Death Certificate - Chandler, Lois_11/24/2020 .... ._.._ ..._ _. e o M. RK Pig>..F0.-":,•• n i t':;:-: x, •p,
a` INDIANA STATE DEPARTMENT OF HEALTH
;::-t .'i = CERTIFICATE OF DEATH
milsd Local No 002575 EDR No 000000818030
064368
4.
1.Decedent's Legal Name (First,Middle,Last) State No
1a. Maiden Name (If female) 2.Sex 3. Time Of Deathath 4. Date Of Death (Month/Day/Year)
LOIS JEAN CHANDLER BONKE FEMALE
1/1
5. Social Security Number 16a. Age-Yrs 6b. Under 1 Year 6c. Under 1 Month�6d. Under 1 Day 6e. Under 1 Hour 7. Date of Birth (Month/Day/Year) 068.BrthAM place(City and State or Foreign
74 Months Days Hours Minutes {_
10.If Death Occurred In A Hospital: LYNNVILLE, IN
10a.'If Death Occurred Somewhere Other Than A Hospital
0 Yes ®No 0 Unknown ®In anentEmergency DepartmentOutpatient ❑Dead on Arrival 0 Hospice Facility 0 Decedent's Home 0 Nursing Home/Long-term Care Facility
P 0 Emer en
❑Other(Specify)
11. Facility Name(If Not Institution,Give Street and Number)
DEACONESS HOSPITAL MIDTOWN
12.City Or Town,State,And Zip Code 13. County Of Death
14, Marital Status At Time Of Death
ElMarried❑Married,But Separated 0 Divorced
EVANSVILLE, IN,47711
15.Surviving Spouse's Name VANDERBURGH 0[Mowed 0 Never Married ❑Unknown
15a.Last Name Before First Marriage 16. Decedent's Usual Occupation -
P 17. Kind Of Business/industry
DAVID CHANDLER
18. Residence-state 18a. County DATA ENTRY MEDICAL
1 18b. City Or Town
INDIANA GIBSON LYNNVILLE
18c.Street And Number
18d.ApL No. 18e. Zip Code 18f. Inside City Limits?
10512 EAST 1050 ROAD SOUTH ❑Yes ®No
19. Decedent's Education 20. Decedent Of Hispanic Origin 47619
HIGH SCHOOL GRADUATE OR GED P 21. Decedent's Race
COMPLETED NOT HISPANIC White
22.Parent's Name(First,Middle,Last) 23.Parent's Name(First,Middle,Last)
23a Parent's Last Name Before First Marriage
VICTOR BONKE .._ MARGARET BONKE SHOOK
24.Informant's Name 24a.Relationship To Decadent 24b.Mailing Address(Street And Number,City,State,Zip Code)
DAVID CHANDLER HUSBAND 10512 EAST 1050 ROAD SOUTH, LYNNVILLE, IN 47619
•
25a.Method Of Disposition 25.Place Of Disposition
p 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): MEMORIAL PARK CREMATORY EVANSVILLE, IN
28.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility
El Yes ❑Na
ALEXANDER FUNERAL HOME, NORTH CHAPEL,4200 STRINGTOWN ROAD, EVANSVILLE 27a. Funeral Home UcensaNumber.
IN 47710 FB41500021
27b. Signature Of Indiana Funeral Service Licensee:
JENNIFER KUEBER, BY.ELECTRONIC SIGNATURE 27c. License Number(Of Licensee):
IFD20500036
Cause Of Death (See Instructions And Examples)
28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Aterva:mOn
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On Inervalt Onset
A Line. Add Additional Lines If Necessary. To Death
Immediate Cause(Final Disease Or Conditio ,,ul r Bath) A. SEPSIS
�} Duo la(Or AsA consequence 01: `�141 DAYS
Sequentially List Conditions, If An, 3 ding o'g•.Cause Lisle. en B. COMPLICATIONS OF FEMUR FRACTURE 2 MONTHS
Line A. Enter The Underlying (i :as= •r Injury�h0 iti.fed Duata(Or AsACosen,, 0
The Events Resulting In D ) as vv C FALL WHILE WALKING IN HOME
414
�. Due to(Or As A Co y.ace eL
Part II.Enter Other$ionificant Conditions Contrl►Rls NrJD to Death Bu' V . tikg .The Underlying Cause Given In Part I 29. Was An Autopsy Performed?
• /�/1"'y P 13 Yes ®No
30.Were Autopsy Finding Available To Complete The Cause Of Death?
31. Did Tobacco Use Contribute To Death? 1' er I ❑Yes ❑No
�s 33. Manner Of Death:
0 Yes 0 Probably®No ❑Unknown '.l �°�g"BN anvn Paw year ❑Pregnant ar Tlma of Daatn ❑Hal Pregnant,Bul PrsgnaoiWlhin 42 Days or Dm15
0 Natural❑Homicide Be Accident 0 Pending Investigation
cONot Pregnant.But Pregnant Al Days To 1 year Before Death ❑UNmorrn If Pregnant WWn Tim Paw year
34. Date Of Injury(Month/Day/Year) �J 35. Time Of Injury ❑Suicide❑Could Notde Area)a)ermined
GN� 36. Place Of Injury(E.G.,Decedent's Home,Construction Site,Restaurant,Wooded 37. Injury At Work?
09/13/2020 03:15 AM HOME ❑Yes ®No
38,Location Of Injury-State 38a. City Or Town 38b. Street&Number
I 38c.ApL No. 38d. Zip Code
INDIANA. LYNNVILLE 10512 EAST 1050 SOUTH 47619
39.Describe How Injury Occurred
40. If Transportation Injury,S ecify:
FELL WHILE WALKING TO BATHROOM ❑o"vegoparatw ❑Pesssnger IPewn I,n❑omu(Specify)
41.Signature;Of Person Certifying Cause Of Death:
STEVEN WYNN LOCKYEAR BY ELECTRONIC SIGNATURE 142. Certifier(Check Only One)
43.Name,Address And Zip Code Of Person Certifying Cause Of Death: i ID CeruHa- '4.4lcian El Coroner ❑Health Officer
- .-License Number 45. Date Certified
STEVEN WYNN LOCKYEAR ,201 S. MORTON AVENUE, EVANSVILLE, IN 47713 - 11/17/2020
48,•Additional'Funeral Service Provider.
48.Signature of Local Health Officer. - - ••M -
ROBERT KENNETH SPEAR,VIA ELECTRONIC SIGNATURE __ 49. Fo RegistrarrOnly.-DateFilsd(MorhlDay/Year):
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) hOV 273 2020_a
.•b - 0 - 6 - 0 0 � od--o \ .\ . ,
tate 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.
W/�R N W I G, ORIGINAL
FROM DOCUMENT
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