Death Certificate - Bryant, Ray_5/10/2022 17 - r ttr"' ,---11.,'t Jr r..,. ..IIrasa - - ---- ..---- -----'---
7-k, 0 INDIANA STATE DEPARTMENT OF HEALTH 3948114
CERTIFICATE OF DEATH
# Local No 000809 EDR No 000011270593 State No 2022-021771
1.Decedent's Legal Name(Frst,Middle,Last) lag Maiden Name (II female) 2.Gender 3. Time Of Death 4. Date
Bryant
5.Social
Death Occurred In A Hospital: 10a. If Death Occurred Somewhere Other Than A Hospital
❑Hospice Facility 0 Decedent's Home ilia Nursing Home/Long-lean Care Facility
®Yes 0 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 01 Death
Evansville,Indiana 47725 Vanderburgh ISI Married Married,But Separated 0 Divorced
❑Widowed ❑Never Married ❑Unknown
15.Surviving Spouse's Name 15a.Last Name Before First Marriage 16. Decedents Usual Occupation 17. Kind Of Business/Industry
Johnson Federal Meat Inspector Meat Industry
Delores J Bryant
18. Residence-State 18a County 18b. City Or Town
IN Gibson Fort Branch
18c.Street And Number tad.Apt.No. 18e.Zip Code 18f. Inside City Limits?
2079 E 600 S 47648 ❑Yes ilia No
19. Decedent's Education 20.Decedent Of Hispanic Origin 21.Decedent's Race
Some college,but no degree Not Spanish/Hispanic/Latino White
22.Parent's Name(First,Middle,Last) 23.Parent's Name(First,Middle,Last) 23a.Parent's Last Name Before First Marriage
Nelson Bryant Isabelle Rose Bryant Satterfield
24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address(Street And Number,City,State,Zip Code)
Delores J Bryant Wife 2079 E 600 S,'Fort Branch,IN,47648
•
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
0 Removal From State Powell Cemetery Norris City,IL
0 Other(Specify):
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility 27a.Funeral Home License Number:
Stodghill Funeral Home Inc FH10900013
CIYes MI No 500 E Park Street,Fort Branch,Indiana,47648
Sib. Signature Of Indiana Funeral Service Ucensee: 7c. Li is, (Of Licensee): FD21400005
Andrea G Krieg Electronically Signed
Cause 01 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 Evep(p Interval: Onset
Such As Cardiac Arrest,Respiratory Arrest.Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.En er Only One �n .1) To Death
A Line. Add Additional Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. presumed MI S sudden
Co,sepror 01T
coronary artery disease `3 tix e(/ON lZ years
Sequentially List Conditions, If Any,Leading To The Cause Listed On B. Des to la A.
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated 417' ��
The Events Resulting In Death)Last C.
w.to la A.A ConsequenceD (ice,.e4Z.1
C;t
Pan II.Enter Other 4ioniticant Conditions Contributine to Detail But Not Resulting In The Underlying Cause Given In Part I 29.Was An Autopsy Performed? -I ❑Yes ®No
30.Were Autopsy Finding Available To Complete The Cause Of Death? ❑yes 0 No
31.Did Tobacco Use Contribute To Death? 32. If Female: 33.Manner Of Death:
0 not Pregnant w Tao.01 Past Year 0 Prplant At Ta of Don ❑...Pregnant.
Preant.an Within 42 Days of 0.ah I1lf Natural 0 Homicide 0 Accident ❑Pending Investigation
❑Yes ❑Probably Din No ❑Unknown
0 net Pregnant.an Pregnant 43 Day.To I year Belem Dearth 0 UnIrneran n Pregnant mesa the Pea Year 0 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?
❑Yes ❑No
38.Location Of Injury-State 38a. City Or Town 38b.Street 8 Number 38c.Apt.No. 38d.Zip Code
•
39. Describe How Injury Occurred 40. IfTransportation Injury.Specify:
❑omarfoperav ❑Peasenger❑P.uean.n Dover lsr.uWI
41.Signature,01 Person Certifying Cause Of Death: • 42.Certifier(Check Only One)
Kari,GVayueSash _• Electronically Sifrled ®Certifying Physician ❑Coroner ❑Health Officer
• 43.Name,Address And Zip Code Of Person Certifying Cause Of Death: _ 44.License Number 45.Date Certified
Karl Wayne Sash Suite 300E,801 St.Marys Drive,Evansville,IN 477.14 - ' .. 01050566A 04/11/2022
46.Additional Funeral Service Provider: ---- ..♦.. .. 47.'Akita:
48. Signature of Local Health Officer: : • . - ,'-49. For Registrar Only -Date Filed (Month/Day/Year):qo . 04/12/2022
Electronically Signed ..
AMENDMENT TO CE FIG'Tti Of PEATI4(ENT,RY OR ORIGINAL)
Other Factors-
O of -\A� -ktotc . 0 V - tC). �`.0
State Form 53395 ATTENTION ESTATE:The Social Security ft is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary and there will be no penalty for refusal.
WARNING: TURNS FROMCORANG TO YELLOW WHEN RDUBBED.ORIGINAL DOCUMENT HAS A$HIDDEN VOID ON FRONT THATEAP EARS WHEN PHOTOCOPIED.INDIANA ON BACK THAT