Death Certificate - Callis, Norma_6/2/2022 r. . - :..."1 :'' ,.---,Felr-„ F,..^tF'lr",. ,,''��7"r-'' r:'''S")#.7
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STATE DEPARTMENT OF HEALTH0
i 1'11`` 'jJlilCtQ�I�OF DEATH
''r"».i'1 Local NIP 1 2022 CUUC
EDR No 00001123249 State No 2022-015238
1.Decedent's Legal Name(Fir..Middle,Last) t-/il / ta.Medan (N female) 2.Gender 3.TM OI Death4. Data Of Death(Morstupayfrear)
Norma Marie cCsilbson County Auditor iRsi Female 09:02 PM 01/20/2022
5.Social Security
Ever in U.S.Armed Fames? 10.If Death Oodned In A Hoyle t /0.,a Death Occured Somewhere Otter Than A Hosp.. -
El Hospice Facility ❑Dacedws's Horne l0 Nursing Fbme&orp-time Care Facility
❑Yee ®No ❑Unknown ❑Mpaient 0 Emergency Department Ou5»ent Q Deed on Arrive 0()thaw fSper;fy)
11.Fealty Name It Not Institution,Give Steel end limber) Good Samaritan Home And Rehabilitation Center
12.City or Town.State,And Ztp Code 13- County of Death 14.Metal Star.At Tine Of Deslh
Oakland City,Indiana 47660 Gibson Mimi.0 Mantua,Bea Separated t10 Divorced
endowed ❑Nev.Married ❑Unknown
15.Surviving Semmees Name 15a.Lest Nan,.Before.First Marriage 16.D.o.d.0.0 Um.Occupation 17.Kind Of Bualnwnndwtry
Logistics Shipping
18 Resew.*-ern. 18a. County 18b City Or Town
IN Gibson Fort Branch
18c. Street And Number led.
Apt No. 18e.Zfp cod. 181.Inside car Linea?
604 E Locust Street 47648 ®Ye. ❑No
19. Decedent's Education 20. Decedent Of Hcp.r.ic Origin 21.Decedent's Race -
Bachelor's degree(e.g.BA,AB,BS) Not Spank White
22.Ptrenrs Naar(Fist.Nide..Last/ 23.Parent's Nan.(Fbst.Middle,Law) 23..Parent.Last.fame Batons Flat MerNag.
Paul J Allmon Wilma AHmon Hensley
24.►formate None 24a.Relationship To Decedent 24b.Mating Address(Street And Number,City,She,Zip Code)
Glenn Canis Son 602 E Locust Street,Fort Branch,IN,47648
25.Place 01 Disposition
25a Method Of Deposition 25b.Place Of Dispcetton(Name Of Cemetery,Crematory.Other Piece) 25c.Location-My,Torn,And Sae
❑BuaW❑Gestation N Donation❑E.w it:inn.
O Removal From Set. Trinity Cremations Portland,Oregon.Multnomah
❑Other(Specify)-
26.Was Coroner Contacted' 27.lone And Compete Address Of Funeral Fere. 27a Funeral Hone Limn...Mar
•Simple Cremation Evansville
❑Ye4 ®No 3101 N.Green River Rd.Ste 320.Evansville,Indiana,47715 FB41800004
27b. sser�ew�..a Mean.Funeral Service License.: 27.Li Num
ber.t,ber(0I Us....)•FD21400064
Cacr('4z sfiew grass Electronically Signed
Cate Of Death(See il.1.uctwn.And Examples) Approximate
28.Part I.Enter The Chain Of Events-Diseases,Intones,Or Con.plc tbM-That Directly Caused The Death-Do Not Enter Terminal Everts Interval. Onset
Such As Cardiac Arrest.Respiratory Arrest,Or Ventricutar Flbrdla*on Wahout Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line.Add Addibnal Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. Metastatic pancreatic cancer tissue diagnosis not available 3 weeks
a.wroe...o...e...r.oe -
Metastatic disease to liver and biliary tract 3 weeks
Sequentially List Conditions, If Any,Leading To The Cause Listed On 8.
a...toe h A c....w .ew 04:
Line A. Enter The Underlying Cause(Disease Or Many Thal Initiated
The Events Resulting In Death)Last C. Pancreatic cancer 3 months
Owe*p.0.Aorerr.rw.04:
D.
Part a.Enter Otherageffeagitcenagsige But Not Resulting In The Utdertyi g Cause Given In Pat 1 29.Masan Autopsy P.rlormed7
(]Yes m No
Essential hypertension,chronic kidney disease _30.Were Autopsy Finding Avrebr To conprl.Th.Cause of Death'? O ye. D No
31.Did Tobacco Use Covent.*To D.ath7 92.If Female, 33.Manner Of Death:
El Yes El Probably®tb El Unknown
0.a,.v,..w.Oar,c. O...,-..,...,aD.., Elr+........as....+e.»ws.42w.«o... MI Natural El Homicide El Accident El Pending Inv.ay�a.
❑.w....e e,e..4 n.r,r..,nw..To 1 Sob,L..», ❑On*..ev.r.wee.t..rat V., 0 Suicide❑Could Na Be Determined
34.Da*Of Np.y(Mont IOay/Year) 35.Tine Of Miuy 3e. Place Of injury(E.G..D.osdwts 14o11e.Construction She.Restaurant,Wooded Are) 37.Mery At Wade?
O Yea CI No
98.Location 01 leery-Stale 38a. City Or Town 313b. Street S Number 38c.Apt.No. Sect Zip Code
39. D.wa.e How Maury Ocared 40.If Tramporlatlon►try,Specify:
❑o-.w,or.e.❑rmamea❑^•e•re❑o•.tO..M
41.Signature.01 Minton Certifying Cause Of D..th: 42.Certifier(Check only One)
. Sean K.(Sw g Electronically Signed ®Candying Pfly1CW. o tow., o treat.Calker
.I An 43.Nan.,Addr. d di on p Code of Person Cog Cause Of Death: 44.License Number 46.Dal.Cedeed
i Kiran K.Bursa 7501 W 15th Avenue.Gary.IN 46406 01070696A 01/24/2022
40.Addacn.1 Funeral Service Provider: 47.'Ana
i48.sg.wur.a Laos Het en Officer 49. For angrier Only O..Find/sio0loV ranee): 03/10/2022
Bntc.Brirt�9F Electronically Signed
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
p6- 19 -is - 3 OLI-0 0 0 _ 0t3 o26
Slats Fenn 53396 ATTENTION ESTATE:The Social Security a Is beep requested by this state agency In cedar to pursue ta.ponalbnlly. Dedosute is voluntary and there we be no penalty tot reheat
i
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