Death Certificate - Davis, Ruth Ann_5/12/2022 (7) MS IS ALA OFFICIAL COPY OF RECORD OF DEATH.ORIGINAL COPY ONE LgAT INDIANA STATE lEPARTMINT OF HEALTH vy
.• INDIANA STATE DEPARTMENT OF HEALTH '.6 3 4 3 3 8
\.,. i CERTIFICATE OF DEATH�v.1 !-/ Local No 000171 EDR No 000000220346 State No 041813
=' t'n 1a. Malden Name(If female) 2.Sea 3. Time Of Death
10.If Death Occurred In A Hospital: 10a. II Death Occurred Somewhere Other Than A Hospital
0 Hospice Facility 0 Decedent's Home 0 Nursing HomeltOng-term Care Family
❑Yes ®No 0 Unknown 0 Inpatient 0 Emergency Department Outpatent ❑Dead on Arrival 0 Other(Specify)
11.Facibty Name(if Not Insabaaon,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
®Married 0 Married.But Separated 0 Divtxced
PRINCETON,IN,47670 GIBSON 0 Widowed 0 NeeerMarrled 0 unknown
15.Surviving Spouse's Name 15a(if Wde)Give Maiden Last Name 16. Decedents Usual Occupation 17.Kind Of Business/Industry
FACTORY WORKER MANUFACTURING
EDDIE DAVIS 18a.County 18b City Or Town ,
te.Residence-State
INDIANA GIBSON PRINCETON tAa. Apt No tA p e. Zap iA+. Inside City Limits?
t8c.Street And Number
❑Yns ®MO
2007 SOUTH 175 EAST 47670
•
19.Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedent's Race
SOME COLLEGE CREDIT,BUT NOT A NOT HISPANIC White
DEGREE 23.Moyers Name(Fast.Middle,Lase) 23a.Mothefs Maiden Last Name
22.Fathers 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 PWGe) 25c.Location-City.Towrn,And State
®Burial❑Cremation 0 Donation❑Entombment
❑Ren.onbe From Slate FORT BRANCH, IN
El Other(Speedy): WALNUT HILL CEMETERY 27d. Funeral Home LKenSe Nu.�rtan.
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility
❑Yes 0 No ICOLVIN FUNERAL HOME INC,425 N MAIN ST.,PRINCETON,IN 47670 FH83005671
27c.License Number(Of Licensee):
27b.O N W WELLS,BY Service Licensee: I FD01009940
JOHN W WELLS,BY ELECTRONIC SIGNATURE Cause Of Death(See Instructions And Enamples) Approximate
Interval: Onset
28.Part I.Enter The Chain Of Events -Diseases.Injuries.Or Comp)ications-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 Additinal Lines It Necessary. 3 MONTHS
Immediate Cause(Final Disease Or Condition Resulting In Death) A. METASTATIC PANCREATIC CANCER WITHLIVER METASTASES
Sequentially List Conditions. If Any,Leading To The Cause Listed On
13- FILEDA.....,:...,...........• lit
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last C. o,ii a to.A.A c.,o.o..r.on
D. MAY 12 202Z
Part H.Enter Omer SIPnMcant Conditions Contnbutine to Death But Not Resulting in The Underlying Cause Gwin in Part I 29.Was An Autopsy Performed
❑Yes ®No
�jL Autopsy Finding Available TO Complete The Cause Of Death? ❑Yes 0 No
NA (ThaC/uc.t.1 z paUpttTOR 33.Manner or Death:
31.Cecil Tabacoo Use Contribute To Death? 32. It Femeie: atp 1h1TY�r i an pp.., 33 Natural❑I ia„<Rl 0 Accident 0 Pending Investigation
® .... w".+..n...a.. ❑e..v.•B.to. " F{AnA*11K m�TM Peal Ye. 0 Suicide❑Could Not Be Determined
No Unknown
0 ves 0 Probably® ❑ 0 u.ime Of injury.o,�.ruo.r.T.+r..tei,w.o.36 u.. (E.G.. i
ry
34.Date Of Injury(Month/Day/Year)
35.Time Injury 36. Place Of Injury E.G..Decedent's Home.DOnSWCWn She,Restaurant.Wooded Area) 37.O Yest Work? No
38.Location Of Injury-State 38a. City Or Town
380. Street&Number 38c.Apt.No. 38d.Zip Code
4❑0. lfTrarsportgtj nlnlrrY.�l>0ih'= ❑oe..rso.w.i
39.Describe How Injury Occurred 'e IIJJ ..w«fie'°"""'
42.CertRer(Check Only One)
41 Signature.Of Person Certaying Cause Or Death: 2. Certifying Phrir On ❑coroner ❑Heath Officer
MAO BOOL AHMED,BY ELECTRONIC SIGNATURE aa.L tense Number 45 Date Certified
43. Name.Address And Tip Code Of Person Certifying Cause Of Death: 01054343A 09 2011
MAQBOOL AHMED 421 CHESTNUT ST,EVANSVILLE,IN 47713 47.•Akas:
46.Additional Funeral Service Provider.
I49. For Registrar Only-DateFiled(Month/Day/Year):
48.Signature of Local Health Officer
BRU CE BRINK JR,VIA ELECTRONIC SIGNATURE SEP 26 2011
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY yy//iti RECEIVED
--Si i vAk cA 1-0L.) - MAY 1 2 2022
State Form 53305 ATTENTION ESTATE:The Social Security#is being requested by this slate agency in order to pursue responsibility. Disclosure is volunlary and there will be no penalty for refusal.
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