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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