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'INDIANA STATE DEPA TMENT OF HEALTH ___
. . CERTIFICATE OF DEATH (- ''''' ,
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N.._;,..• Locil,No 000305 EDR No 00000055 9475 State No 007356 . '
.1,Decedents Legal Name(First,Middle,Last) 1a,Maiden Name,(If female) 2.Sex 3. Time Of Death • 4.•,Date Of Death(Month/Day/Year),. ,,l'•1 .
SHERREL LYNN JOHNSON . , .1 CRAWFORD FEMALE 02:05 AM
5.Social Security Number 6a.Age-Yrs 6b. Under 1 Year Sc. Under 1 Month 6d, Under 1 Day 6e. Under 1 Hour 7. Date of Birth,(Morith/DayNear) 8.Birthplace(City and State or Foreign Country)
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El Hospice Facility El Decedent's Home El Nursing Home/Long.terrn Care Facility
El Yes 12:1 No E Unknown El Inpatient El Emergency Department Outpatient El Dead on Arrival El Other(Specify)
11. Facility Name(If Not Institution,Give Street and Number) '
ST MARY'S MEDICAL CENTER OF EVANSVILLE, INC , , • ,
12.City Or Town,State,And Zip Code 13, County Of Death ' 14. Marital Status At Time Of Death
. • . . Ea Married El Married,But Separated .E]Divorced
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EVANSVILLE,IN,47750 i VANDERBURGH EI Widowed EI Never Married El Unknown
15.Surviving Spouse's Name ' ' 15a.Last Name Before First Marriage • 16. Decedent's Usual Occupation ' 17. Kind Of Business/Industry -
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HAROLD JOHNSON • , , HOMEMAKER .
. HOMEMAKER
18.,Residence-State 18a, County .
18b. City Or Town
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INDIANA ' GIBSON • HAUBSTADT . .
18c. Street And Number . , . 18d.Apt.No, 18e. Zip Code 18f. Inside City Limits?
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3268 EAST 1025 SOUTH '
47639 El Yes• No
19.'Decedent's Education I 20. Decedent Of Hispanic Origin 21. Decedent's Race
HIGH SCHOOL GRADUATE OR GED COMPLETED I NOT HISPANIC 'White
.22.Parents Name(First,Middle,Last) 23.Parents Name(First,Middle,Last) ' 23a Parent's Last Name Before First Marriage
FLOYD CRAWFORD _LUCILLE CRAWFORD WINGFIELD
24.Informants Name • 24a.Relationship To Decedent 24b.Mailing Address(Street And Number,City,State,Zip Code)
HAROLD JOHNSON , HUSBAND 3268 EAST 1025 SOUTH,HAUBSTADT, IN 47639 .
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, 25.Place Of Dispdsition .
25a.Method Of Disposition 25b,Place Of Disposition(Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State
El Burial,IEl'Cremation E3 Donation D Entombment
El Removal From State . .
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El Other(Specify): MEMORIAL PARK CREMATORY EVANSVILLE, IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility 27a, Funeral Home License Number:
Y 10No ALEXANDER FUNERAL HOME, NORTH CHAPEL,4200 STRINGTOWN , VANSVILLE,
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IIN 47710 FB41500021
.27b. Signature Of Indiana Funeral Service Licensee: - 27c.Lic urn (Of Licensee):
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JONATHAN K.ALEXANDER, BY ELECTRONIC SIGNATURE FD204 0
. . Cause Of Death (See Instructions And Ex males) If Approximate
28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death,Do Npt.IE ermine!Es Interval: Onset
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviar<4 r Only One Cf*.c.3) To Death
'.A Line. Add Additional Lines If Necessary.
RESPIRATORY FAILURE FROM END-42), MPHYSEMA,NigATILATOR
Immediate Cause(Final Disease Or Condition Resulting In Death) A. DISCONTINUED 4 DAYS
Due tqa• Consequent:a Ofy tri3:1 .
NIA M PNEUO tea
Sequentially List Conditions, If My,Leading To The Cause Listed On B. Nae,(0,Aia"). ....0
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated ' "
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The Events Resulting In Death)Last ' C.
. Due to(Or As A Co • .
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Part II.Enter Other Significant Conditions Contributing to Death But Not Resulting In The Underlying Cause Given In Part I 29,Was An Autopsyleformed?
El Yes 124 No
SO.Were Autopsy Finding Available To Complete The Cause Of Death? ,...,
CARDIOGENIC SHOCK , . ' Li Yes 0 No
31. Did Tobacco Use Contribute To Death? . 32. If Female: 33.Manner Of Death:
El Not Pregnard Wein Past Year El Pregnant At Tane Of Death 0 Not Pregnant.Bth Pregnant Wilan42 Days Of Death El Natural 1]Homicide Ei Accident Ei Penang Investigation
' El Yes Et Probably El No 0 Unknown
0 Not Pregnant.But Pregnant 43 Daps To 1 year Before Death Ej Unknown If Pregnant wow The Pea Year 0 Suicide El 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?
0 Yes EI No
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. i38. Location Of Injury.State 38a. City Or Town 38b. Street 8,Number 38c.Apt No. 38d.Zip Code
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39. Describe How Injury Occurred ' 40. If Transportation Injury,§piecify:
OOdyer/Operator 0 Passenger Pedestrian Daher(Specify)
41.Signature,Of Person Certifying Cause Of p•ath:i. ' ' 42.Certifier(Check Only One) ,
MICHAEL J.ALLEN,BY ELECTRONIC SIGNATURE , . 0 Certifying Physician El Coroner El Health Officer, '
43. Name,Address And Zip Code Of Person Certifying Causepf Death: k , .1 ' 44. License Number 45.Date Certified
MICHAELJ.ALLEN ,3801 BELLEMEADE AVENUE,SUITE 200-A, EVANSVILLE, IN 47714 01048785A 02/1412017
48.0Additional Funeral Service Provider.. .. ." . 47. *Akas:
48.•Signature of Local Health Officer . : . 49. For Registrar Only•-Date Filed(Month/Day/Year):
ROBERT KENNETH SPEAR,VIA ELECTRONIC SIGNATURE' . FEB 15 2017
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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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: TuRRIGhTAFLRDOCtIACIIRAMENNJEHTAg YAEMLLUOLWTICWOHLEONRERDLIBBBAECDKGORrGNINDALONDIPLIEI,CAIEANLTWHH2TSEAqCORITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT
HIDDEN VOID ON FRONT THAT APPEARS WHEN PHOTOCOPIED. 'i ,