Death Certificate - Reidford, Randy J_4/10/2013 11:16`t)6`I:11D14g011:IGHii4'Al 1ail4KI L111 0010ia;91 1HIHIUL14KLldlslilillinl11P D11:121:4lVAI41114Malftlitlf'la;i ti!I igt,
950651
INDIANA STATE DEPARTMENT OF HEALTH
-TJ.`; CERTIFICATE OF DEATH
Local No 000666 EDR No 000000316539 State No 015964
1.Decedents Legal Name (Fest Mdde,Last) 1a.Maiden Name (If female) 2.See 3. Time Of Dea.••s 4. Date Of Death(MettayiYear)
RANDY J REIDFORD MALE 03:00 PM 04/01/2013
58 Months Days Hours Minces
Hospital
0 He spice Facility 0 Decedents Home 0 Nursing HomesLong-tem Care Faos-y
0 Yes 0 No 0 Unknown 0 Irpalent ❑Emer;ency Department Onyatren 0 Dead on Arrrvat 0 other(Speoy)
11. Fac*ty Name(II Not Ins:Lton,Cure Street and Number)
CHARLIER HOSPICE CENTER
12. City Or Town,State,And Zip Code 13. Canty Of Death 14.Marital Status Al Tex Of Death
0 Married 0 Mamed.But Separated 0 Drip-zed
EVANSVILLE, IN,47715 VANDERBURGH 0 vmdwed 0 Never Married 0 Unwmwn
15. Surviving Spouse's Name 15a. RI W1te)Give Maiden Last Name 16 Decedents Usual Occupation 17. Kin Of BusinessAndusvy
BRIDGET REIDFORD MCELLHINEY MECHANIC GENERATING STATION
18. Residence-State lea County ltb DIY Or Town
INDIANA GIBSON PRINCETON
lac Street And Number led.Apt No 18e. Zip Code tel.Wide City Lyman'
567 SOUTH CURTICE LANE ;.�?, r 47670 0 Yes 0 No
19. Decedent's Education `20. Decedent Of Hispanic Oign • I", I -21. Decedent's Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED INOT HISPANIC White
22.Fathers Name(First Muddle,Last) 23.Mother's Name(First.Midde,Last) 23a.Mothers Maiden last Name
EDWARD REIDFORD RITA REIDFORD ' SPINDLER
24.Informants Name 24a Relsnmshp To Decedent 245 MaAng Address(Street And Number,Cory,Slate,Zap Code)
BRIDGET REIDFORD SPOUSE 567 SOUTH CURTICE LANE, PRINCETON, IN 47670
25 Place Of Disposition
25a Method Of Disposition 25o Pace 01 Disposition ame Of Cemetery,Crematory,Outer Place) 25c Location-City,Town,And State
0 Burial 0 Cremation 0 Donation 0 Entombment
0 Removal From State
0 Other(Specify). ST JOSEPH CEMETERY PRINCETON,IN
26.Was Comer Contacted/ 27. Name And Complete Address Of Funeral Faotty 27a Funeral Hone License Number.
0 Yes 0 No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671
27o Sgn atue Of Indiana Funeral Service Licensee: 270 License Number(O licensee):
JOHN W WELLS , BY ELECTRONIC SIGNATURE FD01009940
Cause Of Death (See Instructions And Examples)
vi Apervai
e
S Part I.Enter The Chain Of -Diseases,Injuries,Or Complications- ng Caused The Death Not Enter Terminal Events Interval. Onset
el
Such A s Cardia c Arrest,Rs ratcry Arrest,Or Venriatl lar Fibrillation Without Showing The Etiology.Do Nd Ahbre ale Enter One Cause On To D eat h
A li e. Add Adtldfinal Lines If Nee essary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A AMYOTROPHIC LATERAL SCLEROSIS 3 12 YEARS
or.w to...curs,w.w on
Sequentially List Conditions, If Any,Leading To The Cause Listed On B.
Underlying A Enter The Underlg Cause(Disease Or Iryoy That totaled wpa.•cw.e,.,e t)9
The Events Resulting hi Death)Lass C
sae to As A cera.w«..oo
D.
Part II.Enter Other Slnnincant Co d,tims castribuclig to Death But Not Resulting In The Underlying Cause Can In Pan I 29. Was An Autopsy Performed? 0 Yes 0 No
NONE 31. Were Autopsy Finding Available To Compete The Cause Of Death? 0 Yes 0 No
31.Oid Tobacco Use ConMbute To Death? 32. If Female. 33. Manic Of Death:
❑Yes ❑Pm4aoy[Ij No ❑Vrinnw wun.wassm�sea t... 0 n.r.+u nun.eo•.e 0 n Pusan.[eenTe<wN.42 Pp Po..e 0 Nataal 0 Homicide 0 Accident 0 Pendinglnresbgaton
�v •r•t M."7..o nn.:e'r..'i.e. •• 0 Lw.enn er.T.4vut T•••e•••• O Ssecjd<0 Cold NO Be Determiners
34.-Date Of Injury(Mona/Dayff ear) 35.Tune Of Irysry 36 Place OI Injury(E G.,Decedents Home,Construction Ste,Restaurant Wooded Area) 37.Injnar At Woes?
0 Yes 0 No
38. Location Of Injury-State 38a. Qty Or Town 365. Street 6 Number Sec.Apt No 3ed Lp Code
39.Desmbe How',jury Occurred 413. If Transpatatien Inpey,Specify:
O••••re Deed .Oe•w semen
41. Signature, 01 Person Certtyvg Cause Of Dean: 42.Certher(Check Of One)
PATRICK C. FLAMION, BY ELECTRONIC SIGNATURE 0 Cerust g Physician 0 Coroner .0 HeahMeet
43.Name,Address And Zip Code Of Person Centying Cause Of Death: 44. License Number 45.Data CC=ed
PATRICK C.FLAMION ,801 ST. MARYS DRIVE# 110 EAST, EVANSVILLE, IN 47714 01027520A 04/02/2013
46.Additional Funeral Service Provider 47. 'A.ar.
49.Slpumre of Local Health Officer 49. For Registrar Only •Data Filed(Mont rDay7Year):
RAYMOND W. NICHOLSON,JR.,VIA ELECTRONIC SIGNATURE APR 03 2013 -
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
(D'.. ID 15--aOD - Oo( e(033-ow?
.d State'F9r1p 53395 ATTENTION ESTATE:Tne Social Seointy a is being requested by this state agency in order to pursue reaponsiblily. Disclosure is voluntary and there will be no penat),for refusal
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