Death Certificate - Bryant, Ray_5/10/2022 (2) I7 '''''. / "^ r'tr "/rr"0 Wr Arr 9»s'F.' r r....
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"'� STATE DEPARTMENT OF HEALTH 3 9 4 81140
CERTIFICATE OF DEATH
Local No 000809 EDR No 000011270593 State No 2022-021771
1.Decedent's Legal Name(First,Middle,Last) la.Maiden Name (If female) 2.Gender 3.Time Of Death
Ray Dean Bryant
10.If Death Occurred In A Hospital: 10a. If Death Occurred Somewhere Other Than A Hospital
0 Hospice Facility 0 Decedents Home CM Nursing Home/Long-tens Care Faohly
pc Yes ❑No 0 Unknown ❑Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival ❑Other(Specify)
11. Facility Name(II Not Institution,Dine Street and Number) North River Health Campus
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12.City Or Town,State,And Zip Code 13.County Of Death 14.Marital Status At Time Of Death
Vartderbur ❑h ®Married❑Mended.But Separated ❑DNorced
Evansville,Indiana 47725 9 Wdoond ❑Never Married ❑unknown
15. Surviving Spouse's Name 15a.Last Name Before First Marriage 16. Decedent's 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 18d.Apt.No. 18e.Zip Code 18f. Inside City Limits?
2079 E 600 S 47648 ❑Yes Ig 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.Parents 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)
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Delores J Bryant Wife 2079 B 600 S,Fort Branch,IN,47648
25.Place Of Disposition
25a.Method Of Dispostion 25b.Place Of Disposition(Name Of Cemetery,Crematory,Other Place) 25c.Location-City.Town,And State
INI Burial 0 Cremation ❑Donation 0 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
p Yes ail NO 500 E Park Street,Fort Branch,Indiana,47648
27b.Signature Of Indiana Funeral Service Licensee: 7c' Lic so er(Of Licensee): FD21400005
Andrea L Krieg Electronically Signed
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 Evqa/ftIyyp� Interval: Onset
Such As Cardiac Arrest,Respiratory Arrest.Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.En er Only One 1318s1)n To Death
A Line. Add Additional Lines If Necessary. . )t
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Immediate Cause(Final Disease Or Condition ResultingIn Death) A. presumed MI rS ,t sudden
0' „.,y cm oo:
e• coronary artery disease ON� � O�1 years
Sequentially List Conditions, If Arty,Leading To The Cause Listed On Due to for As wap9gaer; ),:
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated VNT vJ
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The Events Resulting In Death)Last C.
Due to(Or As A consequence
D. O/1•-
Part II.Enter Other Sienificant Conditions Contribirtin0 to Death But Not Resulting In The Underlying Cause Given In Part I 29.Was An Autopsy Performed? it ❑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 mot P o..n,wm*no Year ❑Pregnant or rin s or Dorm 0 Na P,.gnas.as ereecee worm 42 Days m o..m I>ii Natural❑Homicide 0 Accident 0 Pending Investigation
❑vas ❑Probably®No ❑unknown 0 Not Pr.on..But Pregnant u Days To t year ears.Death 0 w,koo«n n Ptegnen wean The Pam Year 0 Suicide 0 Could Not Be Determined
34. Date Of Injury(Montt/Day/Year) 35.Tme Of Injury 36.Place Of Injury(ED.,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 d Number 38c.Apt.No. 38d.Zip Code
39.Describe How Injury Occurred 40. If Transportation Injury,Specify:
❑Dr orr on,.es ❑Pa®.rs,El Pedestrian❑one ispmmrl
41.Signature,OI Person Certifying Cause Of Death: ••ter'% 42.Certifier(Check Only One)
j rt GyayneSash - Electronically Sigrted Certifying Physician 0 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 Suite 300E,801 St.Marys Drive,Evansville,IN 477.14 ' - 1 -'- 01050566A 04/11/2022
46.Additional Funeral Service Provider: _. ..i-- -_ 47.'Akas:
48.Signature of Local Health Officer: - - _ - `-.49. For Registrar Only -Date Filed(Month/Day/Year):
)Feflcia 9llurphy -. Electronically Signed_- 04/12/2022
AMENDMENT TO CTcIiTIFIG E Of DEATFt(ENTRY OR ORIGINAL)
Other Factors-Tobacco Use- amended on APR-14- 02 f erly Yes; '
' 0� (A -- 1 09- %__k 01_ coot . - D.D
responsibility. Disclosure is voluntary and there will be no penalty for refusal.
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WARNING: TOURNIS FROMORANG TA ELLOW WHEN RUBBED.ORIG NALL N SPITENT HAS A$HIDDE VOID ON FRONT THAT APPEARS WHENE HOTOCOPIEDANA ON BACK THAT