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Death Certificate - Carpenter, Roy_5/26/2020 ::- CERTIFICATE OF DEATH Dek74*:"::,';',‘:-.' e •,..--.4.:',.',-.•A'Zik.4•4`;.".-1...,,.11' ..,7..:.?W•r.. ._,1 •• I ; % .,, !,, h: (-',.. ,.:••,. ' ,:s' : 1/‘IDIAIsik$TAtE'DEPARt r*N17, OP'.14EALTH' ,;.,----.%, ?:: i' . : .;f' ,--••- :. 7'.4 ' CERTIFICATE 00,MAtH -4kErSIMNiit i ..: •'''.'i :::: - i•-• t i it ., ,.., .. - • ;!'',',...4;:. , !;., • i ; :, - •, ::: .. 1. . '. :: •-.• j' ,',. c • . 'f," ' '• X ; i . :- -• .. i ?.. '',, :.- I I • A)) Y"- • -1-.) 0"..---'' ,. ' , ,, ,.. ..i'''" *•:',.,0 , s , : .,- -,-1 , --- ..,-- ., . .,... : . ',.... -,-.....-•-„,. -Lcocai No,• 0 043\ .,' - '.EDR NO; 0000049 1900-- ,ii-..'i ,.. ttat§,N0 003506 - ., • " 0.Decedefit,Legel%Naipe(FysL:MIddle,',L'Ot). .,/,%; '•-%:%%%., ...,;;;'-%%•.,,, ..;;". :la...MaldenNarne (lf,female) :;:s-<„.. , .,,;:%': :::z 2,-,Se9i-j', ,.."...-;%:%;:51::•Timepf,Odatti- , 4...pete,-9,.f:Ds ea'thAlon'th'/Day/year)' -1 % '''... ' ', .,••' „,,, '‘ ,, ..I ..,•„ 20 " ,,,,,.., "'',ROY FMNi<LIN CARPENTER'\-. : ' 'i: 1 ,;''' ....., "%, : .; "': --: .'" WALE . ' .05 pm. -::,:- c ' . .Al 5:Social Security Number •6a.AO-.Yrs 6b. Under 1,Year %Sc. Under 1 Month 6d. Under 1 Day j% 6e:Under 1 Hour 7. Date of Birth(Month/Day/Year)- 8.Eirthplace(City and State ofj-,Forein Country); : •,,,r-. , ;%;.% %-. .-% %; • -J. ' ' .; 79 •,„.., %Months % ', % Days " ,- •''. Hours''; ,,'' ;:-Miraites'''. ,..-% ,.. N9spital --,,.„.,%. ' ,,.. ,..;--- -,,,,, .,"...... :‘ ,,,• '71,1 ''' -, :..."''' ,,--''' '''''' .-',":''''''' ,-; ,•-;''''.-----. '.-:''''''„ .i''-j'ij, .,------''• -.-'''':' --''''::-\s,, [714.16e,r ibiiiry ;,o'becpdeptlibme„-; 0-Nursing HorneiLong4erm Care'Facility, "•„•'-'J... .,. '-••. 0 Yes TE No 0,Unknown El Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival. ID Other(Specify)''''' -'''':- -." = -•''''' %'''' '':' : '-' '' '- • .-•'''--j• '' ‘", "'' '' '''• ''' 'il , •-. • Y.3.). 11. Facility-Name(If Not Institution,Give Street and Number) j" . • . ., , . „ , •- S .' , .. „ DEACONESS GATEWAY ' :". . ". •• . .'• .. '2: . ,.. . ,...:, . ': -,, :. :., : ',, •••••• .• : .. : .: , : " •.: . 121-City Or Town,State,And Zip Code --. „' . % - - 13:County Of Death. - , . ,..7- ., 14. Marital Status At Time Of Death %. 1 -...,-• ,,,,.,-; • '''' -• •; '• -' El Married n Married,But Separated 2 b Divorced ',V , . • ' NEWBURGH,'IN,47630 ---. ' " - .. ' " ' -''' "., •" ' •, ..;-'WARRICK -'""''". :'.' ''.- . - ' '• , -0 Widowed, El:Never Married--%,0 Unknown , • 15.Surviving Spouse's Name. ,, : ' •• • ' 11 • - - • -, 15a. (If lArife)Give Maiden Last Name j, j: - .."'- 16. Decedents Usual Occupation '; ,- -17..,..Kind-Of Business/Industry' • : .riv .",. . ' • -1, ; • DIANE CARPENTER . 2, 2 . •• • 'MARSHALL x' : :, .., .,' . ', ''., SALES , SELF EMPLOYED . 6. ••• 18:Residence-State' ; : ;.j --, _ ,-- 18a.-County - „. .- ,% • ,- - 18b.City Or:Town ', ..."' ' : .,- '" 1. - • • ,.. . :. . . . '-„.,.. .,, '; , . '••, ,•-' "i0 INDIANA,- - . :. .. . "-GIBSON, " ' r.. .. ' . . OWENSVILLE' --:. .• '. ".- ,'' . .- ''' ..... -, - ... - 4.' ' 4 18c.-Street And Number -- ., ;; ..., ' . ,..--: •• .:., •,. • , .., •• , %•"; ' : 18d:Apt.No.'. ':.18e.Zip Code.- • 18f,Inside City Limits? % ' j • . : " j ' 0 Yes 121:No :1) 10567:WEST STATE ROAD 166 - , ' . .,• . : - . ; ' -2 , 47665 .. : . - . 19. Decedents Education:, j.:: • ;' ,• ' 20. Decedent Of Hispanic Origin ' -- j• -.. 21. Decedent's Race' ;• •-, ' ,• - . j- '-..% :' „ j -%i• • • - , ,.;4 • ..„-. HIGH SCHOOLGRACUATE OR GED '- . '.' . ..'" '•...' "'..,.,;‘. .''' . . ; COMPLETED -.... '-' . ,"' . f •-. :-. • NOT HIBPANIG :. s• . ,, z '.. White- ' ,. : .-' '• •--. ;. •- ---,.. -s. s-, 40 ...., 22.Fathers,Narrie(First,Middle,Last) ,- .. -. 1 ; j % • % ' , , - , -; 23.Mothers:Name(First,Middle,Last) j •- -- -', , ,23a.Mothers Maiden Last Name - - .,....., •'. "" ..: ...''. jj :: ':'''• ' • ''; ' . ". : , :-. ' - ••, • . ;4 5 ',JOHN WILLIAM'CARPENTER ... . . • , : . .•. s - •-•...- : PAULINE CARPENTER li' ."... , ; :-. BAKER. 24.Informants Name ,' j: ',-j ' - ' .' Relationship To Decedent --;:•• :24b.Mailing Addresa's(StreetAnd-Nymber,City,State,Zip Code) ,• - - ---" .; ;- • ; .% e .. .„ .. ,4 ... '.' DIANE CARPENTER '' " .. '? .• 'WIFE "-, ;" ''.: '. -' ..10567 WEST STATE ROAD 165; OVVENSVILLE;IN 47665'. ":". - ' -'" ' - -• • .- - " .• '- •-. , ...... '• •••• ' .' ' •"...' ...." '`. "',,'4 25 Places.cif Disposition :... %.::- ''.: -,.. % :• , ' •..--. '::•. -:: ;.- ., \ . : -. ' • 25a.Method Of Disposition;', % ; -.. ;'-: 25b.Place Of Disposition (Name OfCemetery,Crematory,Other Place) -25c.Location City,Town,And State' %. ; - j -; • - • Burial th Cremation D•Conaiiori 0 Entombment j- • : .• ,• - jj •:: '' ,' ,..' i " 1. ,';' .-',' ',.. :' •-•.. : . . - ; . . , ... , El Removal From State . - . El-Other(Specify):•%-' - ;--, --•-,•,;r% ,. OWENSVILLE CEMETERY,-:•.::" ' . .. ---"- .., OWENSVILLE;•IN,,,---' . ••••••-- '.. '''.....'-- "---:-.!, • • - ,•''' '26.Was.Coroner Contacted?, -.."-- 27. Name And Complete Addrets Of Funeral'Facility„y --., -2 jj, ; -%, ,,,, • . :-.,%--- .., '...„.. : -..• •••, •. 27a. Funeral Home License Number: •• ' ' ' -' ' , ji ' -Yes" HOLDERS FUNERAL HOME OF OIBSON'COUNTY;"..INC.,319 SOUTH MAIN STREET, .' '-, .: • f' ", .. : : w 0: ail° . .. . .:,.. -. ". 17.)WENSVILLE, IN 47665 1, . .. - , I. .:: ',. . ;.. * ' ; ... ';:'"; "... -'. .;'.. • ".. -:-.FH89000021 - - • 2711'Signature'Of Indiana Funeral Service Licensee:" % "„ : .. % - % . j, ,. J..,:: ,• ":,.., `,. ,' .", 27c.,'License Number(Of Licensee): ; ...r. ' ; :' •,•• ::: • ,-- - al RANDALL KE)IKE;BY ELECTRONIC SIGNATURE•'• . ' . '--•-' ' ..; -, , '',.... s- FD01010177 .-, '' .: ' , '•••••' ":" . --: ' -. - • ......,;,.,.....-.,.,,, .;,,,,,,,,. -.... .,,..‘",,,,,,;,..,,,,,.,..,- ,,...._,.. ,,,,,,, _":;...,...,-•-•,...‘ ca4p:p\t'Death',(See Inst - onsA.ri!exa ) ••-,,:--; •-•----::•-',' ,,,,..„..: --'',......., '...-:•-•,,- "Aiiiiroximate,--" 1' - •-..-28.:Raril.EnterThethain Of Events,DieeaseS,Injuries,'Or Complications-7 That Directly C. :.="..•-•e Deeth.Do Not Enter Terrill - venti'. '''' „ ' . *J.. ..• j --"' 's. -1 Interim!:Onset'•, Such As Cardiac Arrest Respiratory Arrest;.0r,Ventricular Fibrillation Without Showing Th.,ti•ogy.Do Abbreviate,Enter Only On'Cause On ': i - ;i ,' .- .• .- ''..: -,'i To Death A A Line.idd'Additinat Lines If NeCesSary. jj, -, j-, ': s' "% " - ' • J; •-• ':,""'- ' •'-'- : :: %; ' '"•••j', ':: • •, '-';",j, •'" •::. 1'jj --• • . .., .. , . . . 'Immediate Cause(Final Disease Cr Conditien Resulting In Death) i A. .'s •• 1'.-E Ot4-CHRONIC FtYPERCAPNIC AND HYPDX1C'R PIFtATORY FAILURE : . ' I i' , 10 DAYS ' , , ...„ , . ,„, ‘, • . , . . , . ..„ .. „...,... - ,. • UC L Y ".-i-i---'.:" 10-DAYS••---.... 5,, i•-•... Sequentially List Conditions:If Any;Leading To The Cause Listed' On '' B • ; ,. ,. , ,:,• " pue to(Or AsA Consequence . t.Line A.Enter The Underlying Cause(Disease Or Injury That Initiated - , The Events Resulting In Death)Last, , -I i, .---"-,; „.„ -• :, .„••, Oue to(Or As Itt Consequencs , . , , '24• -I b , .. .. ..), ..: ,,,c ;; '..... .. .' ., ... ; , ,.. :, '„.,.,- .i. ' •. P,'. ' Part II-Enter OtherSionifiCant Conditions Oontributino to Death But Not Resultin•In The Underlying. WIAkpivaiipazon 29,...Was.An Autdes. er.f,971.ei?,• '' .' El Yes 12:1•No'"' '• '''' . • ' ' -1 •. Av,lbie To The Caune Of Death? CORONARYARTERY DISEASE.,.. ...--, . ' . -.A 31.Did Tobacoo Use Contribute To Death? 32. If Female .. 5 ''. -•. j -:. -% -: ""„,-.. %.. -..- 33. Manner Of peat!: % .--.• ,' 'j ".%„• ': ."'„ - -.,.„1 - % % •-•, , " , -.-,I:I Not Regnant was PaM Ye t Eli t/egnani,Aii PeapA' at P t Pteignani Within 420 ays Peath 'ta Naturai,E1 NomiCide'. 0 Accident ti Pending Investigation 0 Yes.;'D Probably El No 10 Unknown ," -....-.•• : .j.' , -, .., 1 , • - ,_, , .... .%. ; .%,... •;, Not Pregnant,But Pregnant 43 saysTel year Before eta s,,,:t gt:f..rdinegrifirdlEffirOrtestY, ;: ,. .1...J,Suicide n Coulci"Noi Be Determined -, --; '4 34. Date Of Injury(Month/Day/Year) - ':' 35.Time Of Injury -" ' cliEl$•. 196.`P*e in)ery(E.O.'iDecedent's H ei Construction Site,Restaurant,WoodedArea)-..,, '37. Injury At Work? -•-- I ..„ ,...., ..., ,,,, ...„,, . •,,„,. - • A ,. 38.Location Of Injury State: -. ' ' •• Ha.:City Or Town '. ,, : ' % ' 38b:Etreet&Number •- :' ",-. -" - % ".,, •-: 38c.Apt.No.- ' 380.ZioCode-;, .. • .'.., .•': S:? •i .. , . , . , , . , , : . • . . ...... • •,... ,:•.• ,• . ••." '', .- , . . ; • • • i "...• 39:Describe.How Injury Occurred : j.,..,..-- -' , . .. ....,,,, ..• ., •,• ,.. •j, ,,,,sj., .: ,j -, 40:If Transportation Injury,§pecify:-. , - •," - , ;„. • , Itil ,. ,.,, ,...•' ".„ .,• , .,.-' .•-•„. ,.,'. arises/Operator :Passenger Pede.ustrian :ather(Specify) ' : .t,', . .,. ..... . fli.Signature, Of Person Certifying Cause Of Death: ".. , . '-: ' •:, - -, ... `:-. "; •--- - -" .. 42.Certifier,(Check Only One) ,. :-- ': • , .- -. '-.. ffSi MUHAMMAD JAWAD HABiB , BY:ELECTRONIC BIGNATURE, ,,‘". •.. • .. 's. ,-. •..' ;,; •, .El Certifying Physician ', El Coroner; -' 0'HeithOffice'r". •,:•.; 43. ,Name,Address And Zip Code Of Person Certifying'Cause Of Death: % 44. License Number ' 45:-Date Certified , , • - : : : ', ,. '• -. . . , 1.: : •-i, - ' MUHAMMAD JAWAD HABIB-;519 HARRIET ST:,'EVANSVILLE,11\1'47710 ,r.'1'"''''.• :,I;",', .,s'' . 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