Death Certificate - Green, Jerry_1/9/2020 . . • •- -
• • -
•
tr - -&''7:-.'"A° - _ . INDIANA STATE DEPARTMENT-OF.HEALTH . . . .
• . •
• • •
C .
.,.
e,.. . . i,,! :,-.Lif . . . .
.CERTIF1CA7pE DEATH - - • - .
. I
0 . - ...-. ..4
ATTENTION The •
ESTATE: e 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.e.• - - . . ..
Local No 0001981- .-•-.EDR No .. ,_ , ..
000000749739.-.:-_' . „•_. State NO_
. .
1.Decadent s Legal Name(First',wile,Last) ".• ' .: - '• ' ; 1a..Maiden Name (If female) - • ---g.Sex 3."Time Of Death 4 Date Of Death(Month/Day/Year)
it JERRY ELSWORTH GREEN " . • , •: , .MALE • 06:30 AM ' '
07 5. Social Security Number 6a.Age-Yrs 6b. Under 1 Year 6c. Under 1 Month"64. Under 1 Day ' Be. Under 1 Hour 7. Date
MOUNT VERNON, IN
9. Ever in U.S.Armed Forces? 10.If Death Occurred In&Hospital: 10a. If Death Occurred Somewhere Other Than A Hospital •
--
• . 0 Hospice Facility El Decedent's Home-. 0 Nursing Home/Long-term Care Facility
0 Yes 01 NO El'Unknown I j-Inbatient 0 Emergency Department Outpatient 0 Dead on Arrival ID
. . . .
11. Facility Name,(1f Not Institution,Give Street and Number) , ". ...
. . . .
V. •. 2802 SOUTH 650 EAST . -, , ._ __ . .
. , , . . .. . • . . ...
.
.
Iv. 12. City Or Town:State,And Zip Code , • - CountyDeath• 13. Of - .
. , 14. Marital Status At Tim Of e Death _
l'-- . • - , 181 Married 0 Married,But Separated 0 Divorced
4. FRANCISCO, IN,47649 . • GIBSON ' -o Widowed 0 Never Manied 0 Unknown
15. Surviving Spouses Name 15a. (If Wfe)Give Maiden Last Name 16. Decedent's Usual Occupation. . 17. Kind Of Business/Industry
MARY ELLEN GREEN .. 7 RUMBLE . . . TOOL AND DIE MAKER :. MANUFACTURING
4k 18; Residence••State ';' 18a. County • 18b. City Or Town
r 'll ' - ... .
.
4 ' I I'l - ' . . - , " • ' : ' . ' ••
OP - INDIANA . -• -, . • '. '•: GIBSON- - ' ' FRANCISCO
.. .. • ,
. . . . ,
Vk 18c. Street And Number -' -18d. Apt.No. 18e. Zip Code 18f. Inside City Limits?
,F4k
1;"'„.• ' . ,
. ; -. „. •t. - ' • , , • - .
. 0 Yes 0 No
2802 SOUTH 650 EAST ' - , .
. . • .. • .
, , .- • • .. , 47649
41. 19.:Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedents Race - -
.
HIGH SCHOOL GRADUATE OR GED - , ,
• l . , ' - - -
M.. COMPLETED NOT HISPANIC . _ WHITE , . • . .
, . . .
. .
.22.Father's Name(First Middle,-Last) ; 23.-Mothers Name(First,Middle,Last) , , , 23a.Mother's Maiden Last Name •0"• . . . .
,(-• ' . .
. . .
CLYDUS MALCOLM GREEN ..
. • ANNA ALICE GREEN • . BURTON
•.
0 , 24.Informant's Name • . „
' ' 24a.Relationship To Decedent , 24b.Mailing Address(Street. And Number,City,State,Zip Code).-• ;,
. ,
c MARY ELLEN GREEN - , VVIFE .
2802 SOUTH 650 EAST, i=tANCISCO, IN 47649 n • •_
< . .• . , . - • ..
. : 25.Flake Of DiSpOsition - . . . . . -
CC 25a.Method Of Disposition . 25b.Place Of Disposition (Name Of Cemetery,Crematory,Other Place) 25c.Location,City,Town,And State
. ,
LU 0 Burial 14 Cremation 0 Donation 0 Entombment, " ' . • '
, .
. .
. .'
CC 0-Removal From State . .
• ' .
. .
O 0 Other(Specify): - ": ' EVANSVILLE CREMATORY • - EVANSVILLE, IN..
• .. .
a , .26.Was Coroner.Contacted? , 27.,Name And Complete Address Of Funeral Facility . . , 27a. Funeral Home License Number
.
-
. . . .
, . , • . •x , El Yes RI No . , . .
. .
-
W • ' ," COLVIN.FUNERAL HOME INC,425 N MAIN ST., PRINCETON;IN 47670 _. FH83005671 - ‘-.•
27b. Signature Of Indiana Funeral Service Licensee:
. . 27c. License (Of Licensee):Number censee):
--I RICHARD DEAN HICKROD, BY-ELECTRONIC SIGNATURE . .
- .
FD01012153
. . • Cause Of Death (See Instructions And Examples) . - I t • , . - •
LL 28.i'arfl.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal EVents , , - Approximate
' Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Shbwing The Etiology.Do Not Abbreviate.Enter Only One Cause On , - . . -.. • ' --Interval: Onset
1-, ii •
A Line. Add Additinal Lines If Necessary. , . - To Death '
o .
> Immediate Cause(Final Disease Or Condition Resulting In Death) A. ACUTE MYOCARDIAL INFARCTION • I
Dr (Or!.AConsegJence C1): - 4 HOURS
• B. CORONARY ARTERY DISEASE. . • . • YEARS
• Sequentially List Conditions If Any,Leading Tome Cause Listed On
Due to(Or As A Corsequenoe 01): .
rcl 'Line A. Enter The Underlying Cause(Disease Or Injury That Initiated . '
V-
ow, The Events Resulting In Death)Ifast C. .
- . , . Due to(Or MA Consequenoe 00:
0 ' 1 • . . ,.,, • . .iL/Li - '''' " . . ' D.- .
. • • .
Part II.Enter Other Significant Conditions Contributing to Death'But Not Resulting In The Underlying Cause Givin In Part I •. 29. Was An Autc/ rme fres 0 No
CHRONIC KIDNEY DISEASE, HYPERTENSION, CHRONIC ANEMIA . 30.Were u Ps ind g Aveil' o C•i' -2, e Cause Of Death? ,-,
i-i Yes D No
la;
31. Did Tobacco Use Contribute To Death? . ., 32. If Female: •
• .
. - • - .
•,., iI •0 Not Pregnant t'Attlin Pad Veer 0.piegrirmt Al Tette Of Death 0 Not Ptegnant,But Pregnant W01942 cap or Death El Nabiral 0 Homicide 0 Accident lfl Pending Investigation
6,( 0 Yes 0 Probably 0 No I-1.Unknown •a, I 0 Not Pregnant But Pregnant 43 Days To 1 year Before Death . 0 Unknown!,Pregnant*in 1111 Past Year Elripliiiidtald Not Be Determined
6,......-- '34.:Date Of Injury(Month/Day/Year);', 35.Time Of Injury - 36. Place Of Injury(E.G.,Deceden't Home,Cons9( Sla Pes coded Area) 37. Injury At Work?
. .
. - I. - ' 0 Yes El No•: . . .
._ .
io-r•N: r 38. Location Of Injury-State i 38a. City Or Town ' . 38b. Street&Number • • '• •. ' C.Apt.No. 38d. Zip Code
iDiTnR
. . .
'1,i,,,,, .... . • -
. - •
39. Describe How Injury Occurred ' • . ; g5. ii...nsporla,tiOn Injuiypeciy.
DrIveripperator Li Passenger U Pedselrlan 0 Other(Specify)
I . , •
'
N.
p41.Signature, Of Person Certifying F.Js?Of Nat1:1!'., • ' ' , , 42. Certifier(Check Only One)
- GIBSON
. . ..
4e;-;\•' ' CHRISTOPHER ALAN WOOD,BY ELECTRONIC SIGNATURE . , -0 Certifying Physician • 0 Coroner 0 Heath Officer
t .43. Name,Address And Zip Code Of Person Certifying Cause Of Death: - I . . . . 44. License-Number 45. Date Certified
4 ' • I .
. -
6
irit 1 • . ,CHRISTOPHER ALAN WOOD ,900 TUTOR LANE,SUITE 102, EVANSVILLE, IN 47715 . . , _
Officer 46.Additional Funeral Service Proitrder.
. •
:
.i..).. Health , •
.
• BRUCE BRINK JR,BY ELECTRONIC SIGNATURE
=7, '
......
0 .
. II ,
_ . ..
„ . . . .
.
. -
_'. . . ..
. AMENDMENT TO CERT1FPATE OF DEATH(ENTRY OR
.. - 01044025A
• - .47:.-Akas:
48.Signature of Loal
,911.149G.INFAorLR:g.istrd.r 0.nrly -Date Filed (Month/Day/Year):
- 'DEC 31 2019 •
„ , , .
,.
12/31/2O19
I '
I
.--:,•2__q ..--. \ o0 -090 -2„)./0-0.0 \ ; . - -_ . .- • .-... , • ,
. . ,
• ,. . . .
.. . - ...
. . , . .
, • ,_ . ,
State Form 10110 (R6/3-07) • .
. .
1 i g FROM ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL VI/HITE SE9DRITY-FAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT '
TURNS F.. ORANGE TO YELLOWWHENRUBBEd.ORIGINAL DOCUMENT HAS A HIDDEN VOID ON FRONT THAT APPEARS WHEN PHOTOCOPIED. .,,i.