Death Certificate - Pauley, Sherrlyn_1/26/2021 • ' 1 1 ' ' I a e I ' ! °I I F DEATH.ORIGINAL COPY ON FILE AT INDIANA STATE DEPARTMENT OF HEALTH
e9,41 INDIANA STATE DEPARTMENT OF HEALTH 3 2 317 5
: t ''I CERTIFICATE OF DEATH
.,. Local No 000000243303 State No 005141
'_u V.,;' 000203 EDR No
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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)
SHERRLYN SUE PAULEY MADDEN FEMALE 06:40 PM
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(Month/Day/Year) 8.Birthplace (City and State or Foreign Country)
75 Months Days Hours Minutes 05/20/1936 GIBSON COUNTY, IN
9.Ever in U.S.Armed Forces? 10.If Death Occurred In A Hospital: 10a. If Death Occurred Somewhere Other Than A Hospital
• 0 Yes ®No El Hospice Facility El Decedent's Home ❑Nursing Home/Long-term Care Facility
❑Unknown ®Inpatient❑Emergency Department Outpatient ❑Dead on Arrival
❑Other(Specify)
11.Facility Name (If Not Institution,Give Street and Number)
ST MARY'S MEDICAL CENTER OF EVANSVILLE, INC
12.City Or Town,State,And Zip Code 13. County Of Death 14. Marital Status At Time Of Death
®Married 0 Married,But Separated ❑Divorced
EVANSVILLE, IN,47750 VANDERBURGH ❑Widowed ❑Never Married ❑Unknown
15.Surviving Spouse's Name 15a. (If Wife)Give Maiden Last Name 16. Decedent's Usual Occupation 17. IGnd Of Business/Industry
WILLIAM CLARK PAULEY SECERTARY MANUFACTURING
18.Residence-State 18a. County 18b. City Or Town
INDIANA GIBSON PRINCETON
18c.Street And Number 18d. Apt.No. 18e. Zip Code 18f. Inside City Limits?
319 SOUTH SEMINARY STREET 47670 ®Yes ❑No
19.Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedent's 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 Maiden Last Name
ARTHUR MADDEN CORRIENE MADDEN LINDSEY
24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address (Street And Number,City,State,Zip Code)
WILLIAM C PAULEY HUSBAND 319 SOUTH SEMINARY STREET, PRINCETON, IN 47670
25.Place Of Disposition
25a.Method Of Disposition 25b.Place Of Disposition(Name Of Cemetery,Crematory,Other Place) '25c.Location-City,Town,And State
®Burial ❑Cremation ❑Donation❑Entombment
❑Removal From State
❑Other(Specify): FAIRVIEW CEMETERY . PRINCETON, IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility 27a. Funeral Home License Number.
❑Yes ®N° HOLDERS FUNERAL HOME OF GIBSON COUNTY, INC.,319 SOUTH MAIN STREET,
OWENSVILLE, IN 47665 FH89000021
27b. Signature Of Indiana Funeral Service Licensee: 27c. License Number(gggg���rricensee):
RANDALL K DIKE, BY ELECTRONIC SIGNATURE FD01010177
Cause Of Death (See Instructions And Examples) jr-jt Approximate
28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On Death
A Line. Add Additinal Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. SHOCK LIVER JA
Due to for As A Consequence oq: A .
Sequentially List Conditions, If.Any,Leading To The Cause Listed On B. HEART FAILURE FROM SEVERE MITRAL REGURGITATION .6 C 021
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated °petatOAeAConeequenaOq J
The Events Resulting In Death)Last C. : 0H CO Q.iy
Due to for as a Consequence on:
D. UIV T}',q �
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? UQ
❑Yes
PULMONARY EDEMA t 30.Were Autopsy Finding Available To Complete The Cause Of D ath? ❑Yes 0 No
31. Did Tobacco Use Contribute To Death? 32. If Female: 33. Manner Of Death:
❑Yes 0 Probabl ®Not Pregnant Wdhin Past Year ❑Pregnant AtT a or Death ❑Not Pregnant Man Pregnant Nn 42 Days Of Death ® ElElElNaturalHomicide Accident Pending Investigation
y®No ❑Unknown
❑Not Pregnant,But Pregnant 43 Days To 1 year Before Death ❑Unknown 1f Pregnantw4Mn The Past Year . ❑Suicide❑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?
❑Yes ❑No
38.Location Of Injury-State 38a. City Or Town 38b. Street 8 Number 38c.Apt.No. . 38d. Zip Code
39. Describe Flow Injury Occurred 40. It Transportation Injury,S ecify:
❑DdveriOperelor ❑Passenger UPedeslrlen❑othe,(
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perm
41.Signature,Of Person Certifying Cause Of Death: 42. Certifier(Check Only One)
MICHAEL GENETA TUANO, BY ELECTRONIC SIGNATURE ®Certifying Physician ❑Coroner ❑Heath Officer
43. Name,Address And Zip Code Of Person Certifying Cause Of Death: 44. License Number 45. Date Certified
MICHAEL GENETA TUANO , 3700 WASHINGTON AVE, EVANSVILLE, IN 47750 01050842A 02/07/2012
46.Additional Funeral Service Provider. 47. •Akas:
48. Signature of Local Health Officer. 49. For Registrar Only -Date Filed (Month/Day/Year):
RAYMOND W. NICHOLSON,JR.,VIA ELECTRONIC SIGNATURE FEB 07 2012
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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:'State'Forrn 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.
_,_,I-: IVRA-20
'': (7/05)