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INDIANA STATE DEPARTMENT OF HEALTH I
CERTIFICATEOFDEATH .
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ATTENTION ESTATE:The Social Security#is being requested by this state agency irtorder,th pursue responsibility. Disclosure is voluntary and there wilt be no penaltyfer refusal.
LO;cal No 000224 EDR No 0000.00823189 state No 068676'.,.:-:'
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1,Decedent's Legal Name'(First,Middle,Last) 1a, Maiden;NeM.1e'(If female) 2.Sex 3.Time Of Death ,
,p Hospice Facility El Deosdenrs Home 0 Nursing Home/Long.term,Care Facility
O Yes Ig'No' 0,Unknown 0 Inpatient 0 Emergency Department Outpatient 13 Dead on Artivali: r,
i--i Other(Specify) • :1',' •
11. Facility Name(If Not Institution,Give Street and Number) •
307 WEST WALNUT STREET ., ,:.';.. . •
12. City Or Town,State,And Zip Code 13.County Of Death '... 14. Marital Status At Time Of Death
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_,;,1_'T'. .,• i EI Married 0 Married,But Separated .4.;Div,orced
FORT BRANCH, IN,47648 , GIBSON '1,,- 0 Widowed 0 Never Married•.0 Urknown
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15. Surviving Spouse's Name 15a. (If Wfe)Give Maiden Last Name"'i i,•"i. "" 16. Decedent's Usual Occupation 17. Knd Of BusinessAndustry
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WI LE3thk.DUANE ELEY CUSTOMS , .; ' GOVERNMENT
18. Residence-State 18a.County ," lab. City Or Town ..
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INDIANA , GIBSON ;',-'r FORT BRANCH
18c.Street And Number i i'' ' ' ' 18d.Apt No. 18e.Zip Code 18f.Inside City Limits?
• , ii',• ,,."1, ,•la,Ye's 0 No
307 WEST WALNUT,STREET .';'5",,, ' '' _ 47648
1E,Decedent's Education ,,i , 20. Decedent Of Hispanic Origin ' i''• ' 21. Decedent's Race
'SOME COLLEGE CREDIT,BUT NOT A .. -, ,'.•;,; ';,I;''
DEGREE NOT HISPANIC'" WHITE
22.Father's Name(First,Middle,Last) 23.Mother's Name(First,Middle,Last) 23a.Mother's Maiden Last Name
ISAAC WYKE . MARGARET VVYKE „ BRENNAN
24.Informants Name • 24a.Relationship To Decedent 24b.Mailing Address'(Street And Number,City,State,Zip Code) ,.
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WILBUR DUANE ELEY SPOUSE 307 WEST WALNUT STREET,FORT BRANCH,IN 47648 ,,' '
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• 25.Place Of DiageSition
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25a.Method Of Disposition 25b.Place Of Disposition(Name'Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State ..
O Burial El:Creniation 0 Donation 0 Entombment
O Removal From State
..ifl,Other(Specify): EVANSVILLE CREMATORY EVANSVILLE,IN
26:Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility "r 27a. Funeral Horne License Number
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0 Yes El No STODGHILL FUNERAL HOME INC,500 E PARK ST;HVVY 168, FORT BRANCH, IN 47648 FH10900013
27b. Signature Of Indiana Funeral Service Licensee: 27c.License Number(Of Licensee);
ANDREA LYNN STODGHILL, BY ELECTRONIC SIGNATURE 1,':'1,111 '-, FD21400005
;rCause Of Death (See Instructions And Examples)
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'28:Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications'-That Directly Caused The Death.Do Not Enter Terminal Events Approximate
. , Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate,Enter Only One Cause On Interval: Onset
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A Line. Add Additinal Lines If Necessary. To ath
Immediate Cause(Final Disease Or Condition Resulting In Death) . ' A. DEMENTIA : 10 YEARS ,
,,Ms to(Or MA Consequence Oh:
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Sequentially List Conditions, If Any,Leading To The Cause Listed On B •-
.cu , ,,D.to(Or As A Consequence Q.
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last " C. . '
Due to(Or As A Consequence Oh: ,, ..
Part II.•Enter Other Significant Conditions Contributing to Death But Not Resulting In Ttr Underlying Cause Givin in Part I 29.Was An Autopsy Performed? i ' L-1,-,
Yes la No
ALTERED MENTAL STATUS • • 30.Were Autopsy Finding Available To Complete The Cause Of Death? 0 yes 0 th,
31. Did Tobacoo Use Contribute To Death? i . 32.If Female: 1,1;::'',, 33, Manner Of Death:
EI Not Pregnant Wein Peat Year 0 Pregnant At Tarte Of Death 0 Not Pregnant.litt*Detjathnt Wallin 42 Days Of Death lia Natural 0 Homicide 0 Accident 0 Pending lnveitigation
O Yes 0 Probably El No 0 Noimowo'
0 Not Pregnant,Bet Pregnant 43 Days Tot year Before Death 0 Unknovin If Pregnant Vitae The Pest Year El Suicide 0 Could Not Be Determined
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34. Date Of Injury(Month/DayNear) 35.lime Of Injury 38. Place OtInjunj(E.G.,Decedent Home,Construction Site,Restaurant,Wooded Ara) 3-(..-.1n(taylitfigiint?
'i'0 Yes 0 No
38. Location Of Injury-State 38a. City Or Town i'',' 38b. Street&Number 38c.Apt No. 38d. Zip Code
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39. Describe How Injury Occurred . '
, . Q.If Tiroanstntii?,r2 intimpecitn 0 , .)
41. Signature,Of Person Certifying Cause Of Death: ,, r,,:1•'', .'•' 42. Certifier(Check Only One)
SHALONDA MAREE NEWCOMB, BY ELECTRONIC SIGNATURE El Certifying Physician 0 Coroner 0 Heath Officer' 1
43. Name,Address And Zip Code Of Person Certifying Cause Of Death: .1',. '
‘ 1 44. License Number 45.Date Certified
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SHALONDA MAREE NEWCOMB , 13330 DARMSTADT,RD:., EVANSVILLE, IN 47725 01080078A 12/06/2020
46.'Additional Funeral Service Provider. , .. , 47.,'Alias::
'48.Signature of Local Health Officer . 49._For Registrar Only-Date Filed(Monr/DayNear):
BRUCE BRINK JR,BY ELECTRONIC SIGNATURE DEC 07 2020
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
FRONT THAT APPEARS WHEN PHOTOCOPIED. .-.