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Death Certificate - Larkins, Jera_6/18/2020 CRA(‘F� Z r. -7'1.f�-.g9 SF 's'*- l›'lr.:".' L fr: - r • 'I ' ■ �, -9/ yin T7u„`, ,�N_ 'P E .' 0 • • • ,----,------------- ' . , . (i • • • . . • .I .,. . 4_i/ ra` INDIANA STATE DEPARTMENT OF HEALTH • a- " I' ` CERTIFICATE OF DEATH i kltf Local No 002088 EDR No 000000765131 State No ' •y. 1.De^_edent's Legal Name(First.Middle.Last) • ta. Maiden Name(If female) 2.Sex • 3.Time Of Death 4.Date Of Death(Month/Day/Year) Ifs\\�,�►►ie ,. s%r JERA LYNN LARKINS WOODS FEMALE" 12:54 PM 03/06/2020 5.Social Security Number 6a.Age-Yrs 65;,Under 1 Year 6c Under 1 Month 6d. Under 1 Day " 6e. Under 1 Hour 7. Dale of Birth (Mmth/Dey/Year) 8.Birthplace,(City and State or Foreign Country) 71 M«ins Days • Hours Minutes - ' ❑Hospice Facilty ❑Decedents Home, ❑Nursing HomelLong-tern Care Facility ❑ Emergency Department 17 ,❑'Deadori Arrival❑Yes �No 0 Unknown >• Inpacent❑Emer en D artment Ou ahem ❑Omer(Specify) td7;i 11. Facility Name(If Nat Instituton.Give Street and Number).. - •. , e INDIANA UNIVERSITY MEDICAL CENTER - i - 'Fid 12.Oty Or Town,State,And Zlp Code 13.County Of Death l 14.'Mental Status At Time Of Donal t I 5l Memed❑Married,But Separated 0 Divorced C�±v INDIANAPOLIS, IN,46202 MARION I ❑:vdrwed 0 NeverMamed ❑Unknown ram• 15.Surviving Spouse's Name 15a,Last Name Before First Marriage 16, Decedent's Usual Ocnupccon v 17. Red Of Businessllndustry ��:/ - , r, JESSE FRANK-LARKINS - _ . - : TAX CONSULTANT". .i,, I., H AND R BLOCK ' 18, Residence-State 18a.,County - _ lab City Or'r own g�gZ\may" INDIANA - GIBSON - - OWENSVILLE • f' 18c Street And Number • • • ,' ' 18d.Apt.No I 1.8e.,Zp Code 181 Inside City Limits? ;1ft 231,2 SOUTH OLD STATE 65 ROAD • � 47665 El Yes p No cI 19 Decedent's Education 20 Decedent Of Hispanic Origin - 21 Decedent's Race fp I ASSOCIATE DEGREE(AA,AS) NOT HISPANIC . White pL1 .• 22 Parent's Name(First,Middle.Last) 23 Parent's Name(First,Middle.Last) 23a-Parents Last Name Before First Mamxge }/a EARL JACKSON WOODS I WANDA NADINEWOODS SIMS 24.Informant's Name 24a,Relationship 7o Decedent 24b Mailing Address,(Street And Number.City.State,Zip Coda) - - W JESSE LARKINS ' SPOUSE - •I 2312 SOUTHOLD STATE 65 ROAD,OWENSVILLE, IN 47665 Cl) - 25.Place Of Disposition • '• Q 25a Method Of Dispostion 25b Place OI Disposition(Name Of Cemetery,Crematory,Other Place) 25c Location-City.Town.And State • Er ©Burial ❑Cremation ❑Donation 0 Entombment ' I ,I W ❑Rernoval From State , I I I_ i • CC . I, ❑Otner(Specify). WHITE CHURCH CEMETERY ' - PRINCETON, IN I 0 - 26.Was Coroner Contacted, 27 Name And Complete Address Of Funeral Featly -27g. Funeral Home License Number. UJ O Yes p No HOLDERS FUNERAL HOME,319 SOUTH MAIN STREET,IOWENSVILLE, IN 47665 FH11700008 .I CC 27b.Signature Of Indiana Funeral Service Licensee. .. 27c License Number(Of Licensee). W BRANDI MACER, BY'EL'ECTRONIC SIGNATURE., ' , FD21400065 ' . I- Cause Of Death (See Instructions And Examples) -1 Approximate a. 28 Part I.Enter The Ctiain'Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Dealt,.Do Not Enter Terminal Events • I' Interval. Onset - Such As Cardiac Arrest,'Respiratory Arrest,Or Ventricular,Fibrilation Without Showing The Etiology.Do Not Abbreviate Enter Only One Cause On 'I . To Death LL ' A Line. Add Additional Lines If Necessary. CI Cause(Final Disease Or Condition Resulting In Death) 'A. NONSMALL CELL LUNG CANCER - • . WEEKS fine itu w,tCm a„w,ce on 0 Sequentially List Conditions. If Any,Leading Tc The Cause Listed On 8 POSTOBSTRUCTIVE PNEUMONIA •f WEEKS Line A. Enter The Underlying Cause,(Disease Or Injury That Initiated - to Or r..t cr,,,,'v.,.re«i -The Events Resulting In Death)Last • " • - C. COPD 'I YEARS �., n,C,.tCmior.nco ng Part II,Enter Other Sionificant Conditions Contributing to De tit,But Not Resulting In The Underlying Cause Given In Part I 29..Was An Autopsy Perfarrnedv L.Yps ®No l �l/c� CA' 30. Were Autopsy Finding Available To Complete'The Cause DeaS1? _❑Yes� ❑No V 3tl Dd Tobacco Use Contribute To Dean? 32 If Fe MI male: n 33. Manner O/Death: �fti:� ❑x Yes ❑Probably ❑Unknown ❑ e-'❑=rp,e, a,aa:L.,dr cr.au.0 ra ,ar•e:wr-oi.i.'n- Q Nataral❑HomlCde ❑Accident ❑Pendinglnvo5igatlon � ❑No �/t, ❑ .w.8.1 9r< 'Amen : veal titian. - ❑:.,:n.,,i,Lo .,e Par+aa O.SVI ide,O Could Not Be Determined 34..Date Of Injury(Month/Day/Year) , 35. Time Of Injury 36 Place Of Injury(E G Decedents Home.Construct on Site,-estourent,Wooded Area) 37. Injury At Wceh7 , ❑Yes ❑No !;Y I 38. LoaUdn Of Injury-State " . 38a. City Or Town 'u;: 38c.Apt.No. 38d.ZIa Code • - c 39. Describe Haw Injury Occurred 40. If T.nsponation Injury,S ed : i tie i� ��I' ❑r]'`m x -.❑Pm en�e,�is m❑«mi5o%Pi) i 41. Signature.Of Person Certifying Cause Of Death: Ill � ' i � 42 Certifier(• eck Only One) CAITRIONA ANN MARY BUCKLEY, B ELECTRONIC SIGN,, EJ. 8 2020 ©Certifyi Pnysicien ❑Coroner ❑Health Officer W`i� 43. Name.Address And ZIp Code Of Person Certifying Ca . Of Death: 44, Ucense Number 45 Date Certified (�L CAITRIONA ANN MARY BUCKLEY , 50 N UNIVERSITY BLVD, STE.2180, INDIANAPO 4S,IN �, 46202 01079171A 03/17/2020' 1 46.Additional Funeral Sennce Provider: 47. 'Akas: f 48.Signature of Local Health Officer: GIBSON C O U TY HUD ITO;i ' 49. For Registrar Only -Date Filed(MondvDay/Year)' `� VIRGINIA A CAINE,VIA ELECTRONIC SIGNATURE . ,' . MAR 23 2020 .,/ p(,- AMENDMENT TO CERTIFICATE OF D (ENTRY OR ORIGINAL)" •- - li! - •' W State F ' 53395 ATTENTION ESTATE The Social Security S is bomb requested by this state agency in order"to pursue responsibility. Disclosure is voluntary and there vat be no penalty for refusal. 26 - 0- 1 - GOO - 'D1 026 -02.1 t�• Wi4 R N I N G. TTURNS FROMOORANGE TO YELLOW WH�N RUBBED.ORIG NAL DOCUMEN HAIS SHIDDEN VO DPON FRONT THAT'APPEARS WHENEPHO OCOPIEDIANA ON BACK THAT