,,/ 24b.Mailing Address,(StreetAnd Number,City,State,Zip Code) ,! '
CI ,' PATSY:WALLACE :" '-', . v' , ' ` - WIFE ~ `- 3857 EAST'100;NORTH,PRINCETON, IN 47670 .
' " ;25"Place•Of Disposition ''"
•
cn ' 25a.Method Of Disposition - ; ; ; 25b.Place Of Disposition,(Name Of Cemetery,Crematory,Other Place) ,25c.Location=.City,Town,And State \
0 CC Burial'❑Cremation 0 Donation,0 Entombment ',
W - ❑Removal From State . - .: -,/ • -
CC ❑Other(Specify): ,, '. . FAIRVIEW CEMETERY:' PRINCETON, IN , ,
0 :'..26.Was Coroner Contacted? -• , 27. Name And Complete Address Of Funeral Facility /'' ,,, " \27a. uneral Home License Number:
❑Yes ®No
W COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 4767► ' ; FH830 67.1 .
CC _' 27b.`Signature Of Indiana Funeral Serylce Licensee:; , - . • , . 27c. License Number(Of Licensee): <
W JOHN W WELLS , BY ELECTRONIC SIGNATURE ' - ' ' FD01009940 '
J Cause Of Death(See Instructions And Examples)' •, , Approximate -r'
Q 28 Part'I.Enter The Chain Of Events'-Diseases,Injuries;Or Complications-That Directly Caused The:Death.DUNotEnte�Term' al Events T Interval; Onset
LL Such As,Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate,Enter On One Cause I To Death
- - A Line. Add Additional Lines If Necessary. \ "•,'
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.. Immediate Cause(Final bisease Or Condition Resulting In Death) A. 'SEPTIC SHOCK - ' % : '
0 ,r : ' ' . . : , F .. ,o • ,i :,j s' ;ou.+o aA.acoraom,enoeorl" 'I
> - NOV-. :2,0 2019
-'t Sequentially List Conditions,If Any;Leading To The Cause Listed On , B. SPONTANEOUS BACTERIAL PERITONITI• . '
);>r Line A. Enter The Underlying Cause(Disease Or Injury That Initiated' `. i' • to egconsew�eop:
The Events Resulting In Death)Last '
C. CIRRHOSIS OF-LIVER' . - . l
)e % D•t le A.ADonepuanu 0o `
D. END STAGE RENAL DISEASE GIBBON COUNTY AU OR•,-, Part II.Enter Other Significant Conditions Contributing to Death But Not Resulting In The Underlying,Cause•Given In Part I - 29. -An Autopsy Performed? • ' -' ; ; • -'•'
o
' ' •'.'' ./''.. 30.'Were topsy Finding Available To Complet❑Ye e Cause Of Death? `O Yes:>❑No••'.
' CARDIOMYOPATHY - _ ,, , l
3•1. Did Tobacco Use Contribute To Death? , 32. If Female:, - ' '-' - i i,. ',, ,• , eath: = •, - -'
•❑rmt Prevnent wman Past Year ❑Payn.ntAt i.ne oroo.tn'JD rb+Pregn•nt,eut Praon:dtvrmm�42 Daroo10.S El Natural'❑.Homicide•❑Accident El'Pending Investigation
❑Yes ❑Probably®No ❑Unknown -
❑NclPrepnaM But PregnentA]Ory•I;lyurBe+aiDe•N ;❑`Unfro..4+PdpruntWW1.Tile Past Yur ; 0 Sulfide,❑Could Not BeDetennined `
O. 34. Date Of Injury(MonthlDay/Year) - 35.Time Of Injury 36.Place Of Injury(E.G.,Decedent's Honie,,Construction Site,Restaurant,Wooded Area) 37. Injury At Work? •
;`
X •El Yes • ''❑No
' 38. Location Of Injury-.State . ,38a.'City'Or Town' £ •,,38b..Street,8 Number • , 38c.Apt.No. 38d.Zip Code-;' ,
39, Describe How Injury Occurred • ' ' , i - 40. If Transportation Injury,S cify: '
1y' - .� • // ❑omedOPa•b ❑P.amnp.r Uw.ewn ❑om.r(SP.r ry)
41. Signature,,Of Person Certifying Cause Of Death: _ ,
4,;( • 42. Certer(Check Only One) ,
REKHA'TUMMALA BY ELECTRONIC SIGNATURE '`N ' - - . ®Certifying Physician ❑Coroner - ❑Health Officer
., 43. Name;Address And Zip'Code Of Person Certifying Cause OfDeath: . . , 44. License Number ' 45. Date Certified ,
,,, ,REKHA TUMMALA ,600,MARY STREET, EVANSVILLE, IN 47710.,.>-' .- 01060018A ' 07/26/2616„,
46„A,dditional Funeral,Sevice peovider. ,. ' ,,._ ;,, •;%r 47.•Akas ,
48.Stgnatureof Local Health'Officer . :•''`„ , % - 49;.For Registrar Only -Date Filed(Month/Day/Year) ,
(' i RICKYB YEAGER',VIA ELECTRONIC SIGNATURE . •t JUL,. 26 2016 . ,
L j / AMENDMENT TO;CERTIFICATE OFDEATH(ENTJtY OR-ORIGINAL) • ,y
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X 'Stdte'Form' •5„ �'' Q -. ,.
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