Death Certificate - Davis, Ruth Ann_5/12/2022 (9) i
THIS IS AN OFFICIAL COPY OF RECORD OF.0,j,ii„,_01pGINAL COPY ON ILEAT .! ,..$1 ,aE,PEPARTMENT OF HEALTH -
INDIANA STATE DEPARTMENT OF HEALTH
EL: \ CERTIFICATE OF DEATH
L :�� Local No 000171 EDR No 00000022034E state No 041813
1.Decedent's legal Name(First.Middle.Le,l)
la.Maiden Name(If female) 2.Sea 3. 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 Facility B)Decedent's Home 0 Nursing Home.tong-terrn Care Facility
0 Yes ®No 0 Unknown 0 Inpatient 0 Emergency Department Outpatient 0 Dead on nnival 0 Other(Specify)
11.Feebly Name(If Nol insetution,Give Street and Number)
2007 SOUTH 175 EAST
12.City Or Town,State,And Zip Code 13.County Of Death 14. Mantel Status At Time Of Death
®Manned 0 Marred.But Separated 0 Divorced
PRINCETON,IN,47670 GIBSON 0 widowed 0 Never Marred 0 Unknown
15.SuMNng Spouse's Name 15a. (If Wife)Glve Maiden Last Name 18. Decedent's Usual Occupation 17.Kind Of Business/Industry
EDDIE DAVIS _FACTORY WORKER MANUFACTURING
18.Residence-State la:, Ccunty 18b City Or Town
INDIANA GIBSON PRINCETON 18d. Apt.No 10e.Zip Code let.Inside City Limits?
18c.Street And Number
❑yes ®NO
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 Wi11(e
DEGREE 23.Mothers Name(First.Middle.Last) 23a Mothers Maiden Last Name
22.Fathers Name(First,'Wade.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
®Burial 0 Cremation 0 Donation 0 Entombment
❑Removal From State FORT BRANCH, IN
❑Other(spec fr). WALNUT HILL CEMETERY27a. Funeral Home License Slimmer.
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
27.License Number(Of Licensee):
2O.Signature Of Funeral LE Licensee, I FD01009940
JOHN W WELLS,BY ELECTRONIC SIGNATURE Cause Of Death(See Instructions And Examples) Approumate
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 Add.tinal Unes If Necessary
METASTATIC PANCREATIC CANCER WITH LIVER METASTASES 3 MONTHS
Immediate Cause(Final Disease Or Condition Resulting In Death)
Death) F I L E�~•c,,,....,a oe
m
Sequentially List Conditis, if Any.Leading To The Cause listed On
B. A.A Gw..a�..o dry
Line A.Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last G. Due le,A A,A re...e...r.do-
D. MAY 1 2 2022
Part II.Enter Other SklnMcant Conditions Contributing to Death But Not Resulting In The Underlying Cause Givin In Part I �/' 29.Was An Autopsy Performed? ❑Yes 121 No
�� a.J/Y/�Autopsy Finding Available To Complete The Cause Of Death? ❑Yes 0 No
NA �UptITOR 33. Manner Of Death:
31.Did Tobacco Use Contribute To Death? 20 IfoF°v e:w ,,, , 0 CJ U 'e. 7 o.r.moo, ®Natural❑Homicide ❑Accident ❑Pending tsnesrgation
0 yes ❑Probabty®No ❑Unknown 0 tieP..a..nt.bit nor...43 ner.re I y...e.t..Due 0 uuuw..tP..pn..t We.The Pat?.., 0 Suicide 0 Could Not Be Determined
34.Date Of Injury(MonthfDey/Year) 35.Time Of Injury 36. Place Of Injury(E.G..Decedent's Home.ConstiuChon Sae,Restaurant,Wooded Area) 37.Injury At Work?
0 Yes 0 No
38.Location Of Injury-State 38a. City Or Town
38b. Street 6 Number I 38c.Apt.No. 38d.Zip Code
I.44 C).fwTransporte.?....0ry,�Peu,Y ,,❑ ,se.,,i
39.Describe How Injury Occurred CJP•^�
42-Certifier(Cheek Only One)
41.Signature,Of Person Certifying Cause Of Death: I ®Certifying Physician ❑Coroner ❑Heath Officer
MAQBOOL AHMED,BY ELECTRONIC SIGNATURE 44.Lcerise Numbe 45 Date fficer
43.Name.Address And tip Code Of Person Certifying Cause Of Death: 09/23fied
01054343A
MAQBOOL ARMED ,421 CHESTNUT ST,EVANSVILLE, IN 47713 47.•Akers:
46.Adddwnal Funeral Service Provider
149. For Registrar Only-Date Filed(Month/Day/Year):
48.Signature of Local Health OfficerS EP 26 2011
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
1o " RECEIVED
-Si I w4A(A UL') ' MAY 1 2 2022
17-, Slate Form 53395 ATTENTION ESTATE:The Social Security#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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