Death Certificate - Beal, Norma_4/14/2022 V INDIANA STATE DEPARTMENT OF HEALTH
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EDR No 000000806690 State No 053032 0
1.Decedent's Legal Name(First,Middle,Last) 1a. Maiden Name(If female) 2.Sex 3. Time Of Death
94 Months Days Hours Minutes
0 Hospice Facility 0 Decedent's Home ®Nursing Home/Long-term Care Facility
0 Yes ®No 0 Unknown ❑Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival 0 Other(Specify)
11. Facility Name (If Not Institution,Give Street and Number)
NORTH RIVER HEALTH CAMPUS
12. City Or Town,State,And Zip Code 13. County Of Death 14. Marital Status At Time Of Death
0 Married 0 Married,But Separated 0 Divorced
EVANSVILLE, IN,47725 VANDERBURGH El Wdowed 0 Never Married 0 Unknown
15. Surviving Spouse's Name 15a.Last Name Before First Marriage 16. Decedent's Usual Occupation 17. Kind Of Business/Industry
HOMEMAKER HOMEMAKING
18. Residence-State 18a. County 18b. City Or Town
INDIANA VANDERBURGH EVANSVILLE
18c. Street And Number 18d. Apt.No. 18e. Zip Code 18f. Inside City Limits?
811 EAST BASELINE ROAD 47725 El 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.Parent's Name(First,Middle,Last) 23.Parent's Name(First,Middle,Last) 23a.Parent's Last Name Before First Manage
LEVI BILDERBACK ELIZABETH BILDERBACK COLEMAN
24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address(Street And Number,City,State,Zip Code)
BONNIE GIBBS DAUGHTER 3626 ORCHARD ROAD, EVANSVILLE, IN 47720
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 0 Cremation 0 Donation❑Entombment
❑Removal From State ST STEPHEN'S COMMUNITY CHURCH
❑Other(Specify): CEMETERY HAUBSTADT, IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility 27a. Funeral Home License Number.
®Yes 0 No WADE FUNERAL HOME INC, 119 S.VINE STREET, HAUBSTADT, IN 47639 FH83002990
27b Signature Of Indiana Funeral Service Licensee: 27c. License Number(Of Licens
ALAN J.WADE, BY ELECTRONIC SIGNATURE FD01 Cause Of Death (See Instructions And Examples) Approximate
28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death-Do Not Enter Terminal Events IL
Interval: Onset
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Additional Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. RESPIRATORY FAILURE nP R 1 42.022 SUDDEN ONSET
Due to(Or As A Consequence Ory:
Sequentially List Conditions, If An LeadingTo The Cause Listed On B. MULTIPLE COMPRESSION FRACTURES OF THE LUMBAR SPINE ,) SUDDEN ONSET
q Y Y. 8u.to(Orp.A coveeW.r,w of /�
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated Liyi _!�� U • up)•`QR
The Events Resulting In Death)Last C. BS0 Cout41 A
Duo to(Or ea a Cons...no*00: G‘B5014
D.
Part II.Enter Other Significant Conditions Contributing to Death But Not Resulting In The Underlying Cause Given In Part I 29. Was An Autopsy Performed? ❑Yes ®No
30. Were Autopsy Finding Available To Complete The Cause Of Death? 0 Yes 0 No
NONE
31. Did Tobacco Use Contribute To Death? 32. If Female: 33. Manner Of Death:
0 Nor Pregnant v m,Pe.Veer El .n Pregnant cut T .Otaath El Not mean....Bv w wrn t Pros...vntn.2 Days or paNatural 0 Homicide ElAccident 0 Pending Investigation
0 Yes 0 Probably®No 0 Unknown
❑cut Pregnant.Bon Pregnant 43 Day.To t year Before D.rh 0 Unwno.n B Pi.go•0 w.n.r Tn.Par roc 0 Suicide 0 Could Not Be Determined
34. Date Of Injury(Month/Day/Year) 35. Time Of Injury 38. Place Of Injury(E.G.,Decedent's Home,Construction Site,Restaurant,Wooded Area) 37. Injury At Work?
\d ❑Yes 0 No
38. Location Of Injury-State 38a. City Or Town 38b. Street S Number _�` 1 38c. Apt.No. 38d. Zip Code
a
al'is D clls �`' ////� C C q( `4 ❑ n p\ �1[•r
39. Describe How Injury Occurred �CJ �/ `� V\ E �_/J . If Transportation Injury, -.city: (B�
eim..L_I�- �!1 - tam631 � �lf/ D D,.r.ta ❑P.�.�.r �.arr.n ❑�n.r raryt
41. Signature, Of Person Certifying Cause Of Death: 42 Certifier(Check Only One)
KARL WAYNE SASH , BY ELECTRONIC SIGNATURE __ , ®Certifying Physician ❑Coroner 0 Health Officer
43. Name.Address And Zip Code Of Person Certifying Cause Of Death: 44. License Number 45. Date Certified
KARL WAYNE SASH ,3801 BELLEMEADE AVENUE,SUITE 200E, EVANSVILLE, IN 47714 01050566A 09/29/2020
46. Additional Funeral Service Provider 47. 'Akas:
48. Signature of Local Health Officer 43. For Registrar Only -Date Filed (Month/Day/Year):
ROBERT KENNETH SPEAR,VIA ELECTRONIC SIGNATURE SEP 29 2020
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR CRIGINAL)
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State 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.
WARNING: ORIGINAL DOCUMENT ULTICOLORED BACKGROUND ON SPECI WHITE SECURITY PAPER AND THE GREAT SEAL OF TT OF INDIANA ON BACK THAT
TURNS FROM ORANGE TOHAS YELLOW WHEN RUBBED.ORIGINAL DOCUMENTAL HAS A HIDDEN VOID ON FRONT THAT APPEARS WHENTHE PHOTOCOPIED.
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