Death Certificate_Akles ,9L,:..n...1 A.?..:n:7 . G', .•n..:, �la.-�?���1 ERT IFICATE.OF.DEATH., ,•;, ��..� �.�;r`i�.-�� � �,�`� _ �. .
a-1r INDIANA STATE DEPARTMENT OF HEALTH
Fi
7a CERTIFICATE OF DEATH 0 )
ri Local No 000099 EDR No 000000784588 state No 031210
,� 1.Decedent'.Legel Name(First.Middle,Last) to Malden Name(1/temeb) 2.Sox 3.Tt no Of Death 4.Date Of Death(IdaneWrylYear) `•+
rr WILUAM G.AKLES MALE 01:26 AM 06/07/2020 ��i
o• S Soda!Seaway Number ea Ago-Yrs ea.Under 1 Yew ea Under 1 Month"eat Under 1 Day Bo.Under 1 Hour 7.Dan of Both(MonthDay/Yeaq a Bid:plaw(City and State or Foreign Country)
�'i 78 Moats Days Horns &Enda
Hosphei
r ® Yes CI No CI Unbwwrh CI ! 0 a Hospice Relay ® Decedent's Homo 0 Nursing Hama/Long dim Cam Raffia ,q
rpalent Ernorgor cy Department Outpatled 0 Dead on Arrive! a Olha(S ) ,U�1<U1]
11.FecBty Name(if Nat Instils,Give Street and Number)C
405 NORTH 1150 EAST 0
ti 12.City Cr Town Sato,AM Zip Code 13.County Of Death 14.diaries Stabs At Time Ot Death
® Manlod0 Married.Bo/Separated CI Divorced
OAKLAND CITY,IN,47660 GIBSON CI Mowed CI Never&Laded CI Unknown!
1 ii 15.Stavfvtrq Spouse's Name 15a Last Nacre Setae First Marriage . • • 16.Decadent's Usual Ocarpatbn 17.KIM Of Bustrhessfrdestry
lO N 04
+C/ CAROL AKLES SERMERSHEIM COAL MINER MINING
Il..t 18.Rmldence-State 18a.County .,..''. lab.City Or Town
P' INDIANA GIBSON .. OAKLAND.CITY
0 18¢St oat AM Number ,„i, ;,I: 18d.Apt.No. 18e.Zip Code 191.Irmmo Cry tlrNts?
� 405 NORTH 1150 EAST • .'I L ^.,1 ,;Yea G1 N 0
P.lS 19.Deadentt.Education 20.Decedent Of Hispanic Origin 21.Deeedenre Rage •
._ ..
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
+•(• 2.Puente Name(Flat Middle.Last) 23.Panes Name(Fiat Middle.Last) 23a Parent's Lest Name Before Brat Marriage
04
►i • HOMER AKLES KATHERINE AKLES BRIDGES 3
Q 24.Irdamonrs Name 24a Relationship To Decadent 246.Melting Address(Str ity,eet And Number.C State,ap Code) •
w CAROL AKLES ,WIFE 405 NORTH 1150 EAST,OAKLAND CITY,IN 47660 . •
Q 25.Place Of DUpoahlm •
CC 25a Malhod Of Dispmlten 256.Race Of Disposition(Name Of Cemetery,Crematory.Odor Place) 25c.Location-City.Town,And State .
w ® Burial 0 Cremation 0 Detemn 0 Erdambme+d
p: 0 Removal From State
O a Other(Spedn): MONTGOMERY CEMETERY . OAKLAND CITY,IN - -
0 26.Was Coroner Corroded? 27.Name And Complete Address Of Fuhaof Facilitya Funeral Home Llama Number. r
w LAMB BASHAM MEMORIAL CHAPEL,INC.,226 E.WASHINGTON STREET •AKLAND CITY,
CC 0 Yes 0 No 1N 47660 . . -• • • FH83005312 10
w 27b.Sigria4ae Of tram Funeral Service Licensoo: 27c. .- .Number(Of Licensee): \
•
JERKY LEE BASHAM,BY ELECTRONIC SIGNATURE Fr a 1
Q cameo Of Death used And Examples)
Term i
Li- 2S.Part L Enter The Chain Of Everts-Dlaeaaea,Injuries,Or CompCeatims-That Directly Caused The Death.Do Not Enter Terminal Eve . 1 t�erv�Ortsel
Such As Curdles Arrest Respiratory Arrest.Or Ventricular Fibrillation W thout Showing The Etiology.Do Not Abbreviate.Enter Only One C•• :0 To Death
O A Lana.Add Additional Lines B Necessary. •'
0 immediate Cause(Final Disease Or Condition Resulting In Death) A. SYSTOLIC CONGESTIVE HEART FAILURE itraA ' ` : I l l
Sequentially List Condlllo s. If Any,Loading To The Cause Listed On B. ISCHEMIC CARDIOMYOPATHY
Una A.The Evade Enter The Resulting In n lying)Cause(Disease Or It'jwy That Initiated C I '" �,i
�, li ;,,
-./
) • • ,. D.:;' IBSON COUNTY AUDITQ'
• Part IL 6derOher But Not Resulting In The Underlying Cause Given In Part I 29.Was An Autopsy--••• 0 Yes ® No
P CORONARY ARTERY DISEASE.PERIPHERAL VASCULAR DISEASE.CHRONIC RENAL FAILURE STAGE 3
30.Wens Autopsy Raring• „ •To Complete The Cause• ;-:• 0 Yes 0 No .?
J 31.Did Tobacco Use Cartrauo To Death?... 32.If Female: . 39.M •. •.;,.,
!� 0 u+onwww m
• wcnm(w 0q,. ma en.a,wru . oua, a tasta4 ui•P,savaasni •a.m o , ® Natural CI Homicide 0 Aoided 0 Pendnglmeslgelon )1)
l 0 Yes ® prepaby0 No 0 UNmam 0 NAPrwa•.DARowl43Oq h•T•IratB• •Diet a VNw t8PnpieivC h Si
siTh. MYou a ddda0 CaddNot BoDalomro Determined
34.Data Of Irdnay(Mail iDayrfear) 35.Tb
ne Of Injury 39.Place Of Inlay(E.G..(HBO.,Decedentsan Homo.Cambodian Ste,Restaurant Wooded Area) 37.Injury At Wait?
333 a Yes O No
( 38.Location Of Injury-Sao 38a City Or Town 38b.Shoo Numb
er ber - _ r 38e Apt.No. 38d Zip Coda p '
( - . 0))
L' 39.Demote How Injury Occurred ❑ � � ,II' . 0 a.soat 1 J 41.Sundae,Of Person Certifying Cease Of Death � . .• Cartfser•(Chedt Only One
APRIL MICHELLE-SIMMONS TOELLE,BY ELECTRONIC SIGNATURE CersfytnpPttyddaru tl cosier 0 HeolehGreeer )
:i
C( 43.Hera,Address And Zip Code Of Person Cmeying Cause Of Doak 44.License Number 45.Due Coladd /-)
fat APRIL MiCHELLE-SIMMONS TOELLE ,600 MARY ST.,EVANSVILLE,IN 47747 - 02003410A- 06/09/2020 1
P 4a.Aral Fanal Santos Provide: 47.•Alias: e!!
`_a . . •• 4g..For Regntmr Only••Data Flied Manan/oaynea): v/I
fl 48..St�nehae d le®!Heeltln Officer
rQ BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE r.. JUN 09 2020 .0
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
VI
2.�} _ 00 - Q00 00 - O06 P 1
i, V
,e. State Porn 63385 ATTENTION ESTATE:The Soda]Security#Is being requested by this state agency In order to pwege1 reaponsibllity. Dtedoaiire Is voluntary end there will be no penalty for refusaL }
vlC� . ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHIT SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT kJ,
WARNING •NSa•• ORANGE_TO YELLOW WHEN RUBBED.ORIGINAL DOCU �a:•..•13•I4I•DEN OIDO. a•O •T.APPEARSWHENPHOTOCOPIED. 'K+
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