Death Certificate - Davis, Ruth Ann_5/12/2022 (8) THIS IS AM OFFICIAL COPY OF RECORD OF DEATH.ORIGINAL COPY ON FILE AT INDIANA SST EPEPIMENT OF HEALTH, p
._ INDIANA TATE DEPARTMENT OF HEALTH ,. O
4. tt CERTIFICATE OF DEATH
_-...../ Local No 000171 EDR No 000000220346 state No 041813
1.Decedents legal Name(First Middle.Last) 1a.Maiden Name(If female) 2.Sex 3. Time Of Death
70.If Death Occurred In A Hospital:
10a. tt Death Occurred Somewhere Other Than A Hospital
0 Hospice Facility El Decedent's Home ❑Nursing Horne/Long-term Care FaaWy
0 Yes ®NO 0 Unknown 0 Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival ❑Other(Specify)
y)
11.Faci6ly Name(N Not Instition,Give Street and Number)
2007 SOUTH 175 tuEAST 13.County Of Death 14.Marital Status a t Time or Death
12.City a Town.Sae,And Zip Code
®Married❑Married.But Separated 0 Divorced
PRINCETON,
GIBSON 0 Widowed 0 Never Mantled 0 Unknown
15a. (If Wife)Give Maiden Last Name 16. Decedents Usual Occupation 17.Kind Of Business/Industry
15.Surviving Spouse'ss N NamMee
FACTORY WORKER MANUFACTURING
EDDIE DAVIS 18a County lab. City Or Town
te. Residence-State
INDIANA GIBSON PRINCETON iBd Apt.No 18e.Zip Code ter.lmweatyum s?
Ilk.Street And Number
0 Yes ®No
2007 SOUTH 175 EAST 47670
19.Decedents Education
20 Decedent Of Hispanic Ong.n 21. Decedents Race
SOME COLLEGE CREDIT,BUT NOT A NOT HISPANIC White
DEGREE 23.Mothers Name(First.Middle,Last) Mother's2aaMother'sMaiden Last Name
22.Fathers Name(First M rdoe,Last)
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 250.Place Of Disposition(Name Of Cemetery.Crematory,Other Place) 25c.Location-City,Town.And State
®Burial 0 Cremation 0 Donation 0 Entombment
❑ReOthmoval y): WALNUT HILL CEMETERY FORT BRANCH, IN
❑ neify): 27a. Funeral Home License Number.r
26.Was Coroner Contacted? 27.Name And Complete Address Of Funeral Facility
❑YeS El No ICOLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON,IN 47670 FH83005671
27c.License Number(Of Uceeeee):
2O.Signature Of .BY ServiceLEUcensee: FD01009940
JOHN W WELLS,BY ELECTRONIC SIGNATURE Cause Of Death(See Instructions And Examples) Apprcumate
Interval: Onset
28.Part I.Enter The Chain Of Events -Diseases.Injuries.Or Complications-That Directly Caused The Not Death.Do Not oe Enter
_EnterOnly One Cause On To Death
nal Events
Such As Cardiac Arrest.Respiratory Arrest.Or Ventricular Fibrillation Without Showing The Etiology.
A Line.Add Add Lines If Necessary, 3 MONTHS
Immediate Cause(Final Disease Or Condition Resulting In Death) A. METASTATIC PANCREATIC CANCER WITH LIVER METASTASES�
Sequentially List Conditions. It Any.Leading To The Cause Listed On
Fi[LE-Diwsi.L.e.ousno.' M
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last C. a.,mis A.A ce,r..a ook do
D. MAY 12 2022
/ 0 Yes El No
Part 11.Enter Other Sidndi(',dnt Cond Mons Conmbutlm to Death But Not Resulting In The Underlying Cause Givin In Pan I j jt An Autopsy
Finding Available To Complete The Cause Of Death? ❑yes ❑No
NA at 33.Manner Of Death:
31.Did Tobacco Use Contribute To Death? 32. tt Femme: ki/ CS t twt PAYPDITOR„0,p� ®Natural 0 Homicide 0 Acddent ❑Penang investigation
®n., Vgms, ❑°1�( Tr3�'s i.. ISP TM Pauyw 0 Suicide 0 Could Not Be Determined
0 yes ❑Probably In No ❑Unknown ❑N. Of ,a„at Da.To t....e.a.p.w ❑uInjury E.G.. +r wmn37.In' At Work?
34.Date Of Injury(Menth/Dey7Year) 35.Time Of Injury 36. Place Of Injury(E.G.,Decedent's Home,Construction Site,Restaurant.Wooded Area) 0 Y 0 No
38.Location Of Injury-State 36a. City Or Town
38b. Street IS Number 38c.Apt.No. _38d.Zip Code
l 40. If«Transport 0n injury,S 1eciN ,,❑owe isP..sr,
39.Describe How Injury Occurred ❑a ro°r. ....o«L�J°�di
42.CCrMer(Check Only One)
41 Signature,Of Person Certifying Cause Of Death 6 Certifying Physician ❑Coroner MAQBOOL AHMED.BY ELECTRONIC SIGNATURE ❑Heath Officer
t6cer
44. L tense Number 45.Date
43.Name.Address And Zip Code Of Person Certifying Cause Of Death: 01054343A 09CeOdOd 1
MAQBOOL AHMED 421 CHESTNUT ST,EVANSVILLE, IN 47713 47.-Akan.
48.Ad.:Mona/Funeral Service Provider
49. For Registrar Only -Date Filed(Montyeaf5
48.Signature of Local Health OfficerSEP 26 2011/Day/Y
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) t�jt RECEIVED
A/'\�1
SQ l wAAeA Lw0 - MAY 1 2 2022
State Form 53395 ATTENTION ESTATE:The Social Secunty#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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