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iii-ecdgz CERTIFICATE OF DEATH
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Local .L 000052 EDR No 000000314818 State me 015090
I.Decedent's Legal Name(First A4ctIe,Lan) 1a. Maiden Name(Iffgtiale) Z.Sex 3. Time Of Death 4. Date Of Death(Mn:MtlDaynear)
CHRISTENA O'NEAL GIESELMAN FEMALE 05:50 PM 03/23/2013
PIKE COUNTY, IN
9. Ever n U.S.Armed Farces? 10.If Dean Occurred In A Hospital: 10a. If Death Occurred Somewhere Other Than A Hospital
❑Hospice Faulty ®Decedent's Hoax ❑Nursing Home/Long-term Care Fealty
❑Yes 0 No ❑Unknown ❑Inpatent❑Emergency Departnem Ouyatent ❑Dead on Anal ❑other(specify)
11. Facility Name(If Not IOstaitor,Give Street and Number)
5010 SOUTH LINCOLN STREET
12. City Or Towed.State,MO Lp Code • 13.County Of Death 14, Mamal Staves At Time Of Death
❑Named❑Mamed,But Separated ❑Divorced
OAKLAND CITY. IN,47660 GIBSON ®Mooed ❑Never Married 0 Unknown
15.Surviving spouses Name tsar(It W'e)Give Maiden Last Name IS. Decedent's Usual Orrupavon 17. Ken Of BusinesslnUamy
HOMEMAKER DOMESTIC
18.Residence-State 18a. COumy 18a. City Or Town
INDIANA GIBSON OAKLAND CITY
18c. Street And Number 18d. Apt No. 18e. Lp Code 1BL Inside City Minim?
5010 SOUTH LINCOLN STREET 47660 ®Yes ❑No
19. Decedents Educator 20. Decedent Of Hispanic Origin 21. Decedents Race
9TH- 12TH GRADE; NO DIPLOMA NOT HISPANIC White
22.Faders Name(First Mdee,Last) 23.Mothers Name(First Middle.last) 23a.Mother's Maiden Last Name
FRANK GIESELMAN BARBARA GIESELMAN DOERNER
24.Informant's Name 24a.Rsatsnship To Decedent 245.Mailing Address(Street And Number,City,State,Zip Cone)
REX O'NEAL NEPHEW 5001 SOUTH LINCOLN STREET, OAKLAND CITY, IN 47660
25.Place Of Disposition
25a.Method Of Otst ositon 255.Place Of Depositor(Name O:Cemetery,Crematory,Other Place) 25c.Location-City.Town.And State
0 Baal ❑Cremator, ❑Donator❑Entombment
❑Removal From State
❑Other(SPecdyt SOMERVILLE CEMETERY _ SOMERVILLE, IN
26.Was Carina Contacted? 27.Name And Complete Actress Of Funeral FaciLy 27a. Funeral Kane License Number.
❑Yes ®No CORN-COLVIN FUNERAL HOME, INC., 323 N. MAIN ST. PO BOX 278, OAKLAND CITY, IN
47660-0278 FH19400002
27o. Signature Of Indiana Funeral Service Licensee: 27c.License Number(Of Licensee)
MARK R WALTER, BY ELECTRONIC SIGNATURE FD01013010
Cause Of Death (See Instructions And Examples) . Approximate
28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Dearr.Do Not Enter Terminal Events Interval: Onset
Such As Cardiac Arrest.Respiratory Arrest.Or VentiMar Fibntatm Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Additinal Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resoling In Death) A. SEPSIS 1 WEEK
a...taa.Gv.a..v on
SequenuaSy List Conditions, If My.Leacing To The Cause Listed On B. DECUBITUS 1 YEAR
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
a...Il}...G..v...e pin
The Events Resulting In Death)Last C. TYPE 2 DIABETES MELLITUS DECADES
0..14.:0....C>,..o..,.o5
D.
Part II.Enter Other Soon:Scait Condoms Contite no to Death But Not Restltng In The Underying Cause Orrin In Pan I 29.Was An Autopsy Performed? ❑Vas 0 N
PRIOR CEREBROVASCULAR ACCIDENT WITH GENERALIZED WEAKNESS 30.Were Autopsy Folding Avalaae To Complete The Cause Of Dean) ❑Yes ❑No
31. Did Tobacco Use Conobute To Death? 32. If Female: 33. Manner Of Death:
❑ 0 0 ❑ ❑,.,nv..we.,eve... ❑Ara,.,,.,Tor.an..w ❑ra■,v.A a.,nor..We.,42 Den a Omar. 0 Natural❑Homicide ❑Accident ❑Penang Inver6gaton
Yes No Unknown ❑.wA.a4.e.4P"7...0o.n+e,',. r.. •.r. ❑w.w.,.w.a,..wew n.e.Y�
❑Suicide❑coda Na Be Determined
34. Dam Of Injury(MOnINDaylYear) 35. Time Of Injury 36. Place Of Injury(E.G.,Decedent's Home.Constructor Site.Restaurant Wooded Area) 37. Injury At Work?
❑Yes ❑No
38. Location Of Injury-Sate 38a. City Or Town 380. Street 8 Number 38c. Apt.No. 38d. is Code
39.Describe How lryJry ORV red 40. If ortation
Trent. inpsry.betry. note, i
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4t.Scram,Of Person Cer.')vg Cause Of Dean: J 1 _ 42. Cenbner(Check Only One)
TERRY GEHLHAUSEN , BY ELECTRONIC SIGNATURE - ._�, _ 0 Certying Physician ❑Coroner ❑HeathO3cer
43. Name.Minas And Zip Code Of Person Cerdyng Cause Of Death:- ' 44.License Number 45. Dam Cert.ed
TERRY GEHLHAUSEN , 1020 W. MORTON'OAKLAND CITY, IN 47660.1 _ _ _ 02000730A 03/27/2013
46.Addtional Funeral Se%lce Provider f 4-) ) 47. 'Alas':
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48. Signature of Local Health Oftcer. - i 1 t 49. For Registrar Only -Date Feed(MantJDay(Year)
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE MAR 28 2013
'AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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a State 53395 ATTENTION ESTATE:The Social Secunry a is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary and there will be no penalty for refusal.
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