Death Certificate - Cain II, Daniel_2/18/2025 . ,•.-... .., -,... - ... . „ --,•
M - , ..,;-•*-'7.7- ..„ ., ,.
INDIANA STATE DEPARTMENT OF HEALTH ..,,
irlp CERTIFICATS,10F DEATH -- 4 6 0 3 3 8 6
- .
N11"4-4. Local No 000015 , EDR No 000011835408 State No 2025-004915
1.Decedent's Legal Name(First,Middle,Last) la.Maiden Name (If tamale) 2.Gender . 3.Time Of Death
Evansville,Indiana , I
9.Ever in U.S.Armed Forces? 10.If Death Occurred In A Hospital: . 10a.If Death Occurred Somewhere Other Than A Hospital
El Hospice Facility CI Decedent's Home 0 Nursing Home/Long-term Care Facility "- ,
0 Yes-{EI No 0 Unknown El Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival 0 Other(Specify)
' t 1.Facility Name (If Not Institution,Give Street and Number)
707 S Hall Street Ho L. V -
1 ', ,
. i
12.City Or Town,State,And Zip Code - 13. County 0)D'eath1.,,' 14.Marital Status At Time Of Death
Princeton,Indiana 47670 Gibsonl', 1 .1' : El Married 0 Married,But Separated El Divorced •
• 0 Widowed [3 Never Married 0 Unknown
15.Surviving Spouse's Name 15a.last Name Before First Marriage : I. 16. Decedent's Usual Occupation 17. Kind Of Business/industry
.._
Jennifer Terri Cain 1 Odom
' Laborer Construction
18.Residence-Slate 18a, County 18b.City Or Town
)IN Gibson Princeton c .
, .
18c.Street And Number 18d.Apt.Na. 18e. Zip Code 18f. Inside City Limits?
707 S Hall Street , , ,. .., I 47670 1:1 Yes CI No
19,..Decedent's Education / 20. Decedent Of Hispanic Origin ,*,1,, ,. 21. Decedert's Race
-
High School graduate or GED completed 1 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
Daniel Lee Cain Cindy Lee Wolf . • , Cutteridge
24.Informant's Name 24a,Relationship To Decedent 24b.Mailing Address.(siTet And Number,City,State,Zip Code)
Jennifer Terri Cain Wife 707 S HallSireet,Princeton, IN,47670 .
. : h
25.Place Of DIspOiltio'n' ' ,
25a.Method.Of Disposition 25b.Place 01 Disposition(Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State
0 Burial 0 Cremation 0 Donation 0 Entombment '
0 Removal From State
Pillars Cremation Servic , Chandler,IN
El Other(Specify):
26.Was Coroner Contacted? 27,Name And Complete Address Of Funeral Facility 27a, Funeral Home License Number: f
Simple Cremation Evansville i
In Yes El No 3101 N.Green River Rd.Ste 320,Evansville,Indiana,47715 ' FB41800004
27b.Signature Of Indiana Funeral Service Licensee: 27c. License Number(Of Licensee):
FD20300
Watt Kopsfiever - Electronically Signed 033
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. multiple sclerosis :' . 15 years •
,,.. 1%,,,a,,a As A CorsequentA Oil.
..----
..„,-
Sequentially List Conditions, II Any,Leading To The Cause Listed On il - ,i' .
.o.; DuA to(Or As A Co m puted:I 01): • •
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated • ;
The Everts Resulting In Death)bast C. '
coo to to,Ao A CoAseutence Oly •
D.
Part It.Enter Other Significant Conditions Contributing to Death But Not Resulting In The Underlying Cause Given In Patti 29.Was An Autopsy Performed? _....
CI Yes lE)No
30,Were Autopsy Finding Available To Complete The Cause Of Death?
1:1 Yes 1:1 No
31.Did Tobacco Use Contribute To Death? 32.If Female: I 33.Manner Of Death:
Ei Nat Pregnant Within Put Year 0 Pregnant At One Of[teeth 0 hiet Preghatt But
c,,TplantI.Yithirt 0 Rays Of Math [3 Natural 0 Homicide 0 Accident 0 Pending Investigation
0 Yes 0 Probably 0 No 0 Unknown
0, P,8,7,2 stir Paytynant AI Days To I year Before Death 0 uram it awn PfSprfant thrthart The Pastr4
....„, ear EI Suicide 0 Could Not Be Determined
34,Date Of Injury(Month/DayfYear) 35.Time 01 Injury 36. Place Of injury(E.G.,Decedent's Home,Construction Site,Restaurant,Wooded Area) 37. Injury At Work?
Dyes 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. If Transportation Injury,Specify:
ElOtiser/Operator ElPassenthe UPodestoan DOther lspvvny)
41.Signature,Of Person Certifying Cause Of Death: " , 42.Certifier(Check Only One)
jon Wattliew.7 fart Electronically Signed ID 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
Jon Matthew Hall 101 N Plaza E Boulevard 200,Evansville,IN 47715 :,, 01050887A 01/30/2025
,
46.Ariditiers:#Funeral Service Provider: '' 47. *Alms:
48. Signature ol Local Health Officer: . 49. For Registrar Only -Date Filed (Month/Day/Year):
Bruce Orinklr Electronically Signed 01/30/20 5
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
.
-(1 -. t'.. ."'0--.1 -. - 0.0 ‘ . 1-49 -09 , ao
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 °fusel.
WARNING. !?...,RAIG,41,,NAFL,D_O_CERMAE_NGTEHTA_S YELLOW
,.; ;_,,,,MULTICOLOREDWHWHEN
SECURITYHIDDN
EVOPIADPOERN AND
DONTTR ET HGARTEAAPTPSEEAARLSOWP HTERNEPSHTOATTOECOOFPIINEDDI,ANA ON BACK THAT
NRUBBBAECDKGORROIUGNINDALONOOSCPUEMCIEANLTW41/11STA _ ..- .... .
....-. -- ..- • ,. ?_ a rs!,,,,,.? i'....„..2., F-....!, ._... ......_.