Death Certificate - Clevenger, Susan_12/30/2019 ���"="ate. • , .INDIANA STATE DEPARTMENT OF HEALTH
I • CERTIFICATE OF DEATH
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i: ' Local No 002481 EDR No 000000746195 State No 059289 -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) ,
SUSAN ANN CLEVENGER CARROLL FEMALE 10:24 PM 12/02/2019
5. Social Security Number 8a.Age-Yrs Bb. Under 1 Year Sc. Under 1 Month,CARROLL
Under 1 Day 8e. Under 1 Hour 7.
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❑Yes ®No 0 Unknown ®I Inpatient ❑Hospice Facility ❑Decedent's Home ❑Nursing HomefLong-form Care Facility I
rip 0 Emergency Department Outpatient 0 Dead on Arrival ❑Other(Specify) SI
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11. Facility Name(II Not Institution.Give Street and Number) J)
DEACONESS HOSPITAL MIDTOWN ,,, ' . ?
12.City Or Twat,State,And Zip Code 1. P'' 13. Comity Of Death 14. Marital Status At Time Of Death 11
t]Married 0 Married,-But Separated 0 Divorced
EVANSVILLE, IN,47747 I VANDERBURGH ❑Widowed ❑Never Married ❑.unknown a
15. Surviving Spouse's Name . 15a.Last Name Before First Marriage 18. Decedent's Usual Occupation 17.Kind Or Business/Industry
BRENT CLEVENGER (
HOMEMAKER I. '�,':, '� HOME I
18. Residence-State 18a. County i 18b. City Or Town '''
INDIANA GIBSON -OWENSVILLE. " '' �",
18c. Street And Number 18d. ApL No. 18e. Zip Code 18f. Inside City Limits? r,
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101 EAST WOODBREE DRIVE 47665 I tEl Yes ❑No i
19. Decedent's Education 20. Decedent Of HispardcOrigin 21. Decedents Race 01,; • 'I
HIGH SCHOOL GRADUATE OR GED " I';i
COMPLETED NOT HISPANIC.. White `11,' '
22.Parent's Name(First,Middle,Last) 23.Parent's Name(First,Middle,Last) I "I_ 23a.Parent's Last Name Before First Marriage 1,
JOHN ORATIO CARROLL III NELLIE LAVELLE CARROLL JARED A
24.informant's Name • 24a.Rtl/tiotship To Decedent 24b.Mailing Address(Street And Number.City,State,Zip Code) .,
BRENT CLEVENGER HUSBAND 101 EAST WOODBREE DRIVE, OWENSVILLE, IN 47665 1
25.Place Of Disposition
25a Method Of Disposition 25b.Place Of Disposition(Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State
❑Burial ❑x Cremation ❑Donation 0 Entombment
❑Removal From State ,'I' '..' ,
❑Other(Specify): HALEY MCGINNIS CREMATORY OWENSBORO, KY 'I'II
28.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facilry I . 27a Funeral Home License Number
❑Yes ®No HOLDERS FUNERAL HOME,319 SOUTH MAIN STREET,OWENSVILLE, IN 47665 FH11700008 '
27b. Signature Of Indiana Funeral Service Licensee: .27c. License Number(Of Licensee): - 1
BRANDI MACER, BY ELECTRONIC SIGNATURE FD21400065
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Cause Of Death (See InsWe�■"auo,, pl „, ,I Approximate
'28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The De o t E er Te al v.. I Interval. Onset
;'Stich As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not evi ter Onl C r e To Death ,
A Line. Add Additional Lines If Necessary. ,
Immediate Cause(Final Disease Or Condition Resulting In Death) ' A. RESPIRATORY FAILURE , 1, • 4 DAYS
a....4 to m,o M A c^..m Om a
y B. CHRONIC OBSTRUCTIVE PULC�70HARY d� 19
SequentiallyList Conditions, If Any,LeadingTo The Cause Listed On 2 YEARS
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated o'43 iO"`"cm"P arsco
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The Events Resulting In Death)Last, C. I
1 I'. 1
aao an 1
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• D. GIBSON (� �,i N'�-A [��!
Part II_Ester Other Sloniricant Conditions Contributing to Dealt]But Not Restating In The,Undertying Cause Given In Part I '29.Was An AO lhaed? J
'I: 0 Yes Ia No Fr
NONE' r ,77
30.Were Autopsy Finding Availblego Complete The Cause Of Death? 0 Yes '❑No
31. Did Tobacco Use Contribute To Death? ,' 32. If Female: - 33. Manner Of Death: /'
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run P
®Yes ❑Probably 0 No 0 Unkrwvip ®norm R.pr.r.Here, .s :I Peers u Tr..a Ik.m CI httl Rap..(ma Pr.pn.A Nan.a.Da,.Of NV, El Natural❑Homicide 0 Accident ❑Pending Investigation
❑rim Rapture.W Pr.p,.v a bar.To i yes,Bata.Dear, ❑wm,o.+,a Prop./Al ww,TM P.a cur ❑Suicide 0 Could Not Be Determined ,' \i
34. Date Of Injury(Month/Day/Year) i 35. Time Of Injury 38. Place Of Injury(E.G.,Decedent's Home,Construction Site,Restaurant,Wooded Area) 37.,Injury,A!Work? J
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❑Yes ❑No
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38:Location Of Injury-Stale 38a. City Or Town 38b. Street 8 Number il,•�' 38c.Apt. 8d J,No. 3 . Zip Code
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39. Descnbe How Injury Occurred _ - 40. If Transportation Injury, edfy. J
❑m,.'opc.mr ❑Pa..rpr Pear ❑Oew lseeoryl J
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41. Signature,Of Person Certifying Cause Of Death.
JULIE A.BURKETT, BY ELECTRONIC SIGNATURE 42. Certifier(cn«konryone)
43. Name,Address And ZipCode Of Person Ceti Cause Of Death: �. i ®Certiying Ptrysician ❑Coroner ❑Hearth CerultOffir_e
Certifying 44. License Number. 45. Date Cenified
No
JULIE A.BURKETT 40 FLETCHALL ST., POSEYVILLE, IN 47633 _ 01077344A 12/05/2019
48.Additional Funeral Service Provider. '� • 47.'Pkes: :3
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48. Signature of Local Health Officer. • 49. For Registrar Only=Date Filed (Month/Day/Year):
ROBERT KENNETH SPEAR;VIA ELECTRONIC SIGNATURE DEC 05 2019 i
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) 1 'I' a
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Stale Form 53395 ATTENTION ESTATE:The Social Security S is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary and there will be no penalty for refusal
WARNING' ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT
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