Death Certificate - Donohoo, Wayne_7/13/2022 (2) 4 INDIANA STATE DEPARTMENT OF HEALTH
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(,� sli CERTIFICATE OF DEATH
'' Local No 001098 EDR No 000000828467 State No 074195
1.Decedent's Legal Name (First,Middle,Last) la. Maiden Name (If female) 2.Sex 3, Time Of Death 4. Date Of Death(Month/Day/Year)
WAYNE DONOHOO MALE 20:43 12/21/2020
It 5. Social Security Number 6a, Age-Yrs 6b. Under 1 Year 6c. Under 1 Month 6d. Under 1 Day 8e. Under 1 Hour 7 Date of Birth (Month/Day/Year) 8.Birthplace (City and State or Foreign Country)
` 308-84-4758 55 Months Days Hours Minutes 09/05/1965 OAKLAND CITY, IN
9. Ever in U.S.Armed Forces? 10.If Death Occurred In A Hospital: 10a. If Death Occurred Somewhere Other Than A Hospital
0 Hospice Facility 0 Decedent's Home 0 Nursing Home/Long-term Care Facility
0 Yes ®No 0 Unknown I El Inpatient 0 Emergency Department Outpatient ❑Dead on Arrival 0 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
®Married 0 Married,But Separated 0 Divorced
NEWBURGH, IN,47630 WARRICK 0 Wdowed ❑Never Married 0 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 lea. County 18b. City Or Town
j.
INDIANA GIBSON ELBERFELD 18tl. Apt.No 18e. Zip Code 18f. Inside City Limita7
18c. Street And Number
❑Yes ®No •
8514 SOUTH 850 EAST 47613
19. Decedent's Education 20, Decedent Of Hispanic Origin 21, Decedent's Race
HIGH SCHOOL GRADUATE OR GED NOT HISPANIC White
COMPLETED 23.Parent's Name(First.Middle,Last) 23a,Parent's Last Name Before First Marriage
22.Parent's Name(First,Middle,Last)
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 ID Cremation ❑Donation 0 Entombment
11. ElRemoval From State
❑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 FB41800004
47715
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 t,i&
To Death
s A Line. Add Additional Lines If Necessary. I
Immediate Cause(Final Disease Or Condition Resulting In Death) A. VENTRICULAR TACHYCARDIA O .�//)�\/■ AICD FIRING
.rotor As a cen«w.nn.on. _V
Sequentially List Conditions, If Any,Leading To The Cause Listed On B. CORONARY ARTERY DISEASE WITH PICA ✓//�
g.ta tgr...�an..w.n«g� v 1r
• Line A. Enter The Underlying Cause(Disease Or Injury That Initiated I]
The Events Resulting In Death)Last C. ACUTE RESPIRATORY FAILURE NEEDING MECHANICA TILATION !+
ou.to lOr A.A C.n..Quaa CU41
Part II.Enter Other Significant Conditions Contributing to Death But Not Resulting In DThe Underlying Cause Given In Part I 29. Was An Autopsy Perfor edtOUN i- -yes o
30. Were Autopsy Finding Available To Comp4N5j se Of Death? El Yes ❑No
31. Did Tobacco Use Contribute To Death? 32. If Female. 33. Manner Of Death' y/�, oR
0 Nor Pregnant furor Past Year 0 Pregnant Oa Tine or o.am El Nol Pregnant.But Pr.an.nt wanin 42 oat.or o.am ®Natural El Homicide ❑Accident 0 Pending Investigation
❑Yes 0 Probably 0 No ®Unknown ❑Not Pregnant.But'wpm..43 o.y. o t year Boer.Death ❑un•nono r Pr.anant wnn n Tn.P..,v..r ❑Suicide❑Could Not Be Determined
34. Date Of Injury(Month/Day/Year) 35. Time Of Injury 0 36. Place Of Injury(E.G. Decedent's Home Construction Site,Restaurant,Wooded Area) 37. Injury At Work?
❑Yes ❑No
38. Location Of Injury-State 38a, City Or Town 38b. Street&Number 38c. Apt.No. 38d. Zip Code
39. Describe How Injury Occurred 0 I/.ran.porta❑tiosnWnjury,le i al.n Eon_lsmo,ryl
41 Signature, Of Person Certifying Cause Of Death: 42 Certifier(Check Only One) ILJJ •
DEEPA GHANTA, BY ELECTRONIC SIGNATURE ®Certifying Physician 0 Coroner ❑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
47. -Pikes:46. Additional Funeral Service Provider:
49. For Registrar Only -Date Filed (Month/Day/Year):
48. Signature of Local Health Officer:
RICKY B YEAGER,VIA ELECTRONIC SIGNATURE DEC 28 2020
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
((� - 100l 0OO _ 4J0 -001 ✓o,ilk".
State Form 53395 ATTENTION ESTATE:The Social Security#is being requested by this state agency In order to pursue responsibility. Disclosure is voluntary and there will be no penalty for refusal.
WARNING: OT
FROM OR NGE TO YELLOW WHEON RDUBBEDGORIGINALL DOCUMIENT HATS ASHIDDEN VO DPON FRONT THATEAP FARSOWHEN PHOTOCO,,PIFDIANA ON BACK THAT