Death Certificate - Isaacs, Terri_11/5/2020 ' INDIANA STATE DEPARTMENT OF HEALTH__ 1 U C bS l d
rerCERTIFICATE OF DEATH
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°�`itir Local No 000184 EDR No 000000351592 state No 051495
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)
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 Be. Under 1 Hour 7. Date of Birth(Month/Day/Year) 8.Birthplace(City and State or Foreign Country)
56 Months Days Hours Minutes
Hospital
0 Hospice Facility ®Decedents Home 0 Nursing Home/Long-tens Care Facility
❑Yes ®No ❑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❑Marled,But Separated 0 Divorced
HAZLETON, IN,47640 GIBSON 0 Widowed 0 Never Married 0 Unknown
15.Surviving Spouse's Name 15a. (If Wife)Give Maiden Last Name 16. Decedents Usual Occupation 17.Kind Of BuslnessMdustry
MARK ISAACS FACTORY MANUFACTURING
18. Residence-State 18a. County 18b. City Or Town •
INDIANA GIBSON HAZLETON
18c.Street And Number 18d.Apt.No. 18e.Zp Code 18f. Inside City Limits?
- •
❑Yes ®No
6585 NORTH 25 EAST _ -•. 47640
19.Decedents Education 20. Decedent Of Hispanic Origin 21. DecedentaRace;:._: _
HIGH SCHOOL GRADUATE OR GED _, ,
COMPLETED NOT HISPANIC White 23a.MothersMaidenLastName
22.Father's Name(First Middle,Last) 23.Mother's Name(First Middle,Last)`r _
WILLIAM EDWARD DAVIS JR MARY JANE RUSSELL. ', _'-_ -'-- •`'NORTHERN
24.Informants Name 24a.Relationship To Decedent 24b.Mailing Address(StreetAnd Number;Cityll ate;>Zip"Code)... -.
MARK ISAACS HUSBAND 6585 NORTH 25 EAST, HAZLETON,.IN 4Z640 ._.
25.Place Of Disposition, - - •'L' ''7:1:%= -
25a.Method Of Disposition 25b.Place Of Disposition (Name Of Cemetery,Crematory,Other Place) 25c.Location-City,TownrAnd;State.•:. :_ ---.
El Burial 0 Cremation 0 Donafion 0 Entombment "�-s-"r-.
❑Removal From State ..
❑Other(Specify): COLUMBIA WHITE CHURCH CEMETERY PRINCETON, IN ; - .•
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility . . -_`f: r-
,- •, '-27a.Funeral Home License Number:
' _ _ .
❑Yes ®No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 ,•:'=_. :`\'s' •. >' FH83005671
27b. Signature Of Indiana Funeral Service Licensee: 27c. License;Number,(Of,L'Icensee):'^ ri`,.?r:y"
JOHN W WELLS,BY ELECTRONIC SIGNATURE FD01009940 `•_-4 =.t,__ :d;' <� ,,.
Cause Of Death (See Instructions And Examples). `:..c;_;- -.1,:''',.. •Approximate
28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events - l:'=1,;-:-.c Interval: Onset
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Onl One Cause On ' To Death
A Une. Add Addiinal Lines If Necessary. '.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. SMALL CELL LUNG CANCER WITH BRAIN e(METASTASES D BONE METASTASES - , 2 YEARS
Consequeoce Oh
Sequentially List Conditions, If Any,Leading To The Cause Listed On B. `_ -
Du.b(Or A.A Consequence Oh fir.
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated .
The Events Resulting In Death)Last C.
De.to(Or A.a Con,.we„e.Orr
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? 0 Yes ®No
30.Were Autopsy Finding Available To Complete The Cause Of Death? ❑Yes 0 No
BRAIN METASTASES - 33. Manner Oi Death:
31.Did Tobacoo Use Contribute To Death? -32. If Female: ���� +
®Not Pregnant within Pad Year P. Al „-Of m .- i.But Pi, •,wiWn42 Days OfDeath ®Natural 0 Homicide 0 Accident 0 Pending investigation
ID Yes ElProbably 0 No 0 Unknown ❑Not Pregnant But on.,,43 Days To7 r eeror.(;«m *❑b
I In u,• Mew The Pig Year El Suicide 0 Could Not Be Determ fined
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?
((�� [ ❑Yes ❑No
38.Location Of Injury-State 38a. City Or Town 108V. beet BZMA((����I ` 38c.Apt.No. ,38d. Zip Code
39. Describe How injury Occurred _ - ' I SI 40. If Transportation Injury, eclfy:
r/ - 4 Pt ❑oneero,er. :Passenger UPed.men DOM.,(Moser/
41.Signature,Of Person Certifying Cause Of Death: __-- ' AUDITOR
42. Certifier(Check Only One)
MAQBOOL AHMED,BY ELECTRONIC SIGNATURE --- -- - ®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, EVANSVi -LE IN 47713 - - - 01054343A 11/11/2013
46.Additional Funeral Service Provider. _ - _ _
48.Signature of Local Health Officer. ✓ r-- 49. For Registrar Only -Date Filed(Mont lDay/Year):
BRUCE BRINK JR,VIA,ELECTRONIC SIGNATURE) NOV 12 2013
a � C 5 OO. 5: _Cb2S -O) S
Stale: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
• (71051 •