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Death Certificate - Douglas, Sharon_3/11/2020 lg:N...el `r'-_rr..-.- -1-l+r-._rm_1l__"in97_ rt.;il' `TrnTr`:.-trAtAtr. .--A -- ---------'A'17F.'r;'Vr. -,'Si`m,_ l7):YQ r.--,•) !a7:404,r-",-..7-4 --1,Y-r1TeA'�,W',.. 77r `' •�a� INDIANA,STATE DEPA-TMENT OF HEALTH ��� 7�� y; ' CERTIFICATE OF DEATH `. 0c es ' '`• Local No 000056 EDR No-000000753771 State No 001288 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) I)i SHARON JUNE DOUGLAS . WOODS FEMALE 05:24 PM 01/10/2020 C: 5. Social Secunty Number 6a. Age-Yrs 6b. Under 1 Year 6c. Under 1 Month 16d. Under 1 Day 6e. Under 1 Hour 7. Date of Birth(Month/Day/Year) 8.Birthplace (City and State or Foreign Country) • �1. ' fri El © El ❑Hospice Facility 0 Decedent's Home ❑Nursing Home/Long-term Care Facility I \ Yes No 0 Unknown Inpatient ❑Emergency DepartmentOutpatient ❑Deadon Arrival ival ❑Other(Specify) I,', 11. Facility Name(If Not Institution,Give Street and Number) , iDEACONESS HOSPITAL MIDTOWN !if, 12, City Or Town,State,And Zip Code - 13. County Of Death 14.Marital Status At lime Of Death +�b 0 Married❑Married,But Separated ❑Divorced EVANSVILLE, IN,47747 VANDERBURGH ®Wdowed ❑Never Married ❑Unknown IV\rr 15. Surviving Spouse's Name 15a.Last Name Before First Marriage 16. Decedent's Usual Occupation 17. Kind Of Business/Industry HOMEMAKER HOME it.,. 18.,Residence State 18a. County 18b. City Or Town - INDIANA GIBSON ' OWENSVILLE (-••\• 18c. Street And Number 18d.Apt.No. 18e. Zip Code 18f. Inside City Limits? la'` 4555 WEST 168 STATE ROAD 47665 ®Yes ❑No k.- 19. Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedent's Race ��-. HIGH SCHOOL GRADUATE OR GED f:. COMPLETED NOT HISPANIC White I\• 22.Parent's Name(First,Middle,Last) 23.Parent's Name(First,Middle,Last) 23a.Parent's Last Name Before First Marriage' lC lYG NOBLE WOODS DORIS WOODS RAINEY 0 24.Informant's Name 24a.Relationship To Decedent .24b.Mailing Address(Street And Number,City,State,Zip Code) N DIXIE DICKERSON DAUGHTER 18304 OLD STATE 37 ROAD, LEOPOLD, IN 47551 _ 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 W ®Burial ❑Cremation ❑Donation El Entombment CC 0 Removal From State 0 ❑Other(Specify): CLARK CEMETERY OWENSVILLE, IN in 26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility ' 27a. Funeral Home License Number. W CC ®Yes 0 No W HOLDERS FUNERAL HOME,319 SOUTH MAIN STREET, OWENSVILLE, IN 47665 • FH11700008 I- 27b. Signature Of Indiana Funeral Service Licensee: 27c. License Number(Of Licensee):, -j BRANDI MACER, BY ELECTRONIC SIGNATURE FD21400 _ Q 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 Terrnin E nt Interval: Onset 0 Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only 0 au r� To Death A Line.Add Additional Lines If Necessary. • 0 Immediate Cause(Final Disease Or Condition Resulting In Death) A. CARDIOPULMONARY ARRESTn�(l HOURS Oo.to(Or As A coneew. �� �U V Sequentially List Conditions, If Any,Leading To The Cause Listed On B. SUBARACHNOID AND SUBDURAL HEMORRHAGES Line A. Enter The Underlying Cause(Disease Or Injury That Initiated Dv.to(a sA ce u<aw.m op I #- The Events Resulting In Death)Last C. BLUNT FORCE TRAUMA TO THE HEAD ��}}7j1 -41 �� Ilse to(Or As Aeone.w.nn.I r '- UDITOR D. STANDING HEIGHT FALL c• aN COUNTY A Part II.Enter Other Sionificant Conditions Contributing to Death But Not Resulting In The Underlying Cause Given In Part I 29. Was All'iluropsy Performed? ❑Yes ®No pYG it I BLOOD THINNERS 30. Were Autopsy Finding Available To Complete The Cause Of Death? ❑Yes El No \ 31. Did Tobacco Use Contribute To Death? 32. If Female: 33. Manner Of Death: ❑Not Ptegna t wean Past v..r El Pregnant Al Tons Of Dean ❑far Prepunr.era [B Pteunr VAN,' Day.Or Death El❑Yes 0 Probably El No 0 Unknown ❑Homicide El Accident ❑ Pending Investigation ❑Not Pregnant.But Pregnant 43 Drys To I year Baby.Death ❑Une,nom a Pregnant Wsnn The Pat.Year ❑Suicide❑Could Not Be Determined Iwo 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? 01/10/2020 11:15 AM HOME ❑Yes ®No ,\�. 38. Location Of Injury-State 38a. City Or Town 38b. Street 8 Number 38c. Apt.No. 38d. Zip Code +7k @ INDIANA PRINCETON 809 BROADWAY STREET 47670 3(_ 39. Describe How Injury Occurred 40. If❑onver Transportation °een upede Pedestrian [Daher(SAWN rFELL BACKWARDS FROM STANDING POSITION , __ . - 41. Signature, Of Person Certifying Cause Of Death: , . 42. Certifier(Check Only One) ' ���''' STEVEN WYNN LOCKYEAR, BY ELECTRONIC SIGNATURE ❑Certifying Physician ®Coroner Et Health Officer [$ 43. Name,Address And Zip Code Of Person Certifying Cause Of Death: 44. License Number 45, Date Certified • STEVEN WYNN LOCKYEAR ,201 S. MORTON AVENUE, EVANSVILLE, IN 47713 01/14/2020 E. 46.Additional Funeral Service Provider. 47. 'Akas: \ 48. Signature of Local Health Officer.1- 49. For Registrar Only -Date Filed (Month/DayNear): t ROBERT KENNETH SPEAR,VIA ELECTRONIC SIGNATURE - 'JAN 14 2020 1y AMENDMENT TO CERTIFICATE OF DEAL H(ENTRY OR ORIGINAL) ,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. 63 WARNING. TURNS FROM ORANGE TO YELLOWWHITE WHEN RUBBED.ORIGINAL DOCUMENT AS HIDDEN VOID PON FRONT THAT APPEARS WHEN PHOTOCOPIED. ON BACK THAT