Death Certificate - Davis, Ruth Ann_5/12/2022 (6) :MIS IS AN OFFICIAL COPY OF RECORD OF!. 4, .ORIGINAL COPY ON FILE,.ATAMNA STATE DEPARTMENT OF HEALTH -7
," INDIANA TATE DEPARTMENT 3 EPATMENT OF H ALTH .46 3 4 38
• CERTIFICATE OF DEATH
k2_,_�'' Local No 000171 EDR No 000000220346 State No 041813
1.Decedent's Legal Name(First.Middle.Last) la. Maiden Name(If female) 2.See Time Of Deatn
PRINCETON,IN
9.Ever In U.S.Armed Forces? 10.1f Death Occurred In A Hospital: 10a. If Death Occurred Somewhere Other Than A Hospital
0 Hospice Facility ®Decedent's Home 0 Nursing Hone/Long-term Care Facility
0 Yes ®NO 0 Unknown 0 Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival 0 Other(Spotty)
It.F7GSy Name(If Not lnsatitton,Give Street and Number)
2007 SOUTH 175 EAST 13.County Of Death 14. Marital Status At Time Of Death
12.Cary O<Town.Sate.And Zip Code
®hWmetl❑MWrtied.But Separated ❑Oriented
PRINCETON,IN,47670 GIBSON 0 Widowed 0 Never Married 0 unknown
15.Surviving Spouse's Name 15a. (If Wde)cive Maiden Last Name IC. Decedents Usual Occupation 17.Kind Of Business/Industry
EDDIE DAVIS _FACTORY WORKER MANUFACTURING
18.Residence-State Ida Ccu7+,y 18b. City Or Town
INDIANA GIBSON PRINCETON iBtl Apt.No 18e.Zia Code ter.Inside City Limits?
18c.Street And Number
0 Yes el No
2007 SOUTH 175 EAST 47670
19.Decedent's Education 20. Decedent O/Hispanic Ongin 21. Decedent's Race
SOME COLLEGE CREDIT,BUT NOT A NOT HISPANIC White
DEGREE 23.Mothers Name(First.Middle,Last) 23a.Mothers Maiden Last Name
22.Father's Name(First Middle,Last)
FLOYD ALLEN ALMEADA ALLEN MONROE
24.Informant's 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
®Burial❑Cremation 0 Donation 0 Entombment
❑Removal From State FORT BRANCH. IN
❑Other(Specify): WALNUT HILL CEMETERY 27a. Funeral Home LdenseNumber.
26.Was Coroner Contacted? 27.Name And Complete Address Of Funeral Facility
0 Yes 0 No COLVIN FUNERAL HOME INC,425 N MAIN ST.,PRINCETON,IN 47670 FH83005671
27c.License Number(Of Licensee):
2O.Signature Of Funeral ServiceLELicensee: I FD01009940
JOHN W WELLS,BY ELECTRONIC SIGNATURE
Cause Of Death(See Instructions And Examples) Approximate
Interval Onset
28.Pert 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 Addtinat Lines If Necessary. 3 MONTHS
Immediate Cause(Final Disease Or Condition Resoling In Death) A. METASTATIC PANCREATIC CANCER WITH LIVER METASTASES�
OD
Sequentially List Conditions. If Any,Leading To The Cause Listed On
F ILE13.. aaDa)
Line A.Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last C. ow..do As/,*a 0,1
D. MAY 1 2 2022
Part II.Enter Other Significant Condllon5 Contributing to Death But Not Resulting In The Underlying Cause Gavin In Part I 220.Was 671 Autopsy Performed? ❑YBs 0 No
1.,�, �v _L/�CfJlpis '"� Autopsy Finding Available To Complete The Cause Of Death? 0 Yes 0 No
NA J h(LC/�� ....Tv pdUDITOR 33.MlannerO/Deem:
31.Did Tobacco Use Contribute To Death? 3®rc5F r..e,. �r V... .6.1 eat ,nnou wa....:Der.or oven ®Natural❑Homicide ❑Accident 0 Pending Investigation
v..o,.,,twe., ❑o1-"�'►.0.41. `I vJ'^n'^^n-'- TMPistYaw 0 Suicide❑Could Not Be Determined
0 Yes 0 Probably®No 0 Unknown 0 r.a w.w.M,Da o,.e,.m o Days To t year e.a..o..v, 0 u,.•.w.,,a Pregnant win.,
34.Date Of Injury(Month/Day/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
30b. Street 8 Number 38c.Apt.No. 38d.Zip Code
38.Location Of Injury-State 38a. City Or Tawsiss..a❑oe.
orl�
14onf.TTow..spw LJ�InIury. m+.,Doe.. ,r
39.pescrtCe Hgw Injury Occurred LJ^ve�ih
42.Certifier(Check Only One)
41 Signature,Of Person CD, Cause Of Team: ®Certifying Phystclan ❑CoronerM ❑Heath Officer
43. Name.
AHMED.BY ELECTRONIC SIGNATURE a.LcenseNumber 45 DataCecred
43. N .Address And Zip Code Of Person Certifying Cause Of Death: 09/2 ified
01054343A
MAQBOOL ARMED ,421 CHESTNUT ST,EVANSVILLE,IN 47713 47.'Akita
46.Addsotlai Funeral Service Provider
'P. For Registrar Only-Data Filed(Month/Day/Year):
48.Signature of Local Health Officer SEP 26 2011
BRUCE BRINK JR,VIA ELECTRONIC SIGNATU RE
MENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
1SiS52
" RECEIVED
--Si it en ta,0 - MAY 1 2 2022
State Form 53395 ATTENTION ESTATE:The Social Security d is being requested by this slate agency in order to pursue responsibility. Disclosure is voluntary and there will be no penalty for refusal. ■
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