Death Certificate - Davis, Ruth Ann_5/12/2022 (5) . THIS IS AV OFFICIAL COPY OF RECORD OF.QEATH.,ORIGINAL copy ONFWT HD STATE DEPARTMENT OF HEALTH - O
I DIANA STATE DEPARTMENT OF HEALTH `6 3 4' 3 3 8
'� CERTIFICATE OF DEATH
,/ Local No 000171 EDR No 000000220346 state No 041813
1.Decedent's Legal Name(First,Middle.Lest) la.Malden barns(If female) 2.Sex 3. Time Of Death
10.If Death Occurred In A Hospilal: 10a. If Death Occurred Somewhere Other Than A Hospital
❑Hospice Facility ®Decedents Home 0 Nursing Home/Long-term Care'Fundy
0 YeS ®No 0 Unknown 0 Inpatient 0 Emergency Department Outpauent 0 Dead on Arrival ❑Omer(Specify)
11.Facility Name(if Not InstitubOn,Give Street and Number)
2007 SOUTH 175 EAST
12.City Or Town.State.And Zip Code 13. County Of Death 14. Marital Status At Time Of Death
®Mamed 0 Mamed.But Separated ❑Divorced
PRINCETON,IN,47670 GIBSON 0 Widowed 0 Never Married 0 Unknown
15.Surviving Spouses Name 15a, (a Wife)Give Maiden Last Name 16. Decedents Usual Occupation 17.Kind Of Businessflndustry
EDDIE DAVIS FACTORY WORKER MANUFACTURING
18.Residence-State 183 Ccunryy 18b City Or Town
INDIANA GIBSON PRINCETON 18d Apt No +ae. Zip Code +ef.Inside City Limits?
18c.Street And Number
2007 SOUTH 175 EAST
47670 ❑Yes 0 No
19.Decedents Education 20. Decedent Of Hispanic Ongin 21. Decedent's Race
SOME COLLEGE CREDIT.BUT NOT A
DEGREE NOT HISPANIC White 2aa.Mothers Maiden Last Name
22.Fathers Name(First.Middle.Last) 23.Mother Middle,s Name(Fest, Last)
FLOYD ALLEN ALMEADA ALLEN MONROE
24.Informant's 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
0 Burial 0 Cremation 0 Donation 0 Entombment
❑Removal Front State FORT BRANCH, IN
❑Omer(Specify): WALNUT HILL CEMETERY z7a Funeral Home Ucense t4umber.
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: 27c.License Number(Of Licensee):
JOHN W WELLS.BY ELECTRONIC SIGNATURE IFD01009940
Cause Of Death(See Instructions And Examples) Approximate
Interval:Onset
28
.Part I.Enter rdia The Chaint. Of Events -Diseases.Ventricular Orib Cation i tth ou-That Directlyg Caused The Ali ao Not. nter Terminal Events To Death
Such As Cardiac Arrest.Respiratory Arrest Or Ventricular Fibrillation W lhout Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On
A Line.Add Addtinal Lines It Necessary.
3 MONTHS
Immediate Cause(Final Disease Or Condition ResultingMETASTATIC In Death) A. PANCREAT IC CANCER WITH LIVER n ETA S.ES
Sequentially List Conditions. If Any,Leading To The Cause Listed On B. FILED..c'ia- -oeu*00
., Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last C. a,.a is As A d.,,,.-Eno,on
D. MAY 12 2022
Part II.Enter Other Sianelcant Condlons Contvbutin0 to Death But Not Resulting In The Underlying Cause Givin in Part I 29.Was An Autopsy Performed? ❑Yes El No
/ , r . f Autopsy Finding Available To Complete The Cause Of Death? ❑Yes 0 No
NA VP, :fYEAAkYonaTOR 33. Manner OfDeam:
31.Did Tobacco Use Contribute To Death? 32. If
Female: �,�p�l C I. 0 .pp..., ®Natural❑Homicda 0 Accident 0 Pending Investigation
❑Yes ❑Probably®No ❑Unknovm ❑,,b,p,p,,,,,t,e,,,v..y,..h n o.n To t v..r e.+>.aide 0 u.si....a warmth win.,ri.a.x yw ❑Suicide 0 Could Not Be Determined
34.Date Of Injury(Month/Dayefear) 35.Time Of Injury 36. Place Of Injury(E.G..Decedents Home.Construction Site,Restaurant.Wooded Area) 37.injury At Work?
0 Yes 0 NO
City Or Town 38b. Street 8 Number ( 38c.Apt.No. .384.Zip Code
38.Location Of Injury-State 38a.
4 If Traen:Ir�tbnln�ury._5peciN' ❑�isow,i
39.Describe How Injury Occurred I��d,....awi+� L,Ji" OO�v.�e..�w'"'
42.Certifier(Check Only One) Coroner 0 Heath Officer
at Signature.Of Person Certifying Cause Of Death: ®Certifying PnysxLic ❑
MAQBOOL AHMED.BY ELECTRONIC SIGNATURE 44.L Cerise Number 45.Date Certified
43.Name.Address And IIP Code Of Person Certifying Cause Of Death:
01054343A 09/23/2011
MAQBOOL AHMED ,421 CHESTNUT ST,EVANSVILLE,IN 47713 47. -Aka,46.Additional Funeral Service Provider
49. For Registrar Only -Date Filed(Month/Day/year):
48.Signature of Local Health Officer. SEP 26 2011
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
�,1 RECEIVED
i.
SQ,wAkeila-,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 them will be no penally for refusal.
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