Death Certificate - Sloan, Susan_3/3/2021 Vit's rr --:,-.17r0k -
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• a#R i c• -i INDIANA STATE DEPARTMENT OF HEALTH•;' -" 1
xt ,tj, :" `Y` CERTIFICATE OF�DEATH _
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t. a ., Local'No 9 . , " - ' I. 'EDR No":.000011054942'..i,{ . State No ?021:002455', "' ' ' ! ,
,�C , -_ 1.Decedent's Legal Name(First,Middle,Last) -• - ta.Malden Name(If female) - 2:Gender : -3:Time Of Death 4.Date Of Death(MonthfDay/Year) .. .- 1
n G - " " I - i Female =. 09'00.PM 1 .01/23/2021 " ,1
! - .Susan G Sloan I • , ".. --; ,.. Bartley 11, { . i' • ,i,,. -.,. , .,-r, 1. ;-'" I
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Princeton,Indiana 1
- Months '= ', Days `- Homs�. t Minutes.: _ ~ `1
'+\ • 9.Byer m U S Armed Forces? 10 If Death Occurred In A Hospital: , , ,t 1 ▪ulOa If Death Occurred Somewhere Other Than A Hospital i '- I,, i
f,B -" 1 f • V.I ."❑"Hospice Feat}, `-❑Decedent's Home'' 0 Nursing Home/Long-term Care Fanljty i
' 0 Yes'MI Not ErUnknown' ®Inpatient 0 Emergency Department Outpatient F❑Dead Oil'Arrival- 1 _ • I ' ' ' . - , I
4 11•Faality Name(if Nat Insgtution,Give Street and Number) - -
ti Indiana University Health University Hospital ;
t2.,City Or Town.State,And Zip Code• „ 1 ' . : , 13.'County Of Death ' 14.,Marital Status At Time Of Death I
�� - I'' :- - - ❑`Married❑Married,But Separated i l Divorced '
Indianapolis,Indiana,- Manon
_ - 0 Widowed ❑Never Married.,❑Unknown
�--- -115..Survlvmg Spouse's Name,, ` - I ,15a LestName Before First Marriage ,'{, .i e. Decedent's Usual Occupation 17:Kind Of Bus,nesslydustnf"- i
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� 11 I • i I a 1` None I None : 1
,,p 18.Residence,,State _ 18a.-County 1, '1'c, -( .18b._City Or Town :a - , -
-\ IN I Gibson 1,1'''- ' I Francisco'
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18c`Street And Number , , II Ill'I,1 ! 1 i ;18d. Apt No. 18e:Zlp Code 18f Inside City Limits?
e 1' 7219 East St Rd 64 I ,' - . I 47649 ❑Yes;I$J No 1-1
19-Decedent's Ed1.ucation -on ,, " = 20.Decedent Of Hispanic Origin -21- Decedent's Rac .e'-
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rSome college but no degree ' Not Spanish/Hispanic/Latino „I wnde •
22,Parent's Name(First,Middle:Last)., - - , '•. ' Z3 Parent's.Name(First,Middle Last)_ _ , _ 23a.Parent's Last Name Before First Marriage'
:Edward Bartley, ,,, Lillian Rowefla Bartley Cadell
-24.Informant's Name • 24a.Relationship To Decedent, 24b.Mailing Address'(Street And Number,City,State,Zip,Code) • { , I 1
I -'Karin Sloan.: - ' . ' - Son - - , . •"7219,East St Rd 64,Francisco,IN,•47649 ' - -
i -- 25"Place OI D s srllori s" . ' I
125a1,,Method Of,Disposition' it Ii , ' 251a,,place 01 Disposition(Name Of Ge m lery,Crematory Other Place) 25c Location City,Town,And Slate �i -1
0 Burial'®Cremation Q Donadon'❑Entombment q �,r- ,1!
❑Removal From Stale I v- r + '� ' ' I
• - - Evansville Crematory i- - :,' Evansville,-IN - - - - i
.❑olher(Specdyl:i` ... r ,
- --' 26.Was Coroner Contacted?. - 27.Name And Complete Addre I I•- I,' r, " ' `I , 27a.,Funeral Home License Number:• "
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1 - Lamb Barham rMemoria. p I, ,. -1, ' + 1,
.`❑Yes ❑No": , I , _ ', : Inc.226E.-Washington r.et, "a and 47660 _, II ; H63005312 I
27b,Signature Of Indiana Funeral Service Licensee: . _ 1 :-I• " . - 27c.-License Number(Of Licensee):' -
:I FD01016589 i
Any-Lee Baskam : ', l .'I r ctronically Signed , ' :t
h I i, L 1 i 1 �IIp���l�1O�f�pP� tructlons And Examples). _ ,Approximate ' ' 1
28.'Part I.Enter The Chain Of Events--'DIseases,injuries,Or Complications ,lre aused,The Death,,Do Not Enter Terminal Events. 1 ',Interval:Onset , -'
Such As Cardiac:Arrest Respiratory'Arrest Or Ventricular Fibrillation Without Showing The Etiology:'ci Not Abbreviate:Enter Only One Cause On ., To Death •I
_ A Line Add Additional,Lines If Necessary `, '---, '' _ ".'I' _ -•'I ," -: ' : - 1 I ' 1
• i• Irnmediate Cause(Final Disease'Or Condition Resulting In Death) ' `Acu •IAfi 14'.+,,. � kgmia`s/p allogenelc stem cell trasnplant I years , "
I I, .' AUDROR DUpr41e A,ADenoq �, . I
a (�1�at� act( days
Sequerrilallly List Conditions;Ii Any,Leading To The Cause Listed On
,� �. - .•, `,` t ` -Due to(Or NAfaeeWerce Oil
,,. -Line A Enter,The Underlying Cause(Disease Orinjury That Initiated f 'f I, " 1
k ,,i -The Events,Resulting In Death)Last II, :''I c I 'Multisystem'organ allure 1 1 , '• " ) days I
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, I 1 I .--. ` 1 1 (• .I„ ill' r,Du,to ierMMACo'eeeueren nit _ ' I `
- ,,-0 ,ISiibarachnoid'hemorrhage _ _ , - . , hours : 1 -
P lt.Enter Other Sicnircant Conditions Caninbutina to Death But Not Resulting In The Underlying Cause Given In Part I - 29.,Was An Autopsy Performed?' ': - -
ar1 . _ .l .❑Yes ❑No,., • I
II I ' 30.Were Autopsy Finding Available To Complete The Cause Of Death?I ' ,1
1 , ' 1 .< ❑:Yes ❑No
� ` 31.Did Tobacco-Use Contribute To Death? 32.it Female: i, ▪ I I , _ , 33..Manner Of Death . -- • -t
• Igl„ P yu,viv`w P y ' .❑P egnaia 4,Time or oraic"❑N,P„pnaet,cut Prepnant t:ilinin 42 see,m Deem I Natural❑r Homicide 0 Accident 0 Pending Investigation
❑Yes ❑Probably I�No-0 Unknown r I .l
I. `• i' ❑Nol Pn.me.anP gneiaeq T rymre.,or oven; .. El°N2ES II Rr'a"'+wew.Tn,Put v "-. ❑Suicide Could Not Be Determined'.. I, ,
, 1 34,- Of,injury(Month/Day/Year) 35.Time OI Injury 36.Place 0f Injury(E.G.,Decedent's Home,Construction Site,Restaurant,Wooded Area) li 37. injury Al Works 1 i i I
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' 38.Location 01 Injury-State= 38a.City Or Town '' - '38b Street 8 Number • '38c Apt.Nei-. 38d.Zip Code • '
OR III, I', I I 1 11 ' „I i` I i 1 f , l I i I,
39,Describe How Injury Occurred -I., i I 1 ' •I- I i,' 1i • 40,if Transportation Injury,Spnaty: I -' I j' • I.1
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.. _. I _ DD'N"rO1er,❑P erem DPoeewv,''•❑omerlswchl I
�a 41;Signature,'01 Person Certifyingy Ccd'se'Of Death - I J -,I i i' 42"Certifier(Check Only One)• - ' l 1I I - I
W._.-, A ry'• kley , • " 9 - . 1 Electron ally Signed I ' •®certifying Physician, ,. ❑Coroner ❑Health Officer,
`l' Cattrtar)h And SKa r6uc �. -�- ` '� Electronically
1 . i 43.•Name,Address And Zip.Code Of Person Certifying Cause OI Death:.:- , , . ' ' ,•I,:' `I 1' ,I i ,,• , I• 44 License Number 45.;Date Certitied .
c Caitnona Ann Mary Buckley 550 N)Jnivw rsiliy Blvd,Ste.`2180 Indianapolis,IN 46202` ' - : 0107,9171A 01/26/2021 _ " : '
! 46:I Additional Funeral Service Provider:, - ', , 1!1l I;. „I , - 1 47 'Alas: -
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d I 48:_ISignatureof Local Health.Officer. ,i '_.- • ;1,I `;,.;, - = 1 .` 49. For Registrar Only i Dale Filed:(Morrlh/Day/Year).• ,J
r' '"'VirginiaA.Caine - = c . ' ' ,Electronically Signed : -,, ' " - : /. 1
of .. •',, . . - " - ',1 , '•" '".'; - -,.. ..AMENDMENT To CERTIFICATE OF DEATH(ENTRY OR ORIGINAL), ' -
'01/2612021;'
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;Ai ilI i `..=`State Form 63395 ATTENTION ESTATE:The Social'Se`my-t,is being requested by this state agency Inpu
rsue to responsibility..Disclosure is voluntary and there will be no penalty for refusal.
(L6:k -" ORIGINAL DOCUMENT HAS A'MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER.AND THE GREA T SEAL OF THE STATE OF INDIANA ON aACKTHAT
Oa. WARNING._TURNSFROM.ORANGETOYELLOW.WHENRUBBED._ORIGINALtD000MENT NAB AHIDDEN.VOID.ON=FRONT_'THAT_APPEARS.WHEN.PHOTOCOPIED.'' _ _._;�_.