Death Certificate - James, Berniece_1/19/2021 J� t ,. 2.E r, -- Gt t �•,_((CERTIFICAT .F DEATH { , •. � (`r _
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is � , Local No 000046 , :EDR`No 0O0:0004:35858 . . state No'010'935 '°\• '-`.
jy 1,DEdedent'sLegalNam¢;(First"Middle,Lestk/ `,�, \1a �faidant' e•'(1femaley /25e3 3 T)ppe'OfDeath -4 Date Of Death(Month/Dey,``
)"S BERNIECE JAMS .:).HICK: '-• \FEMALE :>•``Q6'`40 PM i.03/0312015/
, ';5. Social SecudtyNumber 6a Age:Yrs 6b.,Underr1 Year 6c/Under 1 Month M. Under21 Day 9e. Under 1 Hour j 7. Date of Birth;(Month/Day/Year) 8 Rlrthplatle(City andState or Fdreign Country)
?# , 83 . Months / Days;• H/ ,_ ours :Mi titer '- „ \
Hospital ;C '•, , / '
.. /- ,-/ .. � : ❑Hospice Faulitg. �,Decedents Home ❑:Nursing HomelLong-term Care Faa):ty'`'� \::••\ .\;i�/•
0 Yes;"®No ❑Unknown la Inpatient❑'Emergency Department Outpatient.,0 Dead on Amval 2'0 Omar(Spegfy) '
11. Facility Name;(If Not Institution,Give Street and Number) , ' . ` \
106 SOUTH-4TH ST. • , . • ; <_
y+ 12,City Or Town State,And Zip Code's , 13 County Of Death , 14. Mental Status At Time Of Death
/ '❑•Maned❑Mamed;But Separated ❑Divorced'
FRANCISCO, IN,47649 : ,1-''",, GIBSON . --,', ';:.''!.-. ® `Widowed ❑Neyerm Maed,,„ own❑Unkn •.
0 15 Surviving Spouse's Name - 115a. (If Wfe)Give Maiden Last Name 16,'Decedents Usual Occupation / 17 find Of Busmessllndustry•
,• • , : : . RETIRED CLERK ' DRY CLEANING: '
18a. County. - .. /,' .;18b:;City Or Town• -
18. Residence='State ,
,6 INDIANA '' ' GIBSON / FRANCISCO /` ,/ / ' "--1 '.'
�, � '- / 18d Apt.No 18e Zip Code. 18f Inside City Limits?
• 18c Street AndNurrlber" •` / •
r ;s . ' ` 0 Yes ❑No
,,, 106 SOUTH 4TH ST 47649
19. Decedents Education % / .•, 20. Decedent Of HispanicOngin ` "21,,Decedents Race ` ..•
UNKNOWN , / NOT HISPANIC ' •\ White '. \ '
223 Father's Name;(First,Middles:Last)
3 r /' -23.Mother's Name(First,Middle.Last),• 23a.Mother's Maiden Last,Name/ < .
ry 'JOHN HICKS ' ' " OPHA HICKS, DEFFENDOLL
i'` 24.Informants Name ' ,24a.Relationship To Decedent: ,.,.< 24b.Mailing Address (Street And Number,City,State,Zip Code) N. '%' ,,/ , i
.., . , '
' 'DAVID HICKS '' "` BROTHER. • - 106'SOUTH 4TH:ST FRANCISCO;IN.47649 ..
/ " i' • .; a'' .. '•• 25 Place Of Disposition �' S, ,s.;
25a Method Of
Of Disposition 25b,Place Of Disposition (Name Of Cemetery Crematory Other Place)'/ 25c.Location,City,Town And State
i i;O:Bunal Er Cremation ❑jDonation❑Entombment s ' .s s. ' '
❑Removal Frojn Stale..• / / � �,. >"•`"` .
i ,❑Other'.(Specify):-,<!'/ / , . ''/ EVANSVILLE CREMETERY EVANSVILLE IN �.\ „/ -
26:Was Coroner'Contacted? 27. Name And Complete Address.Of Funeral Facility-,.,,•'/ �,. „ , . '•"•, ,, c' 27e,Fimeral Horne License Ntimbec
a ' 0 Yes ®No " LAMB BASHAM MEMORIAL CHAPEL, INC,226 E\WASHINGTON'STREET;•OAKUAND CITY, /"' i "
, , IN 47660' •. I FH83005312
i - " , `27c>License Number(Of Licensee):,
^�27t%,Signature Of Indana'Funerel Service Licensee: '
JERRY LEE BASHAM,BY ELECTRONIC SIGNATURE -'' ,
FD01016589.
„•- Cause Of De"ath(See'InstructippsAnir Examples) /' Approximate „/
i`' .. Interval Onset•,.,
' 28.Part t Enter The Chain:Of Events'-Diseases,Injuries,Or Complications"That Directly<Caused•The Deattj.Do N t'Enter Terminal Eventss'^., ,
Such As Cardiae'Arrest,Respiratory Ar'res(,'Or Ventricular Fibrillation Without Showing The Etiology.D•o Not Abbreyiate.Ent r Only One Cause;On.:' : To Death
A Line Add Additinal Lines'If Necessary
Immediate"Cause(Final Disease Or ConditionResulting,In Death)' A STAGE 4 NON SMALL CELL LUNG CANCER 1 MONTH.
< / Da ln(O A Corscque oq %
'Sequentially List Conditions,'If Any Leading To The'Cause Listed On B STAGE 2l'IONSMALL CELLLUNG CANCER s> ,' 2,YEARS"
/ / .Due la l0 AeAC Qum 'OB //.,; �,:': /,i,t. ;,.,
' Line A. Enter The,Underlying Cause(Disease Or(njury',That Initiated" /i` „\ j ,
` The'Events Resulting`In Death)Last ` ` C �• ` \ '\'
' • Due to(Or MA rormquencn Oil ` % '
+ Part II Enter OtherSionificant Conditions Contnbutind to Death But Not Resulting In The Underlying Cause Givin In Part1 29 Was An Autopsy Performed? ❑YeS ® '' ,, '''
;'�;, ./ 30.,WereAutopsyFindingAvailableToCompleteThaCauseOf•Death? O'Yes,❑No:
.A.: -
, 31?Did Tobacco Use Cont ibute To Death? , ".32, If Female \,` 1 `\ Tu - " ''- 33.Manner Of Death:Zs ` ` ? °" "
' ' ',❑Nit PnpnantWMhnRewee ❑Pro a oea Op■ in ' Wmin42Daye°roaii ®Natural❑"Homicide i❑Accident El Rending Investigation-`
®;Yes ''Probably 0 No.❑Unknown '..�..FFR11r11 �r anr., , : Pad Suicide Could mot Be Determined
❑ y ' '"O not Pregiarq But;Prepnan143 Days To 1 i ore j nbmwn 15Preen ❑ ❑ N `
I' 34.,Date Of Injury(Month/pay/Year) ', - ''/; 35..Time Of Injury, 36 Place Of Injlry(E:G„Decedent's Home Construction Site,,Restaurant,Wooded Area)`- :,37 Injury At Work?
`. ,p. '1 nn i)�^ ❑Yes ❑No:,..
i 38.Location Of Injury=State; " 38a..CityOr Town' , "+84 Street f-Nuriber•r';� - 38c Apt.No .,38d Zip Code �
•39 Describe How InjuryOccurred ,` , '/ tih, �" 'up("'r V •` 40.,J(Transportation Injufy, edfy s ,
` \ OUNT• Y,:A . ❑Dl erlOkretee❑P d'Peamhan❑ (wedr)
l'- 41 Signature,,Of Person Certifying Cause Of;Deeth j ' 42. Certitter(CheckOnly One)
, CHRISTOPHER BRADEN ,BY ELECTRONIC SIGNATURE \ •.. •®CertifyingPhysmiar( : ❑Coroner, , 'D'HeathOfricer
43 Name;Address And Zip Code Of Persdn Certifying Cause Of Death: ' 44. License Number: 45. Date Certified
''' CHRISTOPHER BRADEN ,4055,GATEWAY BLVD;NEWBURGH IN.47630 - 02003326A"• ." 03/05/2015
,48.'Additional Funeral Service Provider /'" "- 47.•'Akas:
.48 Signature of.Local Health Officer / / ; • 49 For Registrar Only-Date Filed(Month/Day/Year):..
'.'; BRUCE DRINK JR1 VIA ELECTRONIC SIGNATURE .}
MAR 06 20 I6
t ;'AMENDMENT TO,CER11FICATE OF-DEATH(ENTRY OR ORIGINAL) ,
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