Death Certificate - Isaacs, Terri_11/5/2020 (2) r k INDIA H, IU Lt 3.1.0
CERTIFICATE OF DEATH
S1s "p 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(MonBUDaylfear)
TERRI LYNN ISAACS DAVIS FEMALE 08:00 PM 10/31/2013
5.Social Security Number 6a.Age-Yrs fib.Under 1 Year 6c.Under 1 Month 6d.Under 1 Day Be.Under 1 Hour 7.Dale of Birth(Montl/Day/Year) 8.Birthplace(City and Slate or Foreign Country)
56 Months pars Hours Minutes 1111111111111 EVANSVILLE,IN
9, ern . . e a ? 10.If Death Occurred In A Hospital: 10a. If Death Occurred S tat
❑Hospice Facility ®Decedent's Home ❑Nursing HomeiLong•term Care Fealty
0 Yes ®No 0 Unknown 0 inpatient❑Emergency Department Outpatient 0 Dead on Arrival in Odler(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 AI Time Of Death
®Married 0 Married But Separated 0 Divorced
HAZLETON,IN,47640 GIBSON ❑Widowed 0 Never Mauled 0 Unknown
15.Surviving Spouse's Name 15a.(If Wde)Give Maiden Last Name 16.Decedents Usual Occupation 17.Kind Of Business/industry
•
MARK ISAACS FACTORY MANUFACTURING
18.Residence-State 18a.County 18b.City Or Town •
•
INDIANA GIBSON HAZLETON
16c,Street And Number 18d.Apt.No. 18e.Zip Code let Inside City Limits?
•
6585 NORTH 25 EAST ••. 47640 ID Yes el No
19.Decedents Education 20.Decedent Of Hispanic Origin 21.Decede_nt/.:1_3acer.7, ' •_ • -•
HiGH SCHOOL GRADUATE OR GED `. .-,• - •
COMPLETED NOT HISPANIC White >': ,., _
22.Fathers Name(First,Middle,Last) 23.Mother's Name(First,Middle,Lust)-,:i; -- 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 City:LStpte;Zlp,(edt) -;-
MARK ISAACS t ZL`•ET' - ...
ON;�INt4Z64,0:.
HUSBAND 6585 NORTH 25 EAST,k1A ;'.::` _.
25.Place Of Disposition. '• •"�^='i ''-. -•c x%:5.
25a Method Of Disposition 25b.Place Of Disposition(Name Of Cemetery,Crematory,Other Place) 25e.Location•City,TovinrAnd;State.` ,::;•'` :- -
Igl Burial❑Cremation El Donation 0 EntamDmenl - '".-r y. • s•
❑Removal Fromm State •
..fir - .
0 Other(Sprhdfy): COLUMBIA WHITE CHURCH CEMETERY PRINCETON,IN -:u.' . •.•t-
26.Was Coroner Contacted? 27.Name And Complete Address Of Funeral Facility - - •• �35. 27a;Funeral Home License Number
❑Yes ®No ;`• ;; :'.'r ' g
COLVIN FUNERAL HOME INC,425 N MAIN ST.,PRINCETON,IN 47670 . •.;:.�r•fs, �'FF 83005671
27b.Signature Of Indiana Funeral Service Licensee: 27c.LlcenseiNiTipber,'(Of l-Iceruee):_^. •r 1 Z,4t`°
JOHN W WELLS,BY ELECTRONIC SIGNATURE FD0100994.0::=•-:lr -''--_` _k _,
Cause Of Death(See Instructions And Examples)• - Y,;':-:`=s_' :.-0,-..,�:,,z•\- •Approximate
28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events - - •••;j_ is 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 Adctltnat Lines If Necessary. {
Immediate Cause(Final Disease Or Condition Resulting In Death) A. SMALL CELL LUNG CANCER WITH BRAIN MMETASTASESAND BONE METASTASES - • , 2 YEARS
Sequenlialiy Ust Conditions, If My,Leading To The Cause Listed On B. o..to(Or A.Aaana.a..m arc_ 5--:
Line A.Enter The Underlying Cause(Disease Or Injury Thal Initiated {<!a
The Events Resulting In Death)Last C.
ou.e(or s I Gmaquencet4F
D. -
Part II.Enter OtherSlanlficant Conditions Contributing to Death But Not Resulting In The Underlying Cause Givin In Part I 29.Was An Autopsy Performed? ❑Yes ®No
30ilk .Were Autopsy Finding Available To Complete The Cause Of Death? Li Yes 0 No
BRAIN METASTASES Y 33.Manner Of DeatR
31,Did Tobacco Use Contribute To Death? 32.If Female: -
0 Not Pnn.rawkinPadrw 0 • Al ;:-of D . .. • . wmmA2 Dap oro..a Is Natural❑Homicide ❑Accident ❑Pending Investigation
®Yes in Probably 0 No 0 Unknown ❑NmPmlna.t 6,11Proovs143 Days To t r- -.(, •ty,-„ . .WM,MA P.n.., 0 Suicide 0 Could Not Be Determined
34.Date Of Injury(Month/Day/Year) -35.Time Of Injury 38. 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 1 QM.9tieet&tth!r bit 360.Apt No. .38d.Zip Code
39.Describe How Injury Occurred ,-_ -if- 40.If Transportation Injury, Ify:
rI �. 't ❑owvlor.'. QP .wf)ptlarm.❑oftgspetti
41.Signature, Certifier(Check Only One)
,Of Person Certifying Cause Of Death: ___-
MAQBOOL AHMED,BY ELECTRONIC SIGNATURE-- j'•-'/AUDITOR 0 Certifying Physician 0 Coroner El 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,EVANSV3IE IN 47713 01054343A 11/11/2013
46.Additional Funeral Service Provider. _ - -. - - 47.'Alas:
48.Signature of Local Health Officer. . ✓ r^ - ' 49. For Registrar Only-Data Filed(Mont iDey/Year):
BRUCE BRl GNATURE� NOV 12 2013
D,() - 0 - rs •-oos----0 - ) --6 41
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.
'' NRA-20
_- I710.51