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Death Certificate - Grubb, Susan & Stephen_7/7/2022 @ t ,-.-:wr1.�r :�-.i".-,.; , ,.-7.- 's: '.;f�;_ .-�...-��1. , zt' . " . • . .. . ' ..y . c.�:iFry-• r�"a= . r..:i�i i(r.--.ice'- `h` , r 41-IV: INDIANA STATE DEPARTMENT OF HEALTH (� C •! CERTIFICATE OF DEATH0 �� Sf Local No 000079 EDR No 000000778367 State No 024994 - 1.Decedents Legal Name(First,Middle Last) 1a. Malden Name(1f femffie) 2_Sax 3.Time Of Death /s ❑ Hospice Facility ® Deoadanl's Home 0 Nursing Horna/Lorg-term Care Fad:ty y'�! t 0 Yes El No 0 Unknown 0 In n/Meri 0 Emergency Department Outpatient 0 Dead on Arrival inother � o (S ) i ` 11. FatgiYE Name(If No Irostuson,Give Street end NU bar) 4 (0 13090 EAST 275 SOUTH 0 '{0 12.City Or Town,State,And Zip Code 13.Cwnty«Death 14.Mental Stalin At Time Of Death ,v.�f `�. 0 Maned❑ Marred,But Separated 0 Divorced J OAKLAND CITY IN 47660 GIBSON ® idowed 0 Never Married 0 Unknown 1 'ii 15.StavlNrg Sporse's Name 15a.Last Name Bofors First Marriage ' 18.Decedents Usualttt1q��q a . Oxt,parlon 17.fond OfBtntrneaanrMtntry �(4 i))� :I,'�:id,,lj HOUSEWIFE HOUSE P7> 19:,•esteems-State tea Coady 70b. City aTown D �r 1 1 T 18e Street Number GIBSON OAKLAND CITY lea Apt No. lea_Zip Coda 18f. Inside City Limns? 1„ 13090 EAST 275 SOUTH 47660 ❑ Yea ® No (` P9 19.Decedents 20. Decedent Of Hispanic Origin 21. Decedents Race J.\f � . HIGH SCHOOL GRADUATE OR GED ��9d4 r COMPLETED NOT HISPANIC White c. 22.Parents Name(First,Middle,Last) 23,Parents Name(Flat,Middle.Lest) 23s Parents Last Name Before First Marriage �)( i WILBUR YOCOM VERA M YOCOM' MILLER } ` 24.Interments Herne 24a.Relationship To Decedent 24b.MailingAddress Street And Number. 1�/ Cali.Stele,Zip Code) sC w JOSEPH GRUBB SON 13090 EAST 275 SOUTH OAKLAND CITY IN 47660 O ("a 25aCI Method Or Dlsposlton 25b.Place Ofe Prom«D'...t.' Lit 0 Burial ® Cremation 0 Donation CIE Entombment Omwes+tan(Name«C.ernaletyry,Crtmiamry,Other flees) 25c Location-City,town.And State a CC 0 Retrieval From State • ❑ «nor-cspecirc: • EVANSVILLE CREMATORY EVANSVILLE IN ) n 26.Was Coroner CohtdFuneralsd? 27.Name And Complete Address Of Feral Facility 27e.Finland Horne License Number. ,r •-❑"-r1s-.®-No--- __ . LAMB BASHAM MEMORIAL CHAPEL,INC.,226 E.WASHINGTON STREET,OAKLAND CITY, '1J.�•i m - IN 47660 - - _ ..-. - - FH83005362- CI 27b. Signature Of Indiana Funeral Service Licensee 27c. Uoan en se Number(Of Uoseo): 0 JERRY LEE BASHAM BY ELECTRONIC SIGNATURE FD01016589 - Cause Of Death(Sea Inmtrucllone And Examples) 28.Part I.Enter The Chain Of Events-Diseases,Injures,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events IntervalMOnset ate m Such As Cardiac Arrest,Respiratory Anost,Or Ventricular Fibrillation Showing The Etiology.Do Not Abbreviate.Enter Only One Carrie On To Death n ch se A Line. Add Additional Lines H Necessary. CD s- immediate Cause(Final Disease Or Condition R MResulting In Death) A ADENOCARCINOMA OF PANCREAS a..r to.'vow re,�yonew en CI Sequentially List Conditions, if Any,Leading To The Cause Listed On B. v-� )I,. Una A Ender The Underlying Cause(Disease Or Injury That Initiated u..to nor or A.co.,..a..,..cry The Events ReauMing!n Death)Last 7 t .� C . Sr. or.t.tor .A r.w.te .no.ory 0.1 �C D. Peat II.Ert'ar OMer$ianticant Ci rkirbons Cortribut.hm to Death But Not ResmdNp 61 The Underlying Cause Given in Part I 29.Was An Auopsy Pet/omrod7 �� '� :..�. ❑ Yes 01 No ' r//, 30.Were Autopsy Finding Available To Complete The Cans Of Death? ❑ Yes ❑ Na 1 q:\ 31.Did Tobacco Use Contribute To Death? 32. If Female_ 33.Manner Of Death: �•?� ® .a.•.errs sues,n ovw 0 a:.e.x,.,..oro..s. 0 aw fa e.wwwes was,n our.oro.rar ® Nahnal❑ Homicide 0 Accident ❑ Pendng Invesegason 0'1:I,C ❑ Yes ® Probably❑ the ❑ Unknown ❑ Iwo non m.a nr.ews o our.To r t+.t a.d.arm 0 iiw ww anwrev new mo t a Yw ❑ Sulfide 0 Could Not Bo Determined 34.Dabs Of Infamy(umdYDaylyear) 35.Time Of Iriiury 38,Place Of!Nifty(E.G.,Decedents Horne,Cme0nrmon Sao,Reslerli Restaurant,Wooded Area) 37. Injury At Warl[7 f - ❑ Yes ❑ No n` 1 38a City Or Town 38b. Street a Number . 3.9e Apt No. 38d. Ztp Code It __ _ qp it ranspong�ion �,po�+l. 39.DsfalOe How Injury Occurred Oonl T ❑v.«..ry❑..�rw❑ae.w ten.mrn �? r.r`, 41.Signature,Of Person Certifying Cause Of Death: .Q APRIL MICHELLE-SIMMONS TOELLE BY ELECTRONIC SIGNATURE - _C 6 Certifier((P al Chock Only Oro El coroner o Nautili Officer ),n 43. Name,Address And Zip Code Of Person Certifying Cause«Dealt _ 44. Ucertse Number 45. Date CaNMd 0 n` APRIL MICHELLE-SIMMONS TOELLE 600 MARY ST. EVANSVILLE IN 47747 ' 020034.10A 05/09/2020 )� 46.Additional Funeral Service Provider-. .. 47.'Akan: rr 1 49.Signature of Local Hearth Officer 49. For Regisbfr Only-Date Flied(Mone✓Deyryeet. //.l� 9 BRUCE BRINK JR VIA ELECTRONIC SIGNATURE MAY 11 2020 0 n.6 _ - ': C 1 J M se1he S '� '., r 40 26 -tit - (4-20(4 -000 ,Sic( --Os ( -�2.) Stale Form 53395 ATTENTION ESTATE:The Social Se curtly C Is being requested by this state agency to order to pursue responsibility. Disclosure Is voluntary and there will be no penalty for refusal '. WARNING: ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF-INDIANA ON BACK-THAT -I_i TURNS FROM ORANGE TO YELLOW WHEN RUBBED ORIOINAL'DOCUN,EIYT HAS A HIDDEN VOID ON FROM THAT APPEARS WHEN PHOTI,OCOPIED. _ ���� U•�� \J . ;4' it 'vr1.r'l�.✓'�" `w/'} k:J'�J 15�s%=J G�P"!�`� �_ V Irl�l_ ftC�me�"✓�'�t^,%a�oI��vim. .:w..off✓._-ere»U:, 'u�-.STATE.OF..INDIANA.=.:✓ �_*.. :✓ ..a_2_ : s_. .:.Y �' i `n1, '„';_`n��l..`•_-r..G 'r.: :•-i_G'�, �%-�''�i � 1Z; �.i CERTIFICATE OF DEATH r�s". : "i�.1..iCG:-•�:n_r•.; ram. .- .3,. :Sr',= fii, s • • \ - 43 INDIANA STATE DEPARTMENT OF HEALTH 3 9 9.6.8 55 1 ( CERTIFICATE OF DEATH "( 1 Local No 000175 EDR No 000001960652 State No 2016-00431:5'" 1.Decedenre Legal Name(Feel Middle.Last) I Is.Maiden Name(II 1ematel 2-Gender 3. Tinto Of Death NureSg H0nMM1onp-lent Care Faaly ®Yes,�, No El Unknown 0 Inpatient Emergency Department Outpatient ❑,Dead ion f'If ravel ❑other lSf'a"M • Pi 0. t l:Facility Name Of Not irwaution,Olva Street and Number) CHARLIER HOSPICE CENTER Y-pppyyy q12.City Or Town,Slate,And Zip Code 13.County Of Death 14.Marital Status At lime OI Death Evansville,Indiana 47713 Vanderburgh go Mewled D Married.But Separated 0lolr;erced •/ 0 Wdowed 0 Never Married 0 Unknown 6 ' 15.Survling Spouse's Name 15a.Last Name Before First Marriage 16.De<adenrs Usual Oecupetion 17.Kid OI Business/K.0. v C( 0. YOCOM LABORER INDEPENDENT CONTRA ,•1( SUSAN GRUBB J,1 .-L to.Rasdertca-State 18a.County /82.City Or Town IN Gibson Oakland City 1 it le.Street And Number tad.Ara No. tile. Zip Code 18f.tnslde City harts? I CO. 13090 EAST 275 SOUTH ' ' 47660 D Yes tl'B No ;1 `l; 18. DaOderKs Education 20.Deretlertt Of Hbpanld Origin • 21.Decedent's Race • 'Ll High School graduate or GED completed Not Spanish/Hispanic/Latino White ,- i, 22.Parent's Name(Flrat.Middle.last) 23.Parents Nemo(First,Middle,Last) 23.Parente Last Name Before Fest Manage 'IA iy{2 WILLIAM CARR-GRUBB BONNIE AGNES GRUBB JONES ,,,I y >'( il(. 24.in tomrants Name 24a. • Relationship To Decedent 24c.Maaing Address(Street And Number.City.State,Zip Code) , 0 SUSAN GRUBB .i I, Wife 13090 EAST 275 SOUTH,Oakland City,IN,47660 • W I v._i.. • Cl) II'111,":" 25.Place Of Dieddsiovt' CC 25.Method 0(13ispoaition _252.Place Of Disposition(Name 01 Centetary,Crematory.Other Pace) 25e.location-Coy.Tow,And State LU 0 Burial an Cremation 0 DiaWn 0 EnbmWnent CC 0 ❑.Rernoval From State \ .• EVANSVILLE CREMATORY Evansville,IN 0 Other(Specify): 26.Was Coroner Contacted? 27.Name And Complete Address Of Funeral Fecirdy • 27a Funeral Homo License Number: , Com-Colvin Funeral Home, •LU ❑Yee ®No ^'I. OaklandFH19 • 400002 Inc..323 N.MAIN ST. PO BOX 278, City,Indiana,476600278 W 27b.Signature a ln®ana Funeral Prentice Licensee: - -. - - 127r_Ucense eammer(Of tiomwe):FD01012153 • J J Rap 4)H7C P Electionically Signed .1 Cause Ot Death (See Instructions And Etamptee) 'Approximate LL 28.Pan I.Enter The Chain 01 Events -Diseases.Injuries.Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval:Onset • 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 II Necessary. O Immediate Cause(Final Disease Or Cot-Id-Mon Resulting In Death) A. MULTIPLE MYELOMA,PNEUaMONAIACHRONIC OBSTRUCTIVE PULMONA • �41 - Sequentially List Conditions, II Any.Leading To The eQ Cause Listed On B. I b,a u n0 AS Ato.rq,•v at: . Line A. Enter The Undertying Cause(Disease Or Injony That Initiated _ _ F i�� _ The Events Resulting In Death)Last C. �• Ma to 10 4ACSMqwo Oa ` j I ' I• ( 'Pin I.Enter OeVr$lontticattt Condition.Contd./P:to Death But Not Resulting In The Underlying Cause Oben In Pan 1 29.Was An Autopsy Pe 1r1004 r / 0seas (XI No.. .` 30.Were Autopsy Finding Available To Complete The Cause 01 Death7 ❑yes ❑No 31.Did Tobacco Use CorahOtne To Death? 32.II Female: 33.Manner 01 Death: I 0„t tnertw..w.,s,v.a.v.., 0..ere av at n.e e1 Drab Cl an ra.4.4 Pot .',.va.w.u ows a 0..a ®Natural 0 HorNNde 0 Accident 0 Pending Irwesligatbri .`/ (. YeaProtNo UnMovm 0 he r..o ux au raw.u IN,to I,or e.ba oaa O obeOlI: wow tea Pap vas, 2Wciee i ❑ 0 abN 0 MI IE 0 D Card Nw Be Determined l. r f` 34.Dar 01 Injury(Month/Dar/VW 35•limo OI In;ury 38.Place OI In)Itry( D..Decedent's Home.Construction Sae.Restaurant Wooded Area) 37.injury Al Work? L m ❑Yes ❑No J ;C1 rei38.Location 01 Ireury-State 38a. City Or Town 389.Street 4 Number i 138G Apt.No. ZIP Code • t • C.< 39.Dosc,bo How 40,11 Transportation Inkuy.SPori(y: Injury Occurred-r - ❑M+.a.„..ro ❑r.r.P❑c.ew`r.❑oNlanav,l N 1 4,.Slorul5Pa.O1 Person Certifying Cause 01 Death: - '. 42.Gardner(Check Only One) 7..:::! rry 7'ULPrE is(Ett57 ERrp? ; ., Electronically Signed ga Certifying Physician ❑Coroner 0 Health 015car . �\c 43.Name,Address And Zip Code OI Person Certifying Caul Of Death: 44.License Number 45.Dale roll Caed j • �y14 JULIE K.GERHARDT 600 MARY ST.,Evansville,IN 47713 01057271A 01/29/2016 '' L1e 46.Additional Funeral Service Provider: 47..Akan: I ' ' • 49. For Registrar Only-[Maenad( et/Dey/Vear): • 4s sighePrre of Local Hearn,Officer. grgrRjr' ygyrET}(SypEArR. ;j„ Electronically Signed 02/01/2016 ?y� v • :. ��tp`A� Pcv��► Or SP . 1c.v� � 2G - tkA- l g -3Vy - 00 o. °l q' p -7 ll 'Zoz- State Form 5331)5 ATTENTION ESTATE:The Social Security a is being requested by this stale agency In order to pursue responsibility. Disclosure Is voluntary and there will be no peally n o refusal.,-:,-.1 WARNING: ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE.�SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON,T(Ct,TNT -JI rl WARNING. TU FROM•RANGE T•YELLOW WHEN RUBBED ORIGINAL DOC HAS ODEN VOID ON FRONT THAT APPEARS WHEN PHOTO O PIED. I' .• Iv "Otis rt`ui.:v,--t"4 +r•..-r•3irv:•:�.ts--.�Cy��-✓-; • ► e _ ► v:•�l!=�(�r'��•�.L77..p;:%``r•---_i ";'"(:r'�. � -`� ✓'�'�• iq: © 0 m 1