Death Certificate - James, Stacy_4/30/2025 tyt3.,1 fr,7,:45., 1 I. -.",lrkTre---. as-2"- -T"1's., ,f,.'4,,,tr,..,,,z)v - - - -
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--INDIANA-STATEDEP l'FITIVIENT-0.FHEAtTH
CERTIFICATE OF DEATH
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"Q-62s- Local No 000024 EDR No 000011667986 State No 2ciPoP808 (---,.Decedent's Legal Name(First,Middle,Last) 1 a.Maiden Name (If female) 2.Gender 3.Time Of Death
Hospital
P 0 Hospice Facility 0 Decedent's Home El Nursing Home/Long-term Care Facility
0 Yes E3 No 0 Unknown 0 Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival' mii
r.4 Other(Specify) Father's Home
,;. it Facility Name (If Not Institution,Give Street and Number) 122 S 1225 E
E ,.
k 12.City Or Town,State,And Zip Code 13.County Of Death ; 14.Marital Status At Time Of Death
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....., .
Oakland City, Indiana 47660 Gibson , , ' 0 Married 0 Married,But Separated pi Divorced
t ' 0 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 -
, -
( Production Worker Manufacturing
18.Residence-State 18a. County 18b. City Or Town
P, IN Gibson Oakland City
18c.Street AO Number . ,. . 18d. Apt.No. 18e, Zip Code 18f. Inside City Limits?
.• ..
12245 E 100 S , , ; 47660 0 Yes El No
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it "19.Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedenrs Race i
i•-•' •
Some college,but no degree Not SpanishildispaniciLatino White
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e. 22.Parent's Name(First,Middle,Last) 23.Parent's Name(First,Middle,Last) / 23a.Parent's Last Name Before First Marriage
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)
Roomer Myers
(• Cathy Lynn Wood
Farris
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24.Informant's Name 24a.Relationship To Decedent ' 24b.Mailing Address (Street And Number,City,State,Zip Code)
' Misty Michelle Phillips Daughter 12245 E*I00 S,Oakland City,IN,47660
25.Place 01 Disposition '''-'•• ,,
25a.Method Of Disposition . 25b,Place Of Disposition (Name Of Cemetery,Crematory,Other Place) 25c.Location-City'Town,And State
)
0 Burial EI Cremation 0 Donation 0 Entombment .
0 Removal From State
Montgomery Cemetery (Oakland City,IN ,
IE Other(Specify): Cremation/Burial
26.Was Coroner Contacted? 27, Name And Complete Address Cl Funeral Facility ,.
27a. Funeral Home License Number:
a
( Lamb-Basham Memorial Chapel . ,
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I Yes El No LLC 226 E.Washington Street,Oakland City,Indiana,47660 FH12200005
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Vb.Signature Of Indiana Funeral Service Licensee: \,. " 27c. License Number(Of Licensee): FD22200030
Oenjamin A Saunders \ 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
le A Line. Add Additional Lines If Necessary.
acute mixed drug intoxication with/Alpha-PHP and Benzodiazepine hours
I Immediate Cause(Final Disease Or Condition Resulting In Death) A.
.. due lo Or As A Consequence Of):
F.
pr. Sequentially List Conditions, It Any,Leading To The Cause Listed On , B• -
Due lo(Or As A Consequence Off:
;,.... Line A. Enter The Underlying Cause(Disease Or Injury That Initiated'
k The Events Resulting In Death)Last C.
0 . .Due IOU,As A Consequence 011(
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V ' 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?
re El Yes 0 No
Li. 30.Were Autopsy Finding Available To Complete The Cause Of Death?
re Ei Yes 0 No
31.Did Tobacco Use Contribute To Death? 32. If Female: . 33.Manner Of Death:
0 Yes El Probably 0 No lifl Unknown 0 No(Pregnant 1461,1un Past Year 0 PregnaM Al Time 010eath El Nol Pregnant.Bur Pregnant Wiavn 42 Days 01Death 0 Natural 0 Homicide El Accident 0 Pending Investigation
0 Not Pregnant.Bur Pregnant 43 Oays To 1 year Before Dawn El Unknown II Pregnant Wantn The Past Year El Suicide El Could Not Be Determined
34.Date 01 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?
V
01/15/2024 / Unknown Father's Residence 0 Yes I"El No
r• 38.Location Of Injury-State 38a. City Or Town ' 38b. Street&Number 38c.Apt.No. 38d.Zip Code•
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Irl Indiana Oakland City 122 S 1225 E 47660
('1 39. Describe How Injury Occurred ' ,. .
40. If Transportation Injury,Specify:
k'rn. ingesting mixed drugs El Driver/Operator OPassenper El Pedestrian 90ther(Soecifyl
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Signature, 01 Person Certifying Cause Of Death: • 42.Certifier(Check Only One) ,
Barrett W(Do.* Electronically Signed 0 Certifying Physician li3 Coroner N 0 Health Officer ,
43.Name,Address And Zip Code Of Person Certifying Cause Of Death: 44. License Number 45.Date Certified
tt.
ri. Barrett W.Doyle 520 S Main Street,Princeton,IN 47670 - 02/10/2024
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v 46.Additional Funeral Service Provider: , 47. *Akas:
kr, i
r`l 48.Signature of Local Health Officer: 1 . 49. For Registrar Only -Date Filed (Month/DayNeark
02/12/2024
...--4. Bruce Brin/Jr Electronically Signed
' AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
1 .
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0.4. 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.
--iiii ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT
''.. WARN1Nu: TURNS FROM ORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUMENT HAS A HIDDEN VOID ON FRONT THAT APPEARS WHEN PHOTOCOPIED.