Death Certificate - Douglas, Frederick_3/11/2020 (..7.I'Kc NFALC, .: ; 711(r-,�:,er--01al( ES -)71 i • • ' - 4. 17rwift- :G�4. i)'�',i?tr;-,,t st!aG�%;;; TATf = �_�
•" `�'-` INDIANA STATE DEPARTMENT OF HEALTH
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CERTIFICATE OF DEATH -
�0A/// �.;.�s'`� Local No 000058 - - EDR No 0000006297-19 • State No 010380 0
1.Decedent's Legal Name(First,Middle,Last) I 1a. Maiden Name (If female) I 2.Sex 3.Time Of Death 4. Date Of Death(Month/Day/Year)
N, FREDERICK LLOYD DOUGLAS MALE 08:31 PM ' . 02/24/2018 -
5. Social Security Number 6a.Age-Yrs 6b. Under 1 Year 6c. Under 1 Month 6d. Under 1 Day ee. Under 1 Hour 7. Date of Birth'(Month/Day/Year) 8.Birthplace (City and State or Foreign Country)
Forces? 10.If Death Occurred In A Hospital: I 10a.If Death Occurred Somewhere Other Than A Hospital
� ElHospice Facility ®Decedent's Home ❑Nursing Home/Long-term Care Facility
it` ®Yes 0 No 0 Unknown 0 Inpatient❑Emergency Department Outpatient ❑ ❑Other(s h)Dead on Arriyal I
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11. Facility Name (If Not Institution,Give Street and Number) ' •
6 4555 WEST STATE ROAD 168
d�', 12. City Or Toxin,State,And Zip Code - `' 13. County Of Death 14. Marital Status At Time Of Death
i1:
®Married 0 Married,But Separated 0 Divorced
OWENSVILLE, IN,47665 GIBSON 0 Widowed 0 Never Married ❑Unknown
915. Surviving Spouses Name 15a.Last Name Before First Marriage 16. Decedent's Usual Occupation 17. Kind Of Business/Industry
z/J SHARON DOUGLAS WOODS FARMER AGRICULTURAL
' � 18.,Residence-State 18a.County , „ - I 18b. City Or Town . -
p(r INDIANA GIBSON OWENSVILLE '
i : 18c. Street And Number 18d.Apt No. 18e.Zip Code 18f. Inside City Limits?
1�
4555 WEST STATE ROAD 168 - . 47665 . ®Yes 0 No
r{' 19. Decedent's Education 20. Decedent Of Hispanic Origin ' 21. Decedent's Race
HIGH SCHOOL GRADUATE OR GED
rtrICOMPLETED 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
4
ryi LLOYD R DOUGLAS .. - EMMA FRANCES DOUGLAS 'READY
24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address(Street And Number,City,State,Lp Code)
in
SHARON DOUGLAS WIFE 4555 WEST STATE ROAD 168,OWENSVILLE, IN 47665
.25.Place Of Disposition . _
r 25a Method Of Disposition 25b.Place Of Disposition (Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State ,
El Burial 0 Cremation 0 Donation 0 Entombment '
• ❑ Removal From State . '
• 0 Other(Specify): CLARK CEMETERY . OWENSVILLE, IN
a 26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility . I '• , 27a. Funeral Home License Number. '
• ❑Yes ®No
HOLDERS FUNERAL HOME,319 SOUTH MAIN STREET, OWENSVILLE11 IN 47665 FH11700008
2 Signature Indiana Funeral Service Licensee: - i i b^ilk nsee):
BRANDI MACER, BY ELECTRONIC SIGNATURE F 214 5
Cause Of Death (See Instructions And ExamP I ' 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
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Wthout Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
• A Line,Add Additional Lines If Necessary. m y y 1 r�020
Immediate Cause(Final Disease Or Condition Resulting In Death) A. HEART FAILURE ' (, 1 , L 48 HOURS
P.
Du.to(Or A.A Com.gwna DQ:
�� Sequentially List Conditions, If Any,Leading To The Cause Listed On B.
ri Line A. Enter The Underlying Cause(Disease Or Injury That Initiated _ Ow°f0r�x
li\Y The Events Resulting In Death)Last ///��
c. e„01565Q,t .g.Qr,UNTY At ID1TnR
IY ..
t,, D.
Part II.Enter Other Significant Conditions ConlributinD to Death But Not Resulting In The Underlying Cause Given In Part I 29.Was An Autopsy Performed?14 ❑Yes ®No
30.Were Autopsy Finding Available To Complete The Cause Of Death?
q HYPERTENSION ❑Yes El No
I"E 31. Did Tobacco Use Contribute To Death? 32.If Female: - ; 33. Manner Of Death: •
0 Yes El Probably Ei No 0 Unknown ❑Nat Pr.purlMn,Pa You ElPnpumat.oro..h 0 Not P ,rir,aaPr.r tw lron42O.y.oro.dn ® ❑ El Homicide 0 Accident Pending Investigation
//''I' ❑Not Pr.pua.But Pr.punr43D.y.ToryearBear.o..rn ❑Warr.nIfPr.{InrdvvtwTnaP.r.Yam ❑Suicide❑Coulld Not BeDetermined
it, 34. Date Of Injury(Month/Day/Year) ' 35.Time Of Injury 38. Place Of Injury(E.G.,Decedent's Home,Construction Site,Restaurant,Wooded Area) 37. Injury At Work?
P- ❑Yes ElNo
0,1 38. Location Of Injury-State 38a. City Or Town 38b. Street&Number 38c.Apt No. 38d.Zip Code
I0
I 39. Describe How Injury Occurred • . , 40. If Transportation Injury,Specify:
❑om.rrop.,.mr ❑P..ans.r LP,ad..tTi.n❑osw(specify)
41.Signature, Of Person Certifying Cause Of Death: 42. Certifier(Check Only One)
Is JERRY L LIKE, BY ELECTRONIC SIGNATURE ®Certifying Physician 0 Coroner ❑Health Officer
6 43. Name,Address And Zip Code Of Person Certifying Cause Of Death: •_ - _ • 44. License Number 45. Date Certified
WI
k� JERRY L LIKE 110 W.SYCAMORE ST, ELBERFELD,IN 47613 02000254A 02/26/2018
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�/�i 48.Additional Funeral Service Provider. 47.*Altos:
(S\'f 48.Signature of Local Health Officer. 49. For Registrar Only-Date Filed(Month/Day/Year):
0 BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE • . , .• FEB 27 2018
I O AMENDMENT TO CERTIFICATE OF DEATH iENTRY OR ORIGINAL) '
`6 ZG - lg ^07 Cok+8-02-1
y 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: 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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