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. `"'r° INDIANA STATE DEPARTMENT OF HEALTH 1021100
- `'„ CERTIFICATE OF DEATH
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_a e Local No 000117 EDR No 000000373708 State No 010428
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)
PATRICIA J WADE JENKINS FEMALE 11:05 PM 03/06/2014
5. Social Security Number 6a. Age-Yrs 6b. Under 1 Year 6c. Under 1 MonthJ 6d. Under 1 Day 6e. Under 1 Hour 7. Date of Birth (Month/Day/Year) 8.Birthplace(City and Slate or Foreign Country)
76 Months Days Hours Minutes GIBSON COUNTY, IN
9. Ever in U.S.Armed Forces? 10.If Death Occurred In A Hospital: 10a. If Death Occurred Somewhere Other Than A Hospital
❑Yes ®No 0 Unknown Inpatient ❑Hospice Facility ❑Decedent's Home 0 Nursing Home/Long-term Care Facility
® p ❑Emergency Department Outpatient ❑Dead on Arrival ❑Other(Specify)
11. Facility Name(If Not Institution,Give Street and Number)
DEACONESS GATEWAY
12.City Or Town,State,And Zip Code 13. County Of Death 14. Marital Status At Time Of Death
®Married❑Married,But Separated 0 Divorced
NEWBURGH, IN, 47630 WARRICK ❑Widowed ❑Never Married 0 Unknown
15.Surviving Spouse's Name 15a.(If Wife)Give Maiden Last Name 16. Decedent's Usual Occupation 17.Kind Of Business/Industry
RON WADE HOSTESS CUSTOMER SERVICE
18. Residence-State 18a. County 18b. City Or Town
INDIANA GIBSON FORT BRANCH
18c. Street And Number 18d.Apt.No. 18e.Zip Code 18f.Inside City Limits?
1001 SOUTH LINCOLN STREET 47648 ®Yes 0 No
19. Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedent's Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Father's Name(First,Middle,Last) 23.Mother's Name(First,Middle,Last) 23a.Mother's Maiden Last Name
CHARLES JENKINS GRACE JENKINS MILLER
24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address (Street And Number,City,State,Zip Code)
RON WADE 'HUSBAND 1001 SOUTH LINCOLN STREET, FORT BRANCH, IN 47648
25.Place Of Disposition
25a.Method Of Disposition 25b.Place Of Disposition (Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State
❑Burial El Cremation ❑Donation 0 Entombment
❑Removal From State
❑Other(Specify): EVANSVILLE CREMATORY EVANSVILLE, IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility 27a.Funeral Home License Number:
❑Yes ®No STODGHILL FUNERAL HOME INC, 500 E PARK ST HWY 168, FORT BRANCH, IN 47648 FH10900013
27b.Signature Of Indiana Funeral Service Licensee: 27c. License Number(Of Licensee):
ROBERT S STODGHILL,BY ELECTRONIC SIGNATURE FD01024378
Cause Of Death (See Instructions And Examples) Approximate
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 To Death
A Line. Add Additinal Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. RESPIRATORY FAILURE
Due to(Or As A Consequence Or):
Sequentially List Conditions, If Any,Leading To The Cause Listed On B. END STAGE RENAL DISEASE
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated Due to(or As con.eggm ee Of):
The Events Resulting In Death)Last C. HEART FAILURE
Due to(Or As A Consequence Of).
D.
Part II.Enter Other Significant Conditions Contributing to Death But Not Resulting In The Underlying Cause Givin In Part I 29.Was An Autopsy Performed?- ❑Yes ®No
5 30.Were Autopsy Finding Available To Complete The Cause Of Death?F ❑Yes 0 No
31. Did Tobacco Use Contribute To Death? 32. If Female: A .,t 33. Manner Of Death:
0 Not Pregnant Within Pest Yee, ❑Prepn.nn Arr..Of Death Nol Pregnent.eot Pregnant Within 42 Days Of Death ®Natural❑Homicide 0 Accident ❑Pending Investigation
❑Yes 0 Probably ❑No ®Unknown ❑Not Pregnant.But Pregnant aD.r.ret year ❑Unknown If Pregnant wmm The Peat Year ❑Suicide❑Could Not Be Determined
34. Date Of Injury(Month/Day/Year) 35. Time Of Injury reef P2e0f Ir�yip20G.,Decedent's Home,Construction Site,Restaurant,Wooded Area) 37. Injury At Work?
( 1, I lJ L(JL(J ❑Yes ❑No
38. Location Of Injury-Stale 38a. City Or Town 38b. Street 8 Number 38c.ApL No. 38d.Zip Code
39. Describe How Injury Occurred GIBSON COUNTY AUDITOR 40. If Transportationlnjury,S ecify.
❑Drlvm/Opmebr ❑.aserper �Petlestr4n ❑ONm(SpaNy)
41.Signature,Of Person Certifying Cause Of Death:
42. Certifier(Check Only One)
DEEPA GHANTA, BY ELECTRONIC SIGNATURE 121 Certifying Physician 0 Coroner 0 Heath Officer
43. Name,Address And Zip Code Of Person Certifying Cause Of Death: 44. License Number 45. Date Certified
DEEPA GHANTA , 600 MARY STREET, EVANSVILLE, IN 47747 01066897A 03/08/2014
46.Additional Funeral Service Provider: 47. 'Akas:
48.Signature of Local Health Officer: 49. For Registrar Only -Date Filed(Month/Day/Year):
RICKY B YEAGER,VIA ELECTRONIC SIGNATURE MAR 10 2014
AMENDMENT TO CERTIFICATE OF DEATH(
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.
IVRA-20
(7/05)