Death Certificate - Donohoo, Wayne_7/13/2022 /4 fr4, INDIANA STATE DEPARTMENT OF HEALTH 7
((//7e CERTIFICATE OF DEATH
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'� Local No 001098 EDR No 000000828467 State No 0741 955
i.Decedent's Legal Name (First,Middle,Last) I la. Maiden Name (If female) 2.Sex 3. Time Of Death
iii
OAKLAND CITY IN
9. Ever in U S.Armed Forces? 10.If Death Occurred In A Hospital'. 10a, I/Death Occurred Somewhere Other Than A Hospital
0 Hospice Facility 0 Decedent's Home ❑Nursing Home/Long-term Care Facility
❑Yes El No ❑Unknown I El Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival ❑Other(Specify)
11. Facility Name (If Not Institution,Give Street and Number)
DEACONESS GATEWAY
12. City Or Town.State,And Zip Code 13. County Of Death 14. Marital Status At Time Of Death
El Married El Married,But Separated ❑Divorced
NEWBURGH, IN,47630 WARRICK ❑Widowed ❑Never Married ❑Unknown
15. Surviving Spouse's Name 15a.Last Name Before First Marriage 16. Decedent's Usual Occupation 17. Kind Of Business/Industry
MELISSA ANN DONOHOO WARD UNION CARPENTER CONSTRUCTION
18. Residence-State 18a. County 18b. City Or Town
INDIANA GIBSON ELBERFELD
18c, Street And Number 18d. Apt.No. lee. Zip Code 18f. Inside City Limits?
- 8514 SOUTH 850 EAST 47613 ❑Yes ®No
19. Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedent's Race
HIGH SCHOOL GRADUATE OR GED
tCOMPLETED NOT HISPANIC White •
.. 22.Parent's Name(First.Middle.Last) 23.Parent's Name(First,Middle,Last) 23a,Parent's Last Name Before First Marriage
-. BRUCE WAYNE DONOHOO SONJA ANN DONOHOO KROGER •
• 24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address (Street And Number,City,State,Zip Code)
MELISSA DONOHOO WIFE 8514 SOUTH 850 EAST, ELBERFELD, IN 47613
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 ®Cremation 0 Donation El Entombment
0 Removal From State
lb
❑Other (Specify): PILLARS CREMATION SERVICE CHANDLER, IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility 27a. Funeral Home License Number:
El Yes ❑No SIMPLE CREMATION EVANSVILLE, 3101 N. GREEN RIVER RD. STE 320, EVANSVILLE, IN
47715 FB41800004
27b Signature Of Indiana Funeral Service Licensee: 27c. License Number(Of Licensee):
ALEXANDER WAYNE RICKETTS , BY ELECTRONIC SIGNATURE FD21900036
Cause Of Death (See Instructions And Examples) . Approximate
28.Part I.Enter The Chain Of 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
e A Line. Add Additional Lines If Necessary. L
Immediate Cause(Final Disease Or Condition Resulting In Death) A. VENTRICULAR TACHYCARDIA D , AICD FIRING
..to(Or As A c.n..w.ns.on.
SequentiallyList Conditions, If Any.LeadingTo The Cause Listed On B. CORONARY ARTERY DISEASE WITH PICA �/i�
D.,a for AaADan.eA.nu Do C/
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated A
The Events Resulting In Death)Last C. ACUTE RESPIRATORY FAILURE NEEDING MECHANIC TILATION c
Due to for As A cansean�'
D• . Will CS
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. ,,N). --ift,yRs o
30. Were Autopsy Finding Available To Comp4F10' Cause Of Death? ❑Yes ❑No
_ 31. Did Tobacco Use Contribute To Death? 32. If Female: 33. Manner Of Death: U/ O14
0 sot Pregnant wwgan Pas,Saar ❑Pregnant A,Tine of Dram 0 Not Pregnant.an Pngnan,Wentn 92 Days of Dean Ei Natural 0 Homicide 0 Accident 0 Pending Investigation
❑Yes ❑Probably El No ®Unknown 0 Not Pregnant.But Pregnant as Days n,year Baron •.tn 0 unknown B Pr•gn.nf win.,The Past Year El Suicide❑Could Not Be Determined
34. Date Of Injury(Month/Day/Year) 35. Time Of Injury D 36. Place Of Injury(E.G.,Decedent's Home.Construction Site,Restaurant,Wooded Area) 37. Injury At Work?
0 Yes El No
38. Location Of Injury-State 38a, City Or Town 38b. Street&Number 38c. Apt,No. 38d. Zip Code
39. Describe How Injury Occurred 40.❑orlva OP.neon❑P..seengger OPerl rrnn ❑o a.Isp•uryl
41. Signature, Of Person Certifying Cause Of Death- 42 Certifier(Check Only One)
DEEPA GHANTA, BY ELECTRONIC SIGNATURE ®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
DEEPA GHANTA ,600 MARY STREET, EVANSVILLE, IN 47747 01066897A 12/23/2020
46. Additional Funeral Service Provider: 47, -Akas:
48. Signature of Local Health Officer 49. For Registrar Only -Date Filed(Month/Day/Year):
RICKY B YEAGER,VIA ELECTRONIC SIGNATURE DEC 28 2020
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
-fi10.1 3c- 100 - 000 _ 430 -01 _ e„ .
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Disclosure is voluntary and there will Ebe no penalty for refusal.
WARNING: TTURNIS FROM ORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUMENT AS AS HIDDEN VOID ONFRONT T THAT
APPEARS EARSOWHENEPHOTO OPIEDIANA ON BACK THAT