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Death Certificate - Morris, Penny_8/12/2020 - - - __ - _'/�i-Ai ri_.!i__*_,on..,'P:f4Rng_= i/Yr'err. -0.0,,WAIar__'-8.ev'R"_?y
aN INDIANA STATE DEPARTMENT OF HEALTH
0
C � CERTIFICATE OF DEATH .
4 : Y Local No 000867 EDR No 0-00000706876 - State No 020846 •
4y 1.Decedent's Legal Name(First,Middle,Last) la. Maiden Name (If female) 2.Sex 3. Time Of Death 4. Date Of Death (Month/Day/Year)
' PENNY L MORRIS MCFALL FEMALE 01:52 AM _ 04/25/2019
l 5. Social Security Number 6a.Age-Yrs 6b. Under 1 Year 6c. Under 1 Month 6d. Under 1 Day 6e. Under 1 Hour 7. Date of Birth (Month/DayKear) 8.Birthplace(City and State or Foreign Country)
.. 68 Months Days Hours Minutes
Hospital
1'-
��/�' ®Hospice Facility El Decedent's Home ❑Nursing Home/Long-term Care Fadlity
Al-E'•
❑Yes El No ❑Unknown El Inpatient El Emergency Department Outpatient 0 Dead on Arrival ❑Other(Specify)
f' 11..Facility Name (If Not Institution,Give Street end Number)
C LINDA E.WHITE HOSPICE HOUSE . .
)j'd 12. City Or Town,State,And Zip Code .' - . 13. County Of Death . 14. Marital Status At Time Of Death
.'
El Married El Married,But Separated El Divorced
I0 EVANSVILLE, IN,47710 VANDERBURGH Ei Wdowed
El Never Married 0 Unknown
)`.�� 15. Surviving Spouse's Name 15a.Last Name Before First Marriage 16. Decedents Usual Occupation 17. Kind Of Business/industry
LICENSED PRACTICAL
NURSE ' MEDICAL
A 18.Residence-State 18a. County 18b. City Or Town
INDIANA GIBSON FRANCISCO
f 18c. Street And Number 18d. Apt.No. 18e. Zip Code 18f. Inside City Limits?
P.O. BOX 162 ®Yes ❑No
d, •
47649
19. Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedent's Race
re ASSOCIATE DEGREE(AA,AS) NOT HISPANIC White
P� 22.Parent's Name(First,Middle,Last) 23.Parent's Name(First,Middle,Last) 23a.Parent's Last Name Before First Marriage
KENNETH GEORGE MC FALL SHIRLEY JEAN MILLER BARNETT
in 24.Informant's Name 24a.Relationship To Decedent , 24b.Mailing Address (Street And Number,City,State,Zip Code)
W N MICHAEL MC FETRIDGE - BOYFRIEND P.O. BOX 162, FRANCISCO, IN 47649 "
Q 25.Place Of Disposition
CC 25a.Method Of Disposition 25b.Place Of Disposition(Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State
W El Burial El Cremation 0 Donation 0 Entombment -
CC El Removal From State ,
0 ❑Other(Specify): . EVANSVILLE CREMATORY EVANSVILLE, IN
CI 26.Was Coroner Contacted? ' 27.Name And Complete Address Of Funeral Facility 27a. Funeral Home License Number.
W SIMPLE CREMATION EVANSVILLE, 3101 N. GREE RIVER RD.STE 320, EVANSVILLE, IN
CC Ill ❑Yes ®No . 47715 FB41800004
J27b. Signature Of Indiana Funeral Service Licensee: 27c. License Number(Of Licensee):
Q GARY LEE JONES , BY ELECTRONIC SIGNATURE FD08800061
Cause Of Death (See Instructions And Examples) Approximate
V' 28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset
„ Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On i To Death .
A Line. Add Additional Lines If Necessary. ,
Immediate Cause(Final Disease Or Condition Resulting In Death) A. RESPIRATORY FAILURE DAYS
Du.to(Or Co A Consequence Of)'
B. PLEURAL EFFUSION - DAYS
l Sequentially List Conditions, If Any,Leading To The Cause Listed On Dae m for As A Consequence op:
)4. Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
Pk The Events Resulting In Death)Last C. MANTLE CELL LYMPHOMA YEAR
( ,. Due to(Or A.A Consequence 01):
�JJ
) : D. , ,
Part II.Enter Other Significant Conditions Contributing to Death But Not Resulting In The Underling Cause Given In Part I 29. Was An Autopsy Performed? ❑Yes ®No
P 0.ere Aut sy in•,g A J able To Complete The Cause Of Death?
(_.• ATRIAL FIBRILLATION WITH RAPID VENTRICULAR RESPONSE - ❑Yes ❑No
i4' 31. Did Tobacco Use Contribute To Death? t 32. If Female: 33..u'nner Of Death:
® MCI Pregnant tn Past Year El Pre Prem Al Tan.or Deaf, ❑Not P,egna P ..I. atural❑Homicide El Accident ❑Pending Investigation
!.,. El Yes 0 Probably El No ❑Unknown
):/ El Not Pregnant.But Pregnant 43 Days To 1 year Before Death El Unknownunawn If Pregnant In T Pad Year 0 Suicide El Could Not Be Determined
k 34.Date Of Injury(Month/Day/Year) ' '35. Time Of Injury 36. Place Of Injury(E.G.,Dec ���-I° e,2o �i Site,Restaurant,Wooded Area) 37. Injury At Work?
'a�ny `' 1 !r �LU
't.Pr El Yes ElNo
,
4^
;� 38. Location Of Injury-Stale -38a. City Or Town38b. Street&Number 38c.Apt No. 38d.Zip Code
) p39. Describe How Injury Occurred �1 e�. T oriation Injury,S ecify:
;, GIBSON COUNTY A bd o ❑Pa..I rpm jfPeM.tNn❑oBar(sRdry)
. 41.Signature, Of Person Certifying Cause Of Death: 'a" '.- 1 42. Certifier(Check Only One)
0>'' APRIL MICHELLE-SIMMONS TOELLE, BY ELECTRONIC SIGNATURE . 6�Certifying Physician El Coroner El Health Officer
�� C 43. Name,Address And Zip Code Of Person Certifying Cause Of Death: • - I 44. License Number 45. Date Certified
i�Tt/��/
t APRIL MICHELLE-SIMMONS TOELLE ,600 MARY ST., EVANSVILLE IN 47747. 02003410A 04/26/2019
46.Additional Funeral Service Provider. ' 17.7. •Akas:
9er
IAy, 48. Signature of Local Health Officer. - - 49. For Registrar Cnty -Date Filed (Month/Day/Year):
bt ROBERT KENNETH SPEAR,VIA ELECTRONIC SIGNATURE _ APR 30 2019
/ AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
`. 02 lQ - 13-- 0 - IO 1. 7-- o oo . 00 q -- cos
'c
` State Form 53395 ATTENTION ESTATE:The Social Security#is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary and there will be no penalty for refusal.
t
&� WARNING TURNS R M O ANG TO YELLOW WHEEN RUBBED.ORIGINALL DOCUME T HAS ASHIDDE VO DPON AFNRDONTTHE
THAT A PEARS WHEN H O O COP EDIANA ON BACK THAT