Death Certificate - Whitten, Daniel_7/8/2022 !,rT.,4 INDIANA STATE DEPARTMENT OF HEALTH t
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ced - Local No 000986 EDR No
,i CERTIFICATE OF DEATH
�� 000011185144 State No 2021-060727
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1.Decedent's Legal Name (First,Middle,Last) la. Malden Name (If female) 2.Gender 3. Time Of Death
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Daniel Lee Whitten
Kingsville,Texas
61 Months Days Hours Minutesft
9. Ever in U.S.Armed Forces? I 10.If Death Occurred In A Hospital: 1 Oa. If Death Occurred Somewhere Other Then A Hospital f
0 Hospice Facility 0 Decedent's Home Elm Nursing Hoe/Long-term Care Facility ,,
la Yes 0 No 0 Unknown '® Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival ❑Other(Specify) /
11. Facility Name (If Not Institution,Give Street and Number) Deaconess Gateway Hospital
12. City Or Town,Slate,And Zip Code 13. County Of Death 14. Marital Status At Time Of Death
Warrick gig Married❑Married.But Separated El Divorced
Newburgh, Indiana 47630 0 Widowed 0 Never Married 0 Unknown
15. Surviving Spouse's Name 15a.Last Name Before First Marriage 16. Decedents Usual Occupation 17. Kind Of Business/Industry
Banyai Inspector Manufacturing
Jennifer Whitten
18. Residence-State 18a. County 18b. City Or Town
IN Gibson Princeton -
18d. Apt.No. lee. Zip Code 18f. Inside City Limits?
18c. Street And Number
47670 ®Yes El ,
907 E State Street
19. Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedent's Race
Unknown Not Spanish/Hispanic/Latino White
22.Parent's Name(First,Middle,Last) 23.Parent's Name(First,Middle,Last) 23a.Parent's Last Name Before First Marriage
James Whitten Nancy Whitten Nichols
24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address (Street And Number,City,State,Zip Code) ,
Jennifer Whitten Wife 907 E State Street,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,Arid State
❑Burial ®Cremation ❑Donation 0 Entombment
0 Removal From State Evansville Crematory Evansville,IN
❑Other (Specify): 27a. Funeral Home License Number:
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility
Doyle Funeral Home 520 S Main St,Princeton, Indiana,47670 FH10400010
❑yes ®ND
27b. Signature Of Indiana Funeral Service Licensee: 27c. L' e Number(Of Licensee): FD29500009
Barrett'W.'Dayle Electronically Signed
Cause Of Death (See Instructions And Examples) ,ILED Approximate
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 Additional Lines If Necessary. 1 day
A Coronary Artery Disease JU�
Immediate Cause(Final Disease Or Condition Resulting In Death) Care to r«As A cpnsetmenc<on:
End Stage Renal Disease 8 2022 3 years -
Sequentially List Conditions, If Any,Leading To The Cause Listed On B. are to in,As A cent Cfi. W/� ,/{�d
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated GfB "
The Events Resulting In Death)Last C. pa,to to yoAcar,a.aaen�S N r!rtr ry L't'
AUDITOR -
D.
•
Part II.Enter Other Significant Conditions Contributing to Death But Not Resulting In The Underlying Cause Given In Part I 29. Was An Autopsy Performed? 0 Yes ®No -
30.Were Autopsy Finding Available To Complete The Cause Of Death? 0
Yes ❑No
Emphysema
31. Did Tobacco Use Contribute To Death? 32. If Female: 33. Manner Of Death:
0 Nat Pregnant Within Past Year ❑Pregnant At line of Death ❑Nat Pregnant,But Pregnant wnr:n ai Day.a Death ®Natural 0 Homicide 0 Accident 0 Pending Investigation
®Yes 0 Probably 0 No ❑Unknown ❑Not Pregnant.But Pregnant 4s Days Tot year galore oeatn 0 unexm.n a Pregnant wuntn The Peet 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's Home,Construction Site,Restaurant,Wooded Area) 37. Injury At Work?
❑Yes ❑No
38a. Cit Or Town 38b. Street 8 Number 38c. Apt.No. 38d. Zip Code
' 38. Location Of Injury-Stale Y
40. If Transportation Injury,Specify:
39. Describe How Injury Occurred ❑Peeeatnan DDot a(specify) -
El ❑Peaeenge,
41. Signature,Of Person Certifying Cause Of Death: 42. Certifier (Check Only One)
Adrian Lee Carter Electronically Signed AI Certifying Physician 0 Coroner 0 Health Officer
43. Name,Address And Zip Code Of Person Certifying Cause Of Death: 44. License Number 45. Date Certified
Adrian Lee Carter 1808 Sherman Drive,Princeton,IN 47670 02002691A 10/28/2021
47. 'Akas:
46. Additional Funeral Service Provider:
48.Signature of Local Health Officer: 49. For Registrar Only -Date Filed (Month/DayNear): 10/28/2021
jcky43'Yeager Electronically Signed
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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State Form 53395 ATTENTIO OR(G1NAC DOCUM�NT H/�griAyM( MaiaHt�s6ACKC W8t7NU KCI, lNH14e rFPg0PEPI'AN�-niEr8a vATSEAL OF ThOUVil E 8P fANd6�B'A4�T(THAT
WARNING. WHEN PHOTOCOPIED.
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