Death Certificate - Davis, Ruth Ann_5/12/2022 (2) IS IS AN OFFICIAL COPY OF RECORD DF e i.ORIGINAL COPY ON fit,kAT INDIANA STATE DEPARTMENT OF HEALTH - •
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DIANA TATE DEPARTMENT OF HEALTH O
CERTIFICATE OF DEATH
S - .:� Local No 000171 EDR No 000000220346 state No 041813
1.Decedent's Legal Name(First Middle.Last) 1a. Maiden Name(If female) 2.Sea Time Of Death 4. Date Of Death( ntll/DaytYear)
�
RUTHANN DAVIS ALLEN I FEMALE I 3. T ILb
08:45 PM
10.If Death Occurred In A Hospital: 10a. If Death Occurred Somewhere Other Than A Hospital
0 Hospice Facility ®Decedents Home 0 Nursing Home/Long-term Care Facility
0 Yes IS No 0 Unknown 0 Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival ❑Other(Specity)
11.Facilit Sy Name(If Not Insbaioon,Dice Street and Number)
2007SOUTH 175 EAST 12.City Or Town,State.And Zip Code 13. county Of Death 14. Marital Status At Time Of Death
®Martied 0 Married,But Separated 0 Divorced
PRINCETON,IN,47670 GIBSON 0 wio...114 ❑Never Married 0 unknown
15.Surviving Spouse's Name 15a. (if Wde)Give Maiden Last Name 16. Decedent's Usual Occupation 17.Kind Of Business/tndustry
EDDIE DAVIS FACTORY WORKER MANUFACTURING
18.Residence-State 1;3 1 County tab City Or Town
INDIANA GIBSON PRINCETON tBd. Apt.No 19e.ZIP Code ter.Inside City Limits?
18c.Street And Number
2007 SOUTH 175 EAST
47670 0 Yes ®No
19.Decedents Education
20 Decedent Of Hispanic Origin 21. Decedents Race
SOME COLLEGE CREDIT,BUT NOT A NOT HISPANIC White
DEGREE 23.Mothers Name(First.Middle.Last) 23a.Mothers Maiden Last Name
22.Fethefs Name(First Middle.Lest)
FLOYD ALLEN ALMEADA ALLEN MONROE
24.Informants Name 24a.Relationship To Decedent 24b.Mailing Address(Street And Number,City,State,Zip Code)
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.Other Place) 25c.Location-City,Town.And State
B Buriat❑Cremation ❑Donation 0 Entombment
❑Removal(Specify);om S WALNUT HILL CEMETERY FORT BRANCH,IN
❑Ota 27a.Funeral Home License Number.
26.Was Coroner Contacted? 27.Name And Complete Address Of Funeral Fadlity
❑Yes El No COLVIN FUNERAL HOME INC,425 N MAIN ST.,PRINCETON,IN 47670 FH83005671
27c-License Number(Of Licensee):
Signature Of Indiana Funeral Service Licensee: I FD01009940
JOHN W WELLS,BY ELECTRONIC SIGNATURE Cause Of Death(See Instructions And Examples) Approximate
Interval: Onset
28.Pan 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.tinel Lines If Necessary. 3 MONTHSImmediate Cause(Final Disease Or Condition Resulting In Death) A. METASTATIC PANCREATIC CANCER WITH LIVER M�ET!STASES
T T T - :
On
Sequentially List Conditions. If Any,Leading To The Cause Listed On �..a wcl,.
�
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)last C. •
ow.to.A.4*on
D. MAY 1 2 2022
h But Not Resulting in The Underlying Cause Givin In Pan I 29.•Was An Autopsy Performed? ❑Yes ®No
Pan n.Enter Otne+Sipnmcant COfiditfxns ConthbuUnd to Deal a�
/ , �_�/ Q/Autopsy Finding Available To Complete The Cause Of Death? ❑Yes 0 No
NA ��""" s AQUDITOK 33.Manner Or Death:
31.Did TObacoo Use Contribute To Death? 32. if Female: �.(� LnsT'e..i -rt o.ndo.w, El Natural 0 Homicide 0 Accident 0 Pending Investigation
®,b.eive. w.i.,P..rr.. 0°I v'KJ N YY
0 Yes 0 Probably®No ❑Unknown 0 P,p,,,,,y an v,.e,....s Pays r.th+e e.a.o..a ❑U.,iryw,tlP.•on.ni Worn The P.tl You ❑SuiWe 0 Could Not Be Determined
34.Date Of Injury(MontuDay/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 0 No
3eb. Street&Number 38e.Apt No. 3841.Zip Code
38.Location Of Injury-State 38a. City Or Town sawt� �peci
I8onf.T z LJrP.IInjur.E ...y ❑ow.teow,t
39.Describe How Injury Occurred
42.Certifier(Check Only One) Coroner ❑Heath Officer
at.Signature.O AHMED Cause Of Death: tip Certifying Physic an ❑
tutAOBOOL .BY ELECTRONIC SIGNATURE 44.License Number 45.Date Certited
a3. Name.Address And Zip Code Of Person CenifYNnO Cause Of Death: 09/23/2011
MAQBOOL ARMED 01054343A 421 CHESTNUT ST,EVANSVILLE, IN 47713 47.•Akas:
46.Addbonai Funeral Service Provider.
149. For Registrar Only-Date Filed(Month/Day/Year):
48.Signature of Local Health Officer. SEP 26 2011
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURAE
TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
&Ic k 9(r,, RECEIVED
SQ; 0ocA - MAY 1 2 2022
State Form 53395 ATTENTION ESTATE:The Social Security 9 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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