Death Certificate - Isaacs, Terry_11/5/2020 4, INDIANA STATE DEPARTMENT OF HEALTH, v 1 U L�S.L
��---. 1. CERTIFICATE OF DEATH
"' a" Local No 000184 EDR No 000000351592 State No 051495
1.Decedent's Legal Name(First,Middle,Last) 1a. Maiden Name(If female) 2.Sex 3. Time Of Death 4. Date Of Death(Month/Day/Year)
TERRI LYNN ISAACS DAVIS FEMALE 08:00 PM 10/31/2013
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(MonthlDay)Year) 8.Birthplace(City and State or Foreign Country)
' 10.If Death Occurred in A Hospital: 10a. If Death Occurred Somewhere Other Than A Hospital
0 Hospice Facility ®Decedent's Home ❑Nursing Home/Long-tens Care Facility
0 Yes ®No 0 Unknown 0 Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival ❑Other(Specify)
11.Facility Name(If Not Institution,Give Street and Number)
6585 NORTH 25 EAST
12.City Or Town,State,And Zip Code 13. County Of Death 14. Marital Status At Time Of Death
®Married 0 Married,But Separated 0 Divorced
HAZLETON, IN,47640 GIBSON 0 Widowed 0 Never Mauled 0 Unknown
15.Surviving Spouse's Name 15a. (If Wrfe)Give Maiden Last Name 16: Decedent's Usual Occupation 17.Kind Of Business/Industry
MARK ISAACS FACTORY MANUFACTURING
18. Residence-State 18a. County 18b. City Or Town -
INDIANA GIBSON HAZLETON
18c.Street And Number 18d.Apt.No. 18e.Zip Code 18f. Inside City Limits?
_ - El Yes ®No
6585 NORTH 25 EAST 47640
19.Decedents Education 20. Decedent Of Hispanic Origin 21. Decedents•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 Malden Last Name
WILLIAM EDWARD DAVIS JR MARY JANE RUSSELL..'.'.•:' - '.„-.- NORTHERN
24.Informant's Name 24a,Relationship To Decedent 24b.Mailing Address(Street'And Number;tCity State;'Zip'Code)..; •
-
MARK ISAACS HUSBAND 6585 NORTH 25 EAST, HAZLETON, IN 47.640
25.Place Of Disposition •-•1 _-- - ��` _
25a.Method Of Disposition 25b.Place Of Disposition(Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town And State"_._,.,-
®Burial 0 Cremation 0 Donation 0 Entombment -- ,
❑Removal From State
❑Other(Specify): COLUMBIA WHITE CHURCH CEMETERY PRINCETON, IN _ .
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility - `-27a.•,,F,uneral Home License Number.
❑Yes ®No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 ` =v .=: s_ FH83005671
27b.Signature Of Indiana Funeral Service Licensee: 27c. License.Numbergcrtli•Icericee)i - •;, :',-';"
JOHN W WELLS,BY ELECTRONIC SIGNATURE FD01009940 . r
Cause Of Death (See Instructions And Examples) ,, _ r .-•�. Approximate
28.Part 1.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused'The Death.Do Not Enter Terminal Events r._.a`g:,: 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. SMALL CELL LUNG CANCER WITH BRAIN METASTASES AND BONE METASTASES • . 2 YEARS
Due to(Or As A Consequence 00
Sequentially List Conditions, If Any,Leading To The Cause Listed On B.
We m(Or M A CansepuRoe Oft
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated -tom
The Events Resulting In Death)Last C.
Due to(Or M A Consequence O¢.
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 •
30. Were Autopsy Finding Available To Complete The Cause Of Death? ❑Yes ❑No
BRAIN METASTASES
31. Did Tobacco Use Contribute To Death? 32. If Female: 33. Manner Of Death:
®NorProgn.nrVAWn Past Year ❑Pr ^ a elwm
Arni, r +e anao Days ®Natural❑Homicide ❑Accident ❑Pending lnvestiga0on
0 Yes 0 Probably 0 No 0 Unknown El NotPrepnent•But Pregnant AI Days To 1 r Before; m ....., "`'•.•-. Ylig01 n!.pos V.., ❑Suicide 0 Could Not Be Determined
34. Date Of Injury(Month/Day/Year) 35.Time Of Injury - 36. Place Of Injury(E.G.,Decedent's Home,Construction Site,Restaurant,Wooded Area) 37. Injury At Work?
((1�\\�� C ((��,�1n�1 ❑Yes ❑No
38.Location Of Injury-State 38a. City Or Town ''U8 . Leet 826Mtbf ` 38c.Apt No. 38d. Zip Code
i
39. Describe How Injury Occurred - • rrl 40. If Transportation Injury,S eci fy:
11 . r, ❑°rlwr,ODereb ❑P.nerwa UPehatrtn❑OEror(Speirr)
`f
41.Signature,Of Person Certifying Cause Of Death: __ 42. Certifier(Check Only One)
MAQBOOL AHMED,BY ELECTRONIC SIGNATURE---_ _ - .-/AUDITOR ®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
MAQBOOL AHMED ,421 CHESTNUT ST, EVANSVff JIE,IN 47713 01054343A 11/11/2013
47. •Akas:
46.Additional Funeral Service Provider. .. _
48.Signature of Local Health Officer. ✓ .r--- - - 49. For Registrar Only -Date Filed(Month/Day/Year):
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE) NOV 12 2013
AMENDMENT TO CERTIFICATE OF DECtiy(ENTRY OR ORIGINAL)
a6- 0S- S-S_ 0 - - 00 . 213 - OI
- �
�
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
_. r7/f151