Death Certificate - Shannon, Barbara_7/17/2020 ,...y.,•,ll.. .r.....� �l P��. .:r l.�rr/,.llr - t-. r!/.•..\lr;f.... - ill•\lr. -?r - - -. �...._
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- INDIANA STATE DEPARTMENT-OF HEALTH - -
� � ••
__ CERTIFICATE OF DEATH"
'� 000074- - EDR No 0c. i0000'0757402
I,ij '�-'`' Local No
-1.Decedent's Legal Name (First,Middle Last) , ,la..Melderi Name If female ll ' State No
L - - ' ' :_--2 04/ ./ I. ( )i 2.Sex 3.Time Of Death '4.1 Date Of Death(Month/Day/Year)
(, BARBARA ANN SHANNON - J WOODS FEMALE 08:27 AM 01/29%2020
r1�_ 5. Social Security Number 6a.Age-Yrs 6b. Under11'Year"
r Sc, Under 1 Month 6d. Under 1 Day Se. Under 1 Hour 7. Date of Birth (Month/Day/Year)- 8.Birthplace (City and State or Foreign Country)
86 Months 1 ' Days Hors Minutes ' '
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0 Yes El No ❑UnknownInpatient. 181 Hospice-Facility 0 Decedent's Home 0 Nursing Home/Loi{g-term Care Fa ility _
p 0 P ❑Emergency Department Outpatient 0 Dead on' vat
•11.,Facility Name(If Not Institution,Give Street and Number) - 1 _ _ -
: � OUR HOSPICE OF-SOUTH CENTRAL INDIANA,'INC I. '
',% 12. CityOr Town,State,And Zip Coda - - - . . - . ' •.-
'` - ? '� - 13. County Of Death - 14. Marital Status At Time Of Death
•
0 Married 0 Married,But Separated 0 Divorced
COLUMBUS, IN 47201 BARTHOLOMEW Ei Widowed 0 Never Married 0 Unknown
15.Surviving Spouse's Name 15a Last Name Before First Marriage 16. Decedents Usual Occupation . ' 17. Kind Of BusinesslndustryC _ - TELLER-LOAN OFFICER - BANKING .
ir�(�,_; „18. Residence-State - 18a. Co
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'U - - ' County - { I _18b.,City Or Town - 11 -
INDIANA BARTHOLOMEW' COLUMBUS
`( 18c.Street And Number I; • ' ' I 18d.Apt No. I 18e.Zip Code I 18f. Inside City Umits?.
140 OAKBROOK_D_RIVE II - • _ i ras Q No
.
L. 19. Decedents Education 20. Decedent Of His nic Origin , - 47201 ,
itti,.: ,Pa.• -21. Decedent's Race - , - _ i•., .
L% ' SOME COLLEGE CREDIT; BUT NOT-A - - - ' ' -
t . DEGREE -, ' . . . ._NOT HISPANIC ' . -. , White
,0.�- 22.Parents Name(First,Middle,Last) " 23.Parents Name(First,Middle:Last) . 1' 23a.Parent's Last Name Before First Marriage
j, WYLIE M..WOODS -- .' ROSAL'IND,B.WOODS BOGER'
24.Informants Name - _ ' 24a.Relationship To Decedent : 24b.Mailing Address(Street And Number,City,State;Zip Code)
•
W LORI.SHANNON MCI(EE DAUGHTER" . 27824 ARROWHEAD CIRCLE,PUNTA GORDA, EL:33982
Q
1 - 25.Place Of Disposition - , - !I.,-
IX 25a.Method Of Disposition , . 2f b.Place Of Disposition((Jame Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State I, '
LLI 0 Burial®Cremation❑Ddnation❑Entombment '' 1I rl` `. • ' - I . -
CC 0 Remoyal'From State, - BARKES WEAVER GLICK FUNERAL'HOME .
O ❑other(specify): . ANC/CREMATORY . • _ ' COLUMBUS, IN . . _ - .
ci '26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility ' - 1'• - 27a.Funeral Home License Number.-''
LCE U 1 BARKES,WEAVER&GLICK FUNERAL-HOME, INC,,1029 WASHINGTON ST, COLUMBUS, "_ - 1.1111.
❑Yes' ®No " IN 47201
-LU - FH8300106T. 1
J27b.Signature Of Indiana Funeral Service Licensee: - . . • 27c. License Number(Of Ucensee): 1 ,;: -
KASEY L.WRIGHT,i BY ELECTRONICSIGNATURE - ' I. '- - . FD20200004.'
Cause Of Dea =:e nstructlo And Examples) _ '
Approximate
V' `28.Part I.Enter The Chain Of Events=Diseases,injures,Or Complications-That Dir..-y Caused The Death.Do •t Enter Terminal Events - Interval: Onset
CISuch As Cardiac Arrest,Respiratory Arrest,Or Ventricu-ar Fibrillation Without Sh•.- g The Etiology.Do Not Abbreviat- Enter Only One Cause On - To Death - . ' `
A Line. Add Additional Lines If Necessary. - 1
Imimediate Cause(Finl Disease Or Condition Resultirrr-In Death) :', A. E RATION OF THE BRA i UNKNOWN -
toOrA.Acon..a,.nc.d*: 1 II'; I
Sequentially List Conditions, If Any,Leading To The Csu ' '.y+•.Old' -
. 1 o•to for A.A oorww. a): - . .
Line A. Enter The Underlying Cause(Disease Or Injury That ed
D� • The Events Rosulti g In Death)Last, '
c. 10733 r
BB �Nj�,. .
Lk Part II.Enter OtherSi-en(8cant Conditions Contributing to Dealt But Not Resultin,IRThe Underlying Cau en In Part I 29. Was An Autopsy Performed?1 : .. - -
-
❑Yes ®No` 1
- DEMENTIA '- •• ', i ,-` 30.Were Autopsy rindmg Available To Complete The Cause Of Doatn7 -❑Yes',❑No '
rfPD\ 31. Did Tobacco Use Contribute To Death? 32. I,`emale: -- ./ 33. Manner Of Death:
Yes Probably • ❑r'-Pnpnrq W,tM P.q Y..r lu' or peen Nal'.hurt,so PrepaeeNn.2 Dry.ofo..in ®Natural❑Homicide ❑Accident
`E ❑ ❑ 0 No IR Unknown ® Q Penrfing Investigation
., ❑N. PnpuN-BN Pn o year a.rtt.Death a,ovel l r gn.m wvnm m.Past Year
/t ' 1••'1"' '❑ ❑Suicide❑Could Not Be Determined - 'I' '
34. Date Of Injury(MonthrDayiYear)''',, 35.1 .e Of In tG Injury(E.G.,Decedents Home,Construction Site,Restaurant,Wooded Area) 37. Injury'At Work?
I„� 1 �B la � •f
r.:: Ip - ❑Yes- 0 No
,t f 38.Location Of Injury-State 38a. City Or T•• • 33b. Sleet 8 Number , .
N,�\i,1 I - 30c.Apt.No. 38d. Tip Code •
:.9. Describe How Injury Occurred • , 'I - ''11 I •
.1
_ - 40. If Transportation lnlury, ed -
1
QolrnxJpw.tcr QP.uerp.rP.b n QOPu(Spout')
I :I
r. 41.Signature,Of Person Certifying Cause Of Death: 42. Certifier(Check Only One) I 1
,\I SHOBHA SAHI, BY ELECTRONIC SIGNATURE ' _ . ''i.', -_ ®CertifyhgPhysician •.❑Coroner' ❑Healthotticer,
j= 43.Name,Address And Zip Code Of Person Certifying Cause Of Death: - - -
>!( - _ 44. License Number 45. Date Certified
it SHOB.HA SAHI 2626 E:'17TH,STREET, COLUMBUS, IN 47201 01060758A' 01/30/2020
46.Additional Funeral Service Provider. ' ' ' 47."Akas: _
48.Signature of Local Health OfAcer. - _ 49. For Registrar Only-Date Filed(Month/Day/Year):
BRIAN J NIEDBALSKI,'VIA ELECTRONI�SIGNATURE ' ' ,' ' JAN 30 2020
441 P. '�, AMENDMENT TO C hF1CATE OF DEATH(ENTRY OR ORIGINAL)
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p, • WARNING. TURNIS FROM ORANGE TO YELLOWCWHEN RUBBED.ORIGINAL DOCUMENT NA$ASHIDDE VO DPON FRONT THAT A PEARS WHENE PHOTOCOPIED.IANA ON BACK THAT