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4--. INDIANA STATE DEPARTMENT OF HEALTH
yn CERTIFICATE OF DEATH 3717319
`� `_f 001056 EDR No 000011195671 State No 2021-065360
'� Local No
1.Decedent's Legal Name(First,Middle,Last) 1 a. Maiden Name (If female) 2.Gender 3. Time Of Death 4. Date Of Death (Month/DayNear)
Female 08:10 AM 11/
City,Indiana
61 Months Days Hours Minutes
9. Ever in U.S.Armed Forces? 10.If Death Occurred In A Hospital:
10a. If Death Occurred Somewhere Other Than A Hospital
0 Hospice Facility 0 Decedent's Home 0 Nursing Home/Long-term Care Facility
0 Yes all No ❑Unknown 1$1 Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival ❑Other(Specify)
11. Facility Name (If Not Institution,Give Street and Number) Encompass Health-Deaconess Rehabilitation Hospital
12. City Or Town,Slate,And Zip Code 13.County Of Death 14. Marital Status At Time Of Death
Warrick Li Marr ❑Marrie4 But Separted ❑Divorced
Newburgh,Indiana 47630 ❑wieowedied ❑NeveurManieda ❑unknown
15. Surviving Spouse's Name
15a.Last Name Before First Marriage 16. Decedent's Usual Occupation 17. Kind Of Business/Industry
LaMar Disabled Disabled
David Allen LaMar 18b. City Or Town
18. Residence-State 18a. County
IN Gibson Hazleton
I 18d. Apt.No. 18e. Zip Code 18f. Inside City Limits?
1 ec. Street And Number
47640 ❑Yes ❑No
7244 N State Road 65 I
19. Decedent's Education
20. Decedent Of Hispanic Origin 21. Decedent's Race
High School graduate or GED completed
Not Spanish/Hispanic/Latino White
23.Parent's Name(First,Middle,Last) 23a.Parent's Last Name Before First Marriage
22.Parent's Name(First,Middle,Last)
Jerry D Bailey Maxine Lois Bailey Ivy
24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address (Street And Number,City,State,Zip Code)
David Allen LaMar Husband 7244 N State Road 65,Hazleton,IN,47640
25.Place Of Disposition
25a.Method Of Disposaion 25b.Place Of Disposition (Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State
❑Burial ®Cremation 0 Donation 0 Entombment
❑Removal From State Evansville Crematory,LIc Evansville,IN
❑Other(Specify): 27a. Funeral Home License Number:
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility
Colvin Funeral Home Inc 425 N Main St.,Princeton,Indiana,47670 FH83005671
❑Yes ®No
27c. LicenPILee) 2153
27b. Signature Of Indiana Funeral Service Licensee: Electronically Signed
4(yckardrDxckro� Approximate
Cause Of Death (See Instructions And Examples) PP
APR
Interval: Onset
28 Part I.Enter rdia The Chain Of Events -Diseases, ic Orib Complicationstio -That Directly Caused The Death.Dore Not Enter Terminal Events /" To Death
Such A dc Arrest,iRespiratoryINcNecessary.
Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause O, � 1 20
Line. Add Cause Additional
Lines If a Or Condition
Acute pulmonary embolism 22 20 minutes
Immediate Cause(Final Disease Or Condition Resulting In Death) A. ovmcor..Aoo". �
Sequentially List Conditions, It Any,Leading To The Cause Listed On B. Duo to(Or M A CPn•mry m o1O~CO(/ A 0/''
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated �'�-•P J
ow Events Resulting In Death)Last C. a to for M A cor..3,ary 00, R
D.
Part II.Enter Other Sianmcant Conditions Contributing to Death But Not Resulting In The Underlying Cause Given In Part I 29.Was An Autopsy Performed? ❑Yes Im No
30.Were Autopsy Finding Available To Complete The Cause Of Death? 0 Yes 0 No
Severe COPD and recent Death?
19 infection 33. Manner Of Death:
31. Did Tobacco Use Contribute To Death? 32' If Female:
®Not Pr.pnsnt WSW Pal rev 0 Pi .1.t Time otowm 0 NmPrw,•rw a,t P,.m.^t`v"h'"'s wnaDamn ®Natural❑Homicide 0 Accident 0Pending investigation
0 Yes all Probably 0 No 0 Unknown 0 Not P,....do P.9...a o•r.To t rmre.m,•o.am ❑Unkno.,r x P,.gnmuwer,n n.P.m Taw El Suicide 0 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?
0 Yes ❑No
CityOr Town 38b. Street 8 Number 38c. Apt.No. 38d. Zip Code
38. Location Of Injury-State 38a.
40. If Transportation Injury,Specify:
39. Describe How Injury Occurred ❑o"..,.on.,•tor ❑P•...nu«❑,•.e.•w"❑ou..lSe.Nlrl
41. Signature,Of Person Certifying Cause Of Death: 42.Certifier (Check Only One)
Askokl�mar/Dkingra Electronically Signed ®Certifying PhysicIan ❑coroner 0 Health Officer
44. License Number 45. Date Certified.,, 43. Name.Address And Zip Code Of Person Certifying Cause Of Death:
Ashok Kumar Dhingra 9355 Warrick Trail,Newburgh,IN 47630
01041108A 11/16/2021
47. 'Akers:
46. Additional Funeral Service Provider:
48. Signature of Local Health Officer: 149. For Registrar Only -Date Filed(Month/Day/Year): 11/1 T/ZO21
Qifcky0'Yeager Electronically Signed
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
a -06-,,,,Ice,- W.v6--O/7 ail-
Form 53395 ATTENTIOORINAL DOCUMENTI HAS AIMU114_8 LO EED BACKGROUNDtON SPECIAL WHITE SECURIT Y PAPERryAND THE GREAT SEAL OFtTHd E STATEbe OF NDIANA ONrBACK THAT
WARNING. TURNS FROM ORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUMENT HAS A HIDDEN VOID ON FRONT THAT APPEARS WHEN PHOTOCOPIED.