Death Certificate - Brown, Ruth_3/11/2024 l "''A4, INDIANA STATE DEPARTMENT OF HEALTH
Y*� i, CERTIFICATE OF DEATH 4 3 6 7 5 8 3
°"•-' Local No 000202 EDR No 000011688452 State No 2024-011089
1.Decedent's Legal Name (First,Middle,Last) la. Maiden Name (If female) 2.Gender 3. Time Of Death 4. Date Of Death (Month/Day/Year)
Ruth Ann Brown Boyle Female 09:37 AM 03/01/2024
Princeton,Indiana
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 0 Nursing Home Long-term Care Facility
0 Yes El No 0 Unknown El 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,State,And Zip Code 13. County Of Death 14.Marital Status At Time Of Death
Newburgh,Indiana 47630 Warrick 0 Married❑Married,But Separated 0 Divorced
s❑Widowed 0 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
Homemaker Own Home
18. Residence-State 18a. County 18b. City Or Town - -
IN Gibson Princeton
18c. Street And Number 18d. Apt.No. 18e. Zip Code 18f. Inside City Limits?
1904 Taylor Avenue 47670 El Yes 0 No
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
Sam Boyle Ruth Ann Boyle Kendall
24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address (Street And Number,City,State,Lp Code)
Jason Brewer Grandson 1904 Taylor Avenue,Princeton,IN,47670
25.Place Of Disposition �cel
�O l 1
25a.Method Of Disposition 25b.Place Of Disposition (Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State tL
❑Burial El Cremation 0 Donation 0 Entombment
❑Removal From State o
❑Other(Specify): Evansville Crematory,Llc Evansville,IN IPA
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26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility 27a. Funeral Home License Number:
Doyle Funeral Home 520 S Main St,Princeton, Indiana,47670 FH10400010
❑Yes El No
27b. Signature Of Indiana Funeral Service Licensee: 27c. License Number(Of Licensee): FD29500009
Barrett W./Doy& Electronically Signed
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
A Line. Add Additional Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. bilateral pneumonia <24 hours
Dee rotor As A Consequence 01/
acute respiratory failure requiring mechanical ventilator <24 hours
Sequentially List Conditions, If Any.Leading To The Cause Listed On B. oe.to(or As A cone.quen«on
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last c septic shock due to pneumonia and influenza <24 hours
Due to(Or As A Consequence Of)
D. acute kidney failure <24 hours
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? ❑Yes El No
Influenza A,history heart failure,history stroke 30.Were Autopsy Finding Available To Complete The Cause Of Death? ❑Yes 0 No
31. Did Tobacco Use Contribute To Death? 32. If Female: - 33. Manner Of Death:
0 Not Pregnant Wnh,n Peet Year ❑Pregnant At Terse Of Death 0 Not Pregnant.But Pregnant Wah.12 Dap Of Death El Natural 0 Homicide 0 Accident 0 Pending Investigation
0 Yes ®Probably El No ❑Unknown 0 Not Pregnant.But Pregnant 43 Days To t year Before Death ❑Unknown II Pregnant Wro,n The Past Year 1 0 Suicide 0 Could Not Be Determined
34. Date Of Injury(Month/DayNear) 35.Time Of Injury 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 40. If Transportation Injury,Specify:
❑Drherrooentor ❑Passenger❑Padestnen❑timer(sgecey)
1 41. Signature, Of Person Certifying Cause Of Death: 42. Certifier(Check Only One)
James fi&Sop Electronically Signed El Certifying Physician ❑Coroner 0 Health Officer
43. Name,Address And Zip Code Of Person Certifying Cause Of Death: 44. License Number 45. Date Certified
James Alsop 600 Mary Street,Evansville,IN 47747 02005340A 03/04/2024
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 Electronically Signed 03/04/2024
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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