Death Certificate - Goddard, Ted_6/8/2020 ' From Jason Spindler j Fax 18125064074 7 To Fax (812)386.1173 i Page 2 of 2 0610812020 1:55 PM
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� 1 INDIANA STATE DEPARTMENT OF HEALTH b:U 3b:Li D
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CERTIFICATE OF DEATH
\~ awl Local No 000024 EDR No 000000177306 State No 001629
1.Decedent's Legal Name(First,huddle,Last) 1 a. Maiden Name(If female) 2.Sex 3.Time Of Death 4.Dale Of Death(Month/Day/Year)
TED D GODDARD MALE 04:25 PM 01/14/2011
5.Social Security Number 8a.Age-Yrs 60.Under 1 Year 6c. Under 1 Month-6d.Under 1 Day 6o.Under 1 Hour 7.Date of Birth(tdanthiDay/Year) 8.Birthplace(City and State or Foreign Country)
89 Months Days Hours Minutes SEARCY.AR
.0.Ever in U.S.Armed Forces? 10.If Death Occurred to A Hospital: 10a. If Death Occurred Somewhere Other Than A Hospital
0 Hospice Facility 0 Decedent's Home ❑Nursing Horne/Long-term Care Facility
2)r Yes 0 No ❑Unknown ®Inpatient.❑Emergency Department Outpatient ❑Dead on Arrival ❑Other(Specify)
11.Faclty Name-(It Not Institution,Give Street and Number)
DEACONESS GATEWAY .
12.City Or Town,State,And Zip Code 13.County Of Death 14.Marital Status At Time Of Death
1 Married[I Married,But Separated 0 Divorced
NEWBURGH,IN,47630 • WARRICK ❑Widowed ❑Never Marred 0 Unknown
15.SUMvingSpolse`s.t:lamn_ 15a.Of Wde)Givo Maiden Last Name 16. Decedent's Usual Occupation 17,Kind 01eusieess/tndu5try
VIRGINIA GODDARD .• BRUCE FACTORY WORKER MANUFACTURING
16.Residence-Stile " lea.County t013,City Or Town
•
INDIANA GIBSON SOMERVILLE
18c.Street And Number . • ' led.Apt.No. 18e. Zip Code 18f.Inside City Limits?
10155 EAST MAIN ST. ... 47683 •®Yes ❑No
IS.Decedent's Education 20.Decedent Of Hispanic Origin 21-Decedent's Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Father's Name(First,Middle,Last) 23.Mothers Name(First,Middle,Last) 23a.Mother's Maiden Last Name
JOHN GODDARD STELLA GODDARD HOLDERS
24.Informant's Name 24a.Relationship To Decedent 24b.Mating AddreSs(Street And Number,City,State,ZIp.Code)
VIRGINIA GODDARD 'WIFE 10155 EAST MAIN ST., SOMERVILLE, IN 47683
25.Place Of Disposition
25a.Method Of Disposition 25b.Platy Of Disposition(Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State
(sm]Burial 0 Cremation 0 Donation 0 Entombment
❑Removal From State
❑•Oilier(Specify): MONTGOMERY CEMETERY OAKLAND CITY,IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility 27a.Funeral Home License Number.
❑Yes ®No CORN-COLVIN FUNERAL HOME, INC.,323 N. MAIN ST. PO BOX 278, OAKLAND CITY, IN
47660-0278 FH19400002
27b.Signature Of Indiana Funeral Service Licensee: 27e. License Number(Of Licensee):
JOHN W WELLS ,,BY ELECTRONIC SIGNATURE FD01009940
Cause Of Death (See instructions A ,Y-) Approximate
28.Part L:EnterThe-Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do o n
Tm'. final Interval; Onset
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbre E r•r ly Ono au., To Death
A Line.Add Additinai Lines if Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. SEPSIS .. S HOURS
Du.!m(Or As A mCon,.cu eee Obi:Sequentially
Sequentially List Conditions, If Any,Leading To The Cause Listed On B• J U N 8 2020 \
UneA, Enter The Underlying Cause(Disease Or Injury That Initiated buer.aA.Aacn,eauue.o p
The Events Resulting In'Death)Last C
D.
_f it -
Part II.EEnterOther,4imnifieent Conditions Contributing to Death But Not Resulting In The Underlying Cause Chin In Part I ( ION TF�1 1,,s•-.'*. .. •
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❑Yes... .®No.
TOXIC MEGACOLON • 30.Were Autopsy Finding Available To Cornptete The Cause Of.Death? I�Yes ❑No
31.Did Tobacco Use Contribute To Death? 32. If Female: '33.Manner Of Death:
CI'Not Tans"ivo,Pes1Yes/ 0 HrnmlAI Tans OfOast% IDrum Pr nant.CulP,ecvW ,,o weso.,.OrOsam Natural 0 Homicide. 0 Accident_Ei Pending Investigation
0 Yes 0 Probobty El No 0 Unknown
)]Nuvr.w,.vt-wnvr.,,wt as o.y.Tv r war Wore D..n 0 rnwu,.,,,r Newest VMS.TM P.e Ye., ❑Suicide Could Not BeDetermined •
34.Dale Of Injury fhlonth(Day/Year) 35.Time Of Injury 3E. Place Of Injury(E.G.,Decedent's Home,Construction Site,Restaurant.Wooded Area) 37.tnJumyAt Work?
❑Yes ❑No
38.Location Of Injury-State 38a.City Or Town 36b. Sbect&Number 38c.'Apt No. 38d.Zip Code
•
39.Describe How injury Occurred 40.If Transportation Injury,
U S ecify.
❑M DaroDar.yr QPasse.v. P.demiu, ❑Da.,(3Prcar)
41.Signature,Of PerseeCerttytng Cause Of Death: 42.Certifier.(Check Only One)
DAVID-BELL,BY.:ELECTRONIC:SI.GNATURE ®Certifying Pti sician 0 Coroner y0 Heath Officer-
43.Name,Address And Zip Code Of Person Certifying Cause Of Death: 44.License Number 45.,Data Certified
DAVID BELL ,600 MARY STREET,EVANSVILLE,IN 47747 01067238A 01/18/2011
46.Additional Funeral Service Provider. 47. 'Alias:
48.Signature.of Local.feaith.O.flicer- 49. For Registrar Only -Data Filed(Monttt/Day)Year):
R►CKY:B:YEAGER,.VIA.ELECTRONIC SIGNATURE JAN 18 2011
:'`""'`` ``"'•'""" •• AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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i.o.,....Sp.4:p.r.cri.O.Y.q.:-.ATTEqiu2N ESTATE The Social Security#is being requested by this stale,agency in order to pursue responsibility. Disclosure is voluntary and.therre will be.no penalty(or refusal.n
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•\ii 0 IF ALTERf D'OR ERISED;Nit VALID'UNLESS;CER5'IFIED BYHEALTH DEPARTMENT