Death Certificate - Davis, Ruth Ann_5/12/2022 HIS IS AM OFFICIAL COPY OF.F1 e 'D OF DEA H.O LCOPY ON 1 AT INDIANA STATE DEPARTMENT OF HEALTH p
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INDIANA STATE DEPARTMENT OF HEALTH
aleLi. it, CERTIFICATE OF DEATH Y\`• ,_, " Local No 000171 EDR No 000000220346 state No 041813
1.Decedent's Legal Name(First,Meddle.Last) 1a. Maiden Name(II female) 2.Sex 3. Time Of Death
10.If Death Occurred In A Hospital:
10a. 8 Death Occurred Somewhere Other Than A Hospital
0 Hospice FaGtly ®Decedent's Home ❑Nursing HOme/Long-term Care FaG:rty
0 Yes ®No ❑Unknown 0 inpatient 0 Emergency Department Outpatient 0 Dead on Arrival ❑Omer(Specify)
il.Facility Name(If Not Insbtetion,Give Street and Number)
2007 SOUTH 175 EAST 13.County Of Death 14, Mantel Status At Time Of Death
12.City Or Town.State.And Zip Code
0',endowed m �0 NeKctMdrt Cd t 0 Unknown
PRINCETON,I N llie GIBSON
15a. (e Wde)Give Maiden Last Name 16. Decedents Usual Occupation 17. KenoNev r Married
ssllrtdu
15.Stxviving Spouse's Name
FACTORY WORKER MANUFACTURING
EDDIE DAVIS 18 Cc my 18b. City Or Town
18.Residence•State
INDIANA GIBSON PRINCETON
18c.Street And Number 18d. Apt No tee. Zip Code 18r. Inside City Limits?
❑Yes No
2007 SOUTH 175 EAST 47670
19.Decedent's Education
20.Decedent Of Hispanic Ongin 21. Decedents Race
SOME COLLEGE CREDIT,BUT NOT A NOT HISPANIC11e
DEGREE 23.Mothers Name(First,Middle,last) 23a.Mothers Maiden tact Name
22,Fathers Name(First.Middle.Last)
ALMEADA ALLEN MONROE
FLOYD ALLEN 24a.Relanonship To Decedent 24b.Mailing Address(Street And Number,City,State,Zip Code)
24.Informant's Name
EDDIE DAVIS HUSBAND 2007 SOUTH 175 EAST. PRINCETON,IN 47670
25.Place Of Disposition
25a Method Of Disposition 25b,Place Of Disposition(Name Of Cemetery.Crematory.Omer Place) 25c.Location-City.Town.And State
el Burial 0 Cremation 0 Donation 0 Entombment
❑RemOtteoval
(Specify): WALNUT HILL CEMETERY FORT BRANCH.IN
❑ Coroner
(Specify): 27a. Funeral Home License Number.
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility
❑Yes ®NoFH83005671
COLVIN FUNERAL HOME INC,425 N MAIN ST.,PRINCETON,IN 476 a0 License Number(IX t.iCl seo):
27b.Signature Of Indiana Funeral Service Licensee:
JOHN W WELLS,BY ELECTRONIC SIGNATURE FDO1009940
Cause Of Death(See Instructions And Examples) Approximate
Interval. Onset
28 Part I Enter The Chain Of Events -Diseases.Injuries.Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events To Death
Such As Cardiac Arrest.Respiratory Arrest.Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On
A Line.Add Add,tinat Lines If Necessary. 3 MONTHS
Immediate Cause(Final Disease Or Condition Resulting In Death) A. METASTATIC PANCREATIC CANCER WITH LIAs A VER METASTASES
Sequentially List Conditions. If Any.Leading To The Cause Listed On
B. IL E n.s.:cn_ e.00
TLine A.he Events Enter
Resu Uncle Oeau,Cause(Disease Or Injury That Initiated C.
Last o,,.m to♦.♦cw.+a.sesr.or,
D. MAY 1 2 2022
0 An Autopsy Yes el No
Para II.Enter Oa1er eyidnAieant Conditions Contfibutirw to Death But Not Resultng In The Underlying Cause Gitin In Part I Was Autopsy Finding Available To Complete The Cause Of Death? ❑Yes 0 No
NA �Yl�..C44 0GL a' �paUpilTOR 33.Manner Of Heath:
31.Did Tobacco Use Contribute To Death? 32. n F r.e e: o.,n b..c 33 Natural 0 Death: 0 Accident 0 Pending mvestipatoe
®,:e,e iale.....e....,... 0
eip"C3'(.O..t. 4Una,.n° `
0 Yes 0 Probably®No 0 Unknown 0 uae..e.ee eel w.v,.,to an re,..d Se...D..a 0...,.....yR.pve We,e tt+Psis,Yw 0 Suicide 0 Could Na Be Determined
ry
34.Date Of Injury(MonOUDayKear)
35.Time Of Injury 36. Place Of Injury(E.G..Decedent's Home.Construction Site,Restaurant,Wooded Area) 37.0 Yes At
Wdr?El No
38.location Of Injury-State 38a. City Or Town
30b. Street 8 Number 38c.Apt.No. .38d.Zip Code
14❑O. If TransOOrla Wn injury.$PecrfF 0....„,.....,,
39.Describe Hon Injury Occurred L�11 �n.dw..e
42.Corti6er(Check Oniy One)
41.Signature.Of Person Cerefyirq Cause Of Death: , ®CetlOorng Pnysl On ❑Coroner ❑Heath Officer
MAQBOOL AHMED,BY ELECTRONIC SIGNATURE 44.License lumba 45.Date Catered
43.Name.Address And Zap Code Of Person CeMying Cause Of Death: O1054343A Og/2 Certified
MAQBOOL AHMED 421 CHESTNUT ST,EVANSVILLE,IN 47713 1 •Alias:
46.Additional Funeral Service Provider
49. For Registrar Only-Date FiledSEP(Month/Day/Year):
48.Signature of Local Health Officer: 26 2011
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) RECEIVED
EiAtp,-I Sk----,
-- /Cv4A(A 1-0,-) • MAY 1 2 2022
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.
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