Death Certificate - Reavis, Scott_3/22/2022 . _ 71xve., ev :<+v�ewry:s eiwr -..m...liven.
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lk"* INDIANA STATE DEPARTMENT OF HEALTH
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CERTIFICATE OF DEATH
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Local No 000043 EDR No 000011257190 State No 2022 015472
1.D.cedsrta Legal Name(First,WON, ) la.Malden Name(If female) 2.Gender 3.Time Of Death 4.
A.Reavis
'4. 5.
Indiana
55 MomM Day. Hour. Minutes
9. Ever it U.S.Armed Forces? 10.14 Deer.Occurred In A Hospital: 1Oa.11 Death Occurred Somewhere Other Then A Ibe ital
t. ❑Hoapce FxYy ®Deudeer.Hoar El Nurslrg H m.&ong-enm Care F.ciity
ID Yes ®No ID Unknown ❑Inpatient❑EmergencyDepannrrrr Outpatient ❑Deed on Arrive pMr(g (y)
'jJ 11.Facility Nana(i Not Institution.old.Street and Number)201 E Gibson Street j
12.City Or Town State,AM Zip Code 13.County Of Death 14.Marital Statue Al Time Of Death
Haubstadt,Indiana 47639 Gibson Mairried13 Married,Eke Separated 0 Deemed
El endowed Never Married Unknown
15-Sutvaving Snots.**Nara 15a.law Name Before First Marriage 18.Decoders's Uwai Occ paion 17.Kind Of BualnwIln&etly
M
UAngela Reavis May Pump Mechanic Waste Removal
g 18.R.idence.Slate 18s.County 18b.City Or Town
qIN Gibson Haubstadt
V lea Street And Number 18d.Apt.No. 18e.Zip Code ' 181.reside City Linits7
201 E Gibson Street
47639 ®Yes 0 No
19. D.cW.nrs Education 20. Decedent Of Hispanic Origin 21.Decedents Rae
9th-12th grade.No Diploma Not Spanienmispsnlulathe White
22.Parents Name(First,Middle,Law) 23.Parente Naar(First,Minds.Last) 23a.Parents Last Name Before Firm Montage
Jerry Reavis Joan L.Reavis White
24.hlormanI.Nam. 24a.Relationship To Decedent 2416 Mailing Address(Straw And Number,City.State,Zip Cods)
Angela Reavis Wife 201 E Gibson Street.Haubstadt.IN,47639
25.Puce OI Dimdwon
25a.Method Of Disposition 25b.Place Of Dspceition(Name Of Cemetery.Crematory,Outer Prue) 25c.Location•City.Town,AM State
� ❑Burial ElCremationElo Cremation a...1 n IDm Entombne
❑Rend From Sla1e Sts.Peter&Paul Cemetery Haubstadt,IN
®oars(specay):Cremation/Burial
26.Was Coroner Contacted? 27.Name And Complete Address Of Funeral Facility 27a.Funeral Home License Number,
Ziemer Funeral Home North FH83001910
i 0 Yes MI No 6300 First Avenue.Evansville,Indiana,47710
I 27/6 Signature Di Indiana Funeral Service Licensee: 27c License Number(01 Uceneee),FD29400004
Tianie17•Ziemer Electronically Signed
i Cade Ot Death(sea Inerudtwne And Examples) Approximate
28.Pan I.Enter The Chian Cif Events Diseases,Injuries,Or Compicatlone-That Directly Caused The Death.Do Not Enter Terminal Events itrreal Onset
Such As Cardiac Anew.Respiratory Arrest.Or Ventricular FlbriEa8ott Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line.Add Additional Liras If Necessary.
Immediate Cause(Final Disease Or condition Resulting In Death) A. acute on chronic congestive heart failure years
Duo ls,aAsao.w..aos
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B.
Lineo The Cause Listed On
ncovid_19 6 weeks
A. Eter UnderlyingList Conditions,tCad,Leading(01se d°TOr Miley That Indeed ed owls(o a.A Don........04,
The Events Resulting M Death)Last C.
c.ve to.led com...r+0e.
D.
Pen I.Enter Otter term C...erh. ...wew..:w.to Death But Not Resulting In The Underlying Cade Given in Pan I 29.Was An Autopsy Performed? ❑alas ®NO
30.Were Autopsy Finding Available To Constw.The Cause Of Death? ❑Yea ❑NO .
31.Did Tobacco Use Conebule To Dean? 32. I Female: 33.Manner Of Death:
❑w,.•..ew,r vein........ p r.P...o"nem r..a 0 ww...ar.,a,...+o. ow••c o.rs wo.o, ®Nai,rd 17 Hanci e 0 Accident ❑Pending r meitle on
❑Yes ❑Probably®No 0 Unknown ❑....news.aw h.a.r•4 01.0 Tot yr...n>.mew, ❑1ai.o.0 s..,..wnn aw I....... 0 alma.0 Could Not B.Determined
34.Dee Of Injury(Month/Day/Year) 35.Tins Of Injury 36.Pad Of injury(E.G Decedents Home,Construction Site,Restaurant,Wooded Ar..) 37.eery At Work?
p Yes ❑No
' 38.Location OI Injury-Sal 38s.City Or Town 38b.street 6 Nmber 38c.A1x.No. 38d.np Code
39. Describe How M ry Occurred 40.t Trombone-eon Injury.Specify:
Do....a.....law....,❑e.e.s.. ❑oewdean
41. 1 42.Certifier(Check Only Ore) -
; Cerify.tg Cate Of Death: Electronically Signed OnCen814 g Pnyalcien o tutor.. o Health GIoer
43.Name,Address And fop Cod.O1 Person Cerirying Cause Of Death: 44.License Nurrbar 46.Dar cwieed
Karl Wayne Sash Suite 300E,801 St.Marys Drive.Evansville.IN 47714 01050566A 03/10/2022
46.AddldorWProvide:F Service Provide: 47.-Aka.:
48.Signature of Lon Health Officer: 49. Foe Registrar Only .Data : p gar BrinkJr. Electronically Signed J t'
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AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORt(ENAU
4QC2 -cq -31 -3ov -,0 floe (--1 t-t_�szC� MAR 22 2022 -,
Stain Form 59385 ATTENTION ESTATE:The SoeMI Security a is being requested by this stab agency in order to Pureure rapwtabiily. Oi.cbetre is hroi,rllity ariQ wi ban *�itl�
/GIBSON COUNTY AUDITOR
WARNING TURNS FROMOORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUMENTAS ASHIDDEN PON FRONT THARTEAP EARS WHEN PHOTOCOPIED.
ON BACK THAT