Death Certificate - Grubb, Susan_7/7/2022 (2) -(�' rr" r�_�.^`a �t `.` �:w.` .if; • .1 ' . - .:: ?�•(ram:i. 7=cay ,-"%"7- : .: . 1)-''r--.4:. `C®d
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s`L,! INDIANA STATE DEPARTMENT OF HEALTH
rill!** :
o C CERTIFICATE OF DEATH 0 0.4
f; Local No 000079 EDR No 000000778367 State No 024994
1.Daredvtfe teed Name(First Middle.Last) 1a. Malden Name(if female) 2.Sex 3. Time Of Death
❑ Hospice Facifly 01 Decedents Horne 0 Nursing Home/Long-term Care Facility 1
0 Yea 2 No 0 Unknown 0 Inpatient 0 Emergency Department Outpa5ert 0 Deed on Anfvel ❑ Other(Specify)
1 11. Fa gty Name gf Mai uh Crd7 Ca"Stool end Number)
IL„ 13090 EAST 275 SOUTH 13 Carey Of Death 14.Martial Stairs At Time Of Death �4
`( ,2 City o Town.Stem,And 27p Code 0 Marred❑ Married,But Separated 0 Divorced
OAKLAND CITY,IN,47660
'GIBSON ® 'Aidowed 0 NeoerManied 0 Unknown i
�( 15.Surviving 6pouss'e Name 150.Last Name Before First marriage 16_ Decedents Usual O,saprtilon 17. Kind Of Bhgtrhesa/Irduatry '/(�
,.(a - - .- - -
18.Ra4denoo-saes tea tab.City Or Town
County HOUSEWIFE HOUSE 1
INDIANA GIBSON OAKLAND CITY
18c Street And Nhmnbar la/ PA
r lad Apt No. 18a Zip Code t inside City Limits? P
'� 0 Yen ® No
/{t(///;// 13090 EAST 275 SOUTH 47660 �(
P9` 19.Decedents Education 20. Decedent Of Hispanic Origin 21. Decedent Race J
HIGH SCHOOL GRADUATE OR GED ,
` COMPLETED NOT HISPANIC White ��
,, 22.Perente Name(First Midrib.Last) 23.Parents Name(First,Middle.Lest) 23a.Parents Last Name Before First Marriage ��
(2 •
9 r• WILBUR YOCOM VERA M YOCOM MILLER 14
O 24.Informants Name 24a.Relationship To Decadent 24b.Meiling Address(Street And Number.City,Ste•.2119 Code)
rn JOSEPH GRUBB SON 13090 EAST 275 SOUTH,OAKLAND CITY.IN 47660 G
Q 25.Place Of Disposition -
cc 25a Meted Of Dieposlfion 25b.Place Of Disposition(Name Of Cemetery,Cnxnetory,Other Place) 25-Location-City.Town,And Stab TI
W 0 Bhrlal® Cremation 0 Denton 0 Entombmert2 a
Cc 0 Removal Frr:n State r-
• 0 Other(Doaty): EVANSVILLE CREMATORY EVANSVILLE,IN m
0 26.Wes Coroner Contacted? 27.Name And Corr-plebs Address Of Funeral Facility 27a. Funeral Home L(oNHe Number 37
„ ❑ Yon No- LAMB BASHAM MEMORIAL CHAPEL,INC.,226 E.WASHINGTON STREET,OAKLAND CITY, I,IIL!'j,'' v
IN 47660 - -- --- - FH83005312-,__
27b. Signature Of Indiana Funeral Service Licensee: 27c. License Number(Of Ucenseo): 0
JERRY LEE BASHAM,BY ELECTRONIC SIGNATURE IFD01016589
Cause Of Death(See Instructions And Examples) ' Approximate IT1
' 28.Part I.Enter The Chain Of Eventg -Diseases.Injures,Or ComPCicationa-That Directly Caused The Death Do Not Enter Terminal Events bMvyat Onset 33
Such Ae Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibril/titian Wtlwut Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death n
• A Line. Add Ads/Mortal Lines If Necessary. U)
m
Immediate Cause(Final Disease Or Condition Remitting In Death) A ADENOCARCINOMA OF PANCREAS o..„to..Ac .n oa
�+,. List Conditions, I An Load" To The Cause Listed On '
. SeGuo.tfely Y, mg 9. o..h.ca A.A c,....v+.�err-
1 The
E Ets R Tea rig In Death)
Cause(Dlseaee Or lnjLrY TTmt Intialad
1 The Events Reeu3bg to Death)Last
C.
:.� boo for luwe.r+..a..r.o or, /)
11) D. 3-
jyt PM IL Enter Other `-"cam C ggaggi C�'^�m Death But Not Resin g to The Underlying Cause Given In Pen I 29.Wes An Aueopiy Performed? 0 Yea ® No �1
r 30.Were Autopsy Finding Available To Complete The Cause Of Death? 0 Yes 0 No 1J(
1P 31.Dd Tobacco Use Contribute To Death? 32.If Female: 33.Mercer Of Death r
-\� ® eeres,.,ewar.nrvor. ❑ e�.e.ow nue01o.se ❑ weh.va.er axe o vvr..c df+an.mt ® Natural 0 Homicide 0 Accident 0 Pending Investigation ,A,
❑ Yes ® Probably❑ No❑ Unknoown
I6 ❑ ...Repro..ea er.o�.o nays h Tam e.m.Drat 13 tm.,r.aeng.r.war..m.v.a Yrs ❑ Sutcde❑ Could Not Be Dammined }
34.Dam Of Injury(Mont/Day/Year) 35.Time Of Irquy 98.Place Of Irytry(E.G..Decedents Horne,Cansbamon Site.Restaurant Wooded Arm) 37.Injury At Work? '
... , ❑ Yes ❑ No
rf 38a C Or TOMI .' 386.Street S Number __ No. 38d. p
1 3B. tertian Of injury-State �' -
,.-.-'�-�_-__ - .. tali - - _ -�, - •-- -. .r.;- 38a Apt. Zip Code --01
nth If T ryury M ���
rt� 38. Describe How INuy Occurred �o i.�o.T7 o.e.mrA❑oe..r ww.+tt
l iry 41 Signature,Of Peruse Certifying Cause Of Dear: _ '_ I42.Certifier(Chock Only One P 4�
It APRIL MICHELLE-SIMMONS TOELLE,BY ELECTRONIC SIGNATURE -• -- -Corsytng Physician U Coroner 0 H ethOmcer
0 43- Name,Address And Zip Code Of Person Candying Cause Of Dealt - •. 44. UcMee NumbsCertified45. DateCertified
"`- APRIL MICHELLE-SIMMONS TOELLE ,600 MARY ST..EVANSVILLE,IN 47747 02003410A 05/09/2020 TJ,/�
48.Ade-bona!Funeral Service Provider. • _ 47.'Alms: 3.--.,,(1
�� 40.Signature of Local Health Officer. • , 49. For Registrar Only-Date Filed
(MonDay/Yem): I4
9 BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE MAY 11 2020
•1 AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) J�„r Z6--t 4 29 -ZOO - OCR 0 _ 4 -d : �,,, 1 R, J ''''I se Ih cl 41/1
` 1
responsibility. Disclosure is voluntary and there will be no penalty for refusal \(
3; WARNING• ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT ��¢��YA
TURNS FROM ORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUMENT HAS A HIDDEN VOID ON FRONT THAT APPEARS WHEN PPHOTOCOPIED.
,.� ", vr- �r�`--r�-..w.C✓/ ts.`'f =.STATE.OF,.INDIANA ':✓..'4__,.�-s'' ..-,r.s_!._`�v` ..a_i__�v .�_C�2 --��.40
r .r >�- . CERTIFICATE OF DEATH .�ct�1. �,•ri�z�-i:. �',,••.r:w'0,�,n_<-.?� .-t, .,n.
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el • INDIANA STATE DEPARTMENT OF HEALTH 3 9 9.6 8 55 L'--'
gi CERTIFICATE OF DEATH ,
1 Local No 000175 EDR No 000oo1960652 State No 2016 00431'5"'
I.Decedent's Legal Name(Fest,Middle,last) I a.Maiden Name(II female) 2.Gander 3-m...N 01 Deem
;I.',
d - 4i
`(-3,
Oakland City,Indiana....... `
e. Ever in U.S.Armed Forces? t0.11 Death Occurred In A Hospital: 10a. II Death Occurred Somewhere Other Than A Hospital
OM Hospice Facmly El DeceeeilFe Hems ❑Nun"'Horr.ariongiemn Care F.dity
'�` ®Yes ❑No 0 Unknown 0 I padem 0 Emergency Department Outpatient 0 Dead on Arrival pother(Specor) ---
I I.Foamy Nema(I Not In WM''.olva svmt end Nunbx) CHARLIER HOSPICE CENTER
4 12.City Or Town,Stale,And As Code 13.County,Fil:?t.,am 14.Marital Status Al Time 01 Death
Evansville,Indiana 47713 Vandenburgh ®Married❑Married.But Separated p DNowed
❑Wdawed 0 Never Married 0 Unknown
A • ISa.Lest Name Belpre First Merrlsga
16.oecedanrs Usual Occupation 17.Kind ndua d 01 Buelnessltry
15.Surviving Spouse's Name
il
,Q SUSAN GRUBB YOCOM LABORER• INDEPENDENT CONTRA
% to.Residence-State t84.County 18b.City Or Town -
IN Gibson Oakland City
��
f t street nr10 •
Nurturer te Apt Nit tee. Zip Code 1B1_Inside City Lnr.tzt Y!a
(q ec
13090 EAST 275 SOUTH °':� ' a' " 47660 ❑Yea ®No 00
_C( 19.Decedent's Education 20.Decadent 01 Hispanic Origin 21.Decedents Race
.. High School graduate or GED completed Not SpanlehAilspeniclLabno White Kl
1`:'� 22.Parents Name(FInL Midrib.laaq 23.Pvenrs Name(Feat.MlOdle.laaU 23a.Parent's Last
Name Belem First Marriage i.
0. WILLIAM CARR.GRUBB BONNIE AGNES GRUBB 1, JONES
II. 24.informant's Name 24a.Relationship To Decedent 24b.Mating Address(Street And Number.City.Slete.Zip Code) la'
0 Wife 13090 EASE 275 SOUTH,Oakland City,IN,47660
W SUSAN GRUBB
Q25.Place 0)DisdosMon'..
CC zs..Method 01 aspeution _2se Mace o)Disposition(Name 01 Cemetery.amatory.Omer Place) 25d Loraeert-City.Town.And State
W 0 Burial®Cremation 0 Donation 0 Ennombmeol
CC 0 Removal From Stab EVANSVILLE CREMATORY Evansville,IN
O ❑Other(Spedfy): 27a Funeral Roma Liceeoe Number:
26.Was Coroner Contacted? 27.Name And Complete Address C1 Funeral Fadrty
Ci Com-Colvin Funeral Home, • - - Tril,'I I FH19400002
W I Yes ®No " i Inc.323 N.MAIN ST. PO BOX 278,Oakland City,Indi In ,•476600278 \
•
W27b.signature 0)Indiana Funeral Service Licensee: _ - .. - - 27'Lt<arue Number(ot Licerseeti FD01012153
J R/O01 09fIC7 Q' Electronically Signed
•Cause Ot Death (See Instructions And Examples) ' Approximate
28.Pan I.Enter The Chain OI Events -Diseases.Injuries.Or Comphcatlons-Thal Directly Caused The Death.Do Not Enter Terminal Events Interval:Onset
LL Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
0 A Line. Add Additional Lines ti Necessary. Ii'„
Immediate Cause(Final Disease Or Condition Resulting In Death) A_
MULTIPLE MYELOMA,PNEUMONIA•CHRONIC OBSTRUCTIVE PULMONA
Oa.jnnn r ACe.*.....at-
_! B.
i�,r Sequentially List Conditions, II My,Loading'To The Cause Listed On - n.nx 11. co..e..�oo: -Line A. Enter The Underlying Cause(Disease Or In-pry Thal Initiated _The Events ResuMng In Death)Last C. -• _-•-_ -_ ••a�{F,.`( Arm 16 AsA(.q.vv on
tr.� •Poi II.Enter Oder�'t-a:tt c rdi ens c r ILK to Death Bun Not Resulting to The Uwodying cause Gi en In Pan 1 z9.wait An AutoPar Penn med7 p ves ®No t!
-i. 1 i 30.Were Autopsy Finding Available To Complete The Cause OI Death? p Yes 0
No
II
•
31. Did Tobacco Use Contribute To Death? 32. tl Female. ) 33.Manner 01 Death:
p...win..me.w v..r CI. .v.WI*1.o non 0 no wow.srw.ewwe«.a ore..own ®Nakra1❑1omrld. ❑Accident 0 Pending Inveatlgatiori
`� ❑vita ❑Probably 0 N. ® M unown 0 ew.e•een.a a o...w ow.T.1 ww env..bus, 0 wow.a�4r.t l ..Ire
..a v.., 0 Suicide 0 Could Not Be Determined 13
38.Piece 01 tnkay le..fC,Decedent's Home.Construction Ste,Restaurant.Weeded Area) 37.tn(cty Al Work?
34.Data 01 Injury lMonttvDay/rear) 35.Tinto 01 Injury _-_
C., / ❑Yes ❑No
rs el^ly 38.Location 01 injury-gate 3Ba City Or Town 38b. Street a Number ,".,',� i-41Bc.Ap.No. 38d. Zip Code
1r
�. 1
EG 39.oeac be How Injury of x red _ . . 4Q.;11 Trsnsportedon hyty,Spec1ly. '.
`t ���,I.Ili. � ••u p.s..P❑ebw.M pew laPrxrl .J-J1
1 4,.Signature.01 Person Certifying Cause 01 Death: • 42.Cenittar ICnWr Only Or1e(
�C 9 t)L/E T( QER7CARAr Electronically Signed 1»Certifying Physidan 0 Coroner ❑Health 0l5o,r
43.Name.Adarese And ap Cote 01 Person CoOttying Cawq 0)Death: 44.License Number 45.Dare Cartticd '
�tL JULIE K.GERHARDT 600 MARY ST.,Evansville,IN 47713 01057271A 01/29/2016
�� 4s.,Addignu funeral Service Provider: .-- 47.•AMae:
as sgnaaune of Local Health dieter. 49. For Ragl.ery Only-dal.Filed IMonnwevn.ar)' 02101/2016
�[. .R.PCBEcR`I- IKETJf WEAR. 'I
Electronically Signed do
v' AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
F< ?G ILA- Zcl -� c�- v- �-(- ,. C WO \ ecv` O� Spw\��k.>r�.s 4cc_ . j
, •
0 Disclosure Ia voluntary and there will be no pelnally or refusal. ]
`�tI/j
`-� ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECW_WHITE,TSECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON, C?HAT )- .
WARNING. TU•• FROM•RANGE T•YELLOW WHEN RUBBED •RIGWAL•• .!'HAS DOEN VOID FRONT THA vAPP R WHEN PHOT• `3IED /''I _/•tw44�- '8
j::,�.�i.';�'� ri :r`t_;rs v:�,J.?•�,,. . .1.7"n-y-.u. `i .-..L` •^ 1 e u ► s ► _ - -
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