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`,'�k°� INDIANA STATE DEPARTMENT OF HEALTH /� �^y �q u 1
f •. ? CERTIFICATE OF DEATH 4'O 1 O 6 U !
�isia` 002751 EDR No' 000011811981 i
Local NoState No 2024-063068
1.Decedent's Legal Name(First,Middle,Last) 1 a.Maiden Name(If female) 2.Gender 3.Time Of Death -
10.If Death Occurred In A Hospital: \ 10a.If Death Occurred Somewhere Other Than A Hospital .
I l l Hospice Facility Ej,Decedent's Home 0 Nursing Home/Long-term Care Facility
0 Yes ®No ❑Unknown ❑Inpatient 0 Emergency Department Outpatient ❑Dead on,Arrival Other(Specify)
Li I
11.Facility Name (If Not Institution,Give Street and Number) Linda E.White HOSpICe House
12.City Or Town,State;And Zip Code ' 13.County Of Death - 14. Marital Status At Time Of Death i
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I Evansville,Indiana 47710 _ • Vanderburgh 0 Married❑Married,But Separated ❑Divorced
. g.Widowed 0 Never Married 0 Unknown
15.Surviving Spouse's Name 15a.Las!Name Before First Marriage i 16.Decedent's Usual Occupation 17.Kind Of Business/Industry I
Visiting Nurse Medical •
18.Residence-State 18a.County 18b.City Or Town
IN _-- Gibson Oakland City
,
18c.Street And Number - . 18d. Apt.No. 18e.Zip Code 18f. Inside City Limits?
219 E Columbia 47660 ®Yes ❑No
i9.Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedent's Race
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High School graduate or GED completed 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
Harvey Reeves Ivy Reeves I Shepard
24.informant's Name 24a.Relationship To Decedent 24b.Mailing Address(Street And Number,City,State,Zip Code)
Tim Lance , Son 219 E Columbia,Oakland City,IN,47660
_--- 25.Place Of Disposition
25a.Method Of Disposition i 25b.Place Of Disposition(Name 01 Cemetery,Crematory,Other Place) 25c.Location-City.Town,And State
• in Burial ❑Cremation ❑Donation❑Entombment
❑Removal From State -- "- ''Montgomery Cemetery Oakland City,IN
❑Other(Specify): _ _
26.Was Coroner Contacted? 27.Name Ahd Complete Address Of Funeral Facility . 27a. Funeral Home License Number: '
Lamb-Basham Memorial Chapel
❑Yes In No LLC 226 E.Washington Street,Oakland City,Indiana,47660 FH12200005
27b.Signature O1 Indiana Funeral Service Licensee:.. -. 27c.License Number(Of Licensee):
tenjarnittASaunders .-. • ' Electronically Signed FD22200030
' Cause Of Death (See Instructions And Examples)--= � Approximate
28.Part I.Enter The Chain Of Events -Diseases,Injures,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. Non ST elevation myocardial infarction Days
Due to to•As A Cmsegvence on'
Sequentially List Conditions, If Any,Leading To The Cause Listed On 13' Due Ig tar As AConsent/en.Oil
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated ,.
The Events Resulting In Death)Last C.
Use to(Or As A Consequence Oil. I,
D. '
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
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Metastatic breast cancer 30. Were Autopsy Finding Available To Complete The Cause Of Death? ❑Yes ❑No
31.Did Tobacco Use Contribute To Death? 22 !I Female: // 33. Manner Of Death:
El Not Prep tol WOW Past Year 0 Pregnant Al Una 01Death ❑Not Pregnant,Art Pregnant Within 42 Gays OfDealt, El Natural❑Homicide ❑Accident 0 Pending Investigation
0 Yes d Probably 0 No gl Unkr-orrn
❑Nc'Pregnant_LW Pregnant 43 Days To1 year Bel ore Death 0 Unknown tt Pregnant WMin The Past neat ❑Suicide 0 Could Not Be Determined
34.Date Ot Injury(McethiDayl'Yenp • J5. 7,(...,Of Iniur, 36. Place Of Injury(E.e,Decedent's Home,Construction Site,Restaurant,Wooded Area) 37. Injury At Work?
❑Yes ❑No
38.Location 01 Injury-Stale '' Ariz.City Or Tom 38b.Street&Number ' 38c.Apt.No. 38d. Zip Code
' 39.Describe How Injury Occurred 40. II Transportation Injury,Specify:
❑Driver/Operate, QPassengo,Pedestrian Pieter(Specify)
41.Signature, 01 Person Certifying Ca me Of Dean• - ' 42.Certifie1(Check Only One)
Julie Gerhardt 9ttrD Electronically Signed ID Certifying Physician ❑Coroner 0 Health Officer
43.Name,Address And Zip Code Of,'arson Certifying Cu.av Of 7aath 44. License Number 45. Date Certified
Julie Gerhardt MD 600 Mary€.i'.raet Suite 3203,Evansville,IN 47747 01057271A 12/09/2024
46.Additional Funeral Service Provider: \ - 47. 'Akas:
48.Signature of Local Health Officer: 49. For Registrar Only -Date Filed(Month/Day/Year):
Ip&ert 9(.Spear Jr Electronically Signed 12/09/2024
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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,State Form 53395 ATTENTION ESTATE:The Social Security N is being requested by this state agency in Order to pursue responsibility. Disclosure Is voluntary and there will be no pen sal.
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WARNING. TURNS FROM ORANGEN TO YELLOW WHEN RUBBED.ORIGINAL DOCUMENT HAS AS HIDDEN VO DPON FRONT THA GREATAPPEARS WHEN PHOTOCOPIED.ANA ON BACK THAT