Death Certificate - White, Freda_11/23/2022 ayy.;r: o INDIANA STATE DEPARTMENT OF HEALTH 3 7 2 213 0
at -':''\ CERTIFICATE OF DEATH
Local No 000350 EDR No 000011273352 2 Gender State N Timeor Death 2-0227
Freda Vivian White Davis
Unknown,Indiana
• 89 Months Days Hours Minutes
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 ❑Decedent's Home al Nursing Home/Long-term Care Facility
❑Yes 0 No X Unknown ❑ 0 Dead on Arrival Inpatient 0 Emergency Department Outpatiente ❑Other(Specify)
n.Facility Name(n Not Institution,Give Street and Number) Hamilton Pointe Health And Rehab
12.City Or Town,State,And Zip Code 13.County Of Death 14. Marital Status At Time Ot Death
Newburgh,Indiana 47630
Warrick ®MarrieeD Mpieck ButSeR,'aated unooncum ed
15.Surviving Spouse's Name 15a.Last Name Before First Marriage 16. Decedent's Usual Occupation 17.Kind Of Business/industry
Domectic Housewife
18. Residence-State lea.County lab. City Or Town
IN Gibson Oakland City
18c.Street And Number I 18d. Apt.No. 16e. Zip Code 1st. Inside City Limits?
47660 ❑Yes ®No
1 8642E 450 S 1
19. Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedent's Race
8th grade or less
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
Lucas Davis Ruby Davis Riggs
24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address (Street And Number,City.State,Zip Code)
Linda Stolz Daughter 8810 E Base Road,Oakland City,IN,47660
25.Place Of Disposition
25a.Method Of Disposition 25b.Place 01 Disposition(Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State
MI Burial 0 Cremation 0 Donation 0 Entombment
❑Removal From State Mt.Olive Cemetery Hazleton,IN
❑Other(Specify): 27a. Funeral Home License Number:
26.Was Coroner Contacted? 27.Name And Complete Address Of Funeral Facility
Lamb-Basham Memorial Chapel FH12200005
0 Yes ®No LLC 226 E.Washington Street,Oakland City,Indiana,47660
27b. Signature Of Indiana Funeral Service Licensee: 27c. License Number(Of Licensee): FD20400059
Evan t'Thayer Electronically Signed
Cause Of Death (See Instructions And Examples) 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.
DIASTOLIC CONGESTIVE HEART FAILURE unknown
Immediate Cause(Final Disease Or Condition Resulting In Death) A. a,. 10,Ma Cnr.Oano o,1: •
Sequentially List Conditions, If Any,Leading To The Cause Listed On B. d,.,o to.Se in c.n..v,.nceon:
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last C. one to(Or..A csnsequenn.v0;
D.
Part II.Enter Other Sionificent Conditions Contributine to Death But Not Resulting In The Underlying Cause Given In Part I 29.Was An Autopsy Performed? ❑Yes ®No
•
30.Were Autopsy Finding Available To Complete The Cause Of Death? 0 Yes 0 No
aortic stenosis,atrial fibrillation,chronic kidney disease 33.Manner 01 Death
31.Did Tobacco Use Contribute To Death? 32.If Female: esr Prs „s,w,,,,n,e20ev.a own 122 Natural 0 Homicide 0 Accident 0 Pending Investigation
0 Yes ❑Probably®No ❑Unknown 0
,n
ID Nu.,P'.s Eonn•.wm n loreesint
-_ . e
43 ,y „ s,n In u ant NM.. Pen Year ❑Suicide 0 Could Not Be Determined
34. Date Of Injury(Month/Day/Year) 35 Time Of Injury 36. PI • In) .,Decedent's
s Home,Cong etton Site.Restaurant,Wooded Area) 37. Injury At Work?
❑Yes ❑No
38. Location Of Injury-State 38a. City Or Town 38b.Street&NumberV 38c.Apt.No. 380.Zip Code
NOV 2 3 2022 `�� .
39.Describe How Injury Occurred 40. If Transportation Injury,Specify:
-/ �( ❑o,,.a,r0n.•.,or ❑P.s.reer❑P.ae.wn Clothe heat v,
41.Signature,Of Person Certifying Cause Of Death: Y2GKiter-g e 5t' ZZf'!/7L4) 42.Certliler(Check Only One)
April -Simmons'oe/e PARSON rtni1NTV�.II9atiP'fic Iy Signed i Certifying Physician ❑Coroner 0 Health Officer
44.License Number 45. Date Certified
43.Name,Address And Zip Code Of Person Certifying Cause Of Death:
April Michelle-Simmons Toelle 600 Mary St.,Evansville,IN 47747 02003410A 04/18/2022
47.•Akas:
46.Additional Funeral Service Provider:
48.Signature of Local Health Officer: 49. For Registrar Only-Date Filed(Month/Day/Year): 04/18/2022
4(jcky 43'Yeager Electronically Signed
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
C- \3 -3A-300 -001 010_ OO6•
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- ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT "
TURNS FROM ORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUMENT HAS A HIDDEN VOID ON FRONT THAT APPEARS WHEN-PHOTOCOPIED.....- :.�