Death Certificate - Davis, Ruth Ann_5/12/2022 (3) NIS IS AM OFFICIAL COPY OF REC'RR I F ! t'I AL.CO'.YvQU F LE T.INmANA STATE DEPARTMENT OF HEALTH
,0a� INDIANA STATE DEPARTMENT OF H ALTH �-5 3 4 3 3 8
/ t CERTIFICATE OF DEATH -
' Local No 000171 EDR No 000000220346 State No 041813
1.Decedents Legal Name(First.Middle.Last) ie.Malden Name(If female) 2.See Time Of Death
PRINCETON,IN
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 FaoTty ID Decedent's Home 0 Nursing Home.Long-term Care Faciidy
0 Yes El No 0 Unknown 0 Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival ❑Other(Specify)
11.Faciety Name(If Not Insablbon,Give Street and Number)
2007 SOUTH 175 EAST
12.City Or Town.State.And Zip Code 13. County Of Death 14. Marital Status Al Time Of Death
®Mamed 0 Married.But Separated 0 Divorced
PRINCETON,IN,47670 GIBSON 0 Widowed 0 Never Married 0 unknown
15.SuMNng Spouse's Name 15a. (If Wile)Give Ma den Last Name 18. Decedents Usual Occupation 17.Kind Of Business/Industry
EDDIE DAVIS FACTORY WORKER MANUFACTURING
18.Residence-State 19a Ccunt lab Coy Or Town
INDIANA GIBSON PRINCETON 180. Apt No tad.zpcoda ter'. Inside city Limits?18c.Street And Number
❑Yes ®No
2007 SOUTH 175 EAST 47670
19.Decedents Education 20. Decedent Of Hispanic On9in 21. Decedent's Race
SOME COLLEGE CREDIT,BUT NOT A NOT HISPANIC White
DEGREE 23.Mothers Name(First.keddle.Last) 23a.Mother's Maiden Last Name
22.Fathers Name(First,MtidGa,Last)
FLOYD ALLEN ALMEADA ALLEN MONROE
24.Informants Name 24a.Relationship To Decedent 24b.Malting 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
®Burial 0 Cremation 0 Donation 0 Entombment
❑Removal From State FORT BRANCH, IN
❑Other(Specify): WALNUT HILL CEMETERY 27a.Funeral Home License Number.
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility
❑Yes ®No COLVIN FUNERAL HOME INC,425 N MAIN ST.,PRINCETON,IN 47670 FH83005671
27b.Signature Of Indiana Funeral Service Licensee: 27.License Number(Of Licensee):
JOHN W WELLS,BY ELECTRONIC SIGNATURE IFD01009940
Cause Of Death(See Instructions And Examples) Apprommate
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 Addtinal Unes If Necessary.
3 MONTHS
Immediate Cause(Final Disease Or Condition Resulting In Death) A. METASTATIC PANCREATIC CANCER WITH LIVER M�ETAS ES
Sequentially List Conditions. If Any,Leading To The Cause Listed On
F ILE :. on
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last C. D,,,o„a A.♦cov..o..nr.on
D. MAY 12 2022
Part II.Enter Other Significant Conditions Contributing to Death But Not Resulting In The Underlying Cause Givin In Part I 29.Was An Autopsy Performed? 0 Yes ®No
/ ,•� rra Autopsy Finding Available To Complete The Cause Of Death? 0 Yes 0 No
r4n � �' ,uDIT Off/ 33.Manner Of Death:
31.Did TODxoo Use Contribute To Death? 32. N Female 0
a'•'''0 NN C I LN'[Yei t Don a o.•w ®Natural❑Homicide ❑Acddent 0 Pending Investigation
0 Yes 0 P.00391y®No ❑Unknown 0 voi PT...Our...MAT O.r.To' •1...+ `G❑biiiirve.,,ee•r,emnr Wit.,m.Pout Too 0 Suicide 0 Could Not Be Determined
34.Date Of Injury(Month/Day/Year) 35.Time Of Injury 38. Place Of Injury(E.G..Decedent's Home.Construction Site,Restaurant,Wooded Area) 37.Injury At Work?
0 Yes ❑No
38.Location Of Injury-State
38a. City Or Town 38b. Street 8 Number 38c.Apt.No. _38d.Zip Code
Isoeuni400. IfM7ranspo 0 Inju'Y'aectN One.39.Describe How injury Occurred I rot. ....... �P'•°°''
42. Cert der(Check Only One)
41.59natiire•Of Person Certifying Cause Of TR ®Certfying Physician 0 Coroner ❑Heath Certified
MAQBOOL AHMED,BY ELECTRONIC SIGNATURE tile.L cerise Number 45 Date Officer
43.Name.Address And Zip Code Of Person Certifying Cause Of Death: 09/23/2011
MAQBOOL AHMED ,421 CHESTNUT ST,EVANSVILLE,IN 47713 01054343A 47.'Alias
48.Add.utal Funeral Service Provider
49. For Registrar Only -Dale Filed(Month/Day/Year):
48.Signature of Local Health Onicer. SEP 26 2011
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
tNl1 SkC'" RECEIVED
S,,-,„. .. ' MAY 1 2 2022
3395 ATTENTION ESTATE:The Social Security#is being requested by this slate agency in order to pursue responsibility. Disclosure is voluntary and there will be no penalty for refusal.
State Form 5 1VHA 20
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