Death Certificate - Barrett, Doyin_5/24/2022 N 4`• INDIANA STATE DEPARTMENT OF HEALTH
1 CERTIFICATE OF DEATH
Security g requested by agency inpursueresponsibility. voluntary penalty
♦:- i ATTENTION ESTATE:The Social #is being a ested this state a enc order to Ines sibil' Disclosure is and there will be no na for refusal.
Local No 000218 EDR No 000000821390 State No 067848
1.Decedent's Legal Name(First,Middle,Last) la Maiden Name (If female) 2.See 3. Time Of Death
❑ Hospice Facility ® Decedent's Home ❑ Nursing Home/Long-tens Care Facility
❑ Yes ® No ❑ Unknown ❑ Inpatient 0 Emergency Department Outpatient 0 Dead on Anival ❑ Other(Specify)
11. Facility Name(If Not Institution,Give Street and Number)
208 3RD AVENUE
12. City Or Town,State,And Zip Code 13. County Of Death 14. Marital Status At Time Of Death
® Married 0 Marred,But Separated 0 Divorced
PRINCETON, IN,47670 GIBSON ❑ Widowed ❑ Never Maniac! 0 Unknown
15. Surviving Spouse's Name 15a. (If Wife)Gtve Maiden Last Name 16. Decedent's Usual Occupation 17. Kind Of Business/Industry
PATRICIA BARRETT WHITE SCHOOL BUS DRIVER TRANSPORTATION
18. Residence-State 18a. County 18b. City Or Town
INDIANA GIBSON PRINCETON
18c. Street And Number 18d. Apt.No. 18e. Zip Code 18f. Inside City Limits?
® Yes 0 No
208 3RD AVENUE 47670
19. Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC WHITE
22.Fathers Name(First,Middle,Last) 23.Mother's Name(First,Middle,Last) 23a.Mothers Maiden Last Name
BEN BARRETT ANNABELLE BARRETT SOKELAND
24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address(Street And Number,City.State,Zip Code)
PATRICIA BARRETT WIFE 208 3RD AVENUE, 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
❑ Other(Specify): COLUMBIA WHITE CHURCH CEMETERY PRINCETON, IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility 27a Funeral Home License Number
❑ 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):
JAYANNA WEAVER, BY ELECTRONIC SIGNATURE F �1
Cause Of Death (See Instructions And Examples) j�-J{ 1■,./■
28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Ev s Approximate
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One C se O Interval: Onset
A Line. Add Additinal Lines If Necessary. To Death
Immediate Cause(Final Disease Or Condition Resulting In Death) A. ACUTE MYELOID LEUKEMIA 0 c022
ou.rolor A+A , w DPr..u.r DlI-MAY 2
Sequentially List Conditions, If Any,Leading To The Cause Listed On B. Dr to for A.A c.n.•a..nce Dry.
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated a'... /�
• The Events Resulting In Death)Last C. ,♦yAY
Du.w co,A.A c. a AILG Q /
D. GIBSON COUNTY AUDITOR
Part II.Enter Other Sionificant Conditions Contributino to Death But Not Resulting In The Underlying Cause Givin In Part I 29. Was An Autopsy Performed? ❑ Yes ® No
PARKINSONS DISEASE 30. Were Autopsy Finding Available To Complete The Cause Of Death? ❑ Yes 0 No
31. Did Tobacco Use Contribute To Death? 32. If Female: 33. Manner Of Death:
• 0 Net Integra,.won Pea y.., 0 Pregnant At Time ore..s. ❑ Not Pregnant.But re.n.,,one,.a Der.or Death ® Natural Homicide 0 Accident 0 Penang Investigation
0 Yes 0 Probably® No 0 Unknown ❑ Not P,.gn•ta But Regnant a oars re t yr.Boehm Deem 0 Unknown n Pregnant wvhr Inn.Past Year 0 Suicide 0 Could Not Be Determined
34. Date Of Injury(Month/Day/Year) 35. Time Of Injury 36. Place Of Injury(E.G..Decedent Home,Construction Site,Restaurant Wooded Area) 37. Injury At Work?
❑ Yes ❑ No
38. Location Of Injury-State 38a. City Or Town 38b. Street&Number 40 ponapon38c.Apt.No.
38d. Zip Code
38. Describe How Injury Occurred ❑a...rrrans o, ❑P.I.jq'❑r.a++,+.n❑oin.r tsowrrl
41. Signature,Of Person Certifying Cause Of Death: 42. Certifier(Check Only One)
APRIL MICHELLE-SIMMONS TOELLE, BY ELECTRONIC SIGNATURE ca Certifying Physician 0 Coroner 0 Heath Officer
43. Name,Address And Zip Code Of Person Certifying Cause Of Death: 44. License Number 45. Date Certified
APRIL MICHELLE-SIMMONS TOELLE ,600 MARY ST., EVANSVILLE,IN 47747 02003410A 12/02/2020
48. Additional Funeral Service Provider 47. •Akers:
48. Signature of Local Health Officer: 49. For Registrar Only-Date Filed(Month/Day/Year):
BRUCE BRINK JR,BY ELECTRONIC SIGNATURE DEC 03 2020
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
a�� 12_ , g- 10 , -o00 Uq4 - COZ Y
State Form 10110 (R6/3-07)
WARNING: TTURNISN FROMCORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUME T HAIS ASHIDDE VOID ON FRONT THATT AP EARS WHEN HOTOCOPIEDI.ANA ON BACK THAT