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Death Certificate - Field, Charles E_5/6/2013 •1•. I ' I '. ., . 1 'l' , L ' s p:• i>°° !ph INDIANA-STATE DEPARTMENT OF HEALTH °• t)`_ - CERTIFICATE OF DEATH•< %tLocal No 000230 EDR No 000000304424 State No 004933 1.Decedents Legal Nai�(First Middle,Last) 1a. Maiden Name(If fema:e) 2.Sex 3. Time Of Death 4. Date Of Deem(Mr-T./Day/Year) i CHARLES EUGENE FIELD MALE 06:57 PM 01/28/2013 Yes No ❑Vni�Mn'r1 ®ImaYeN Et ❑Hospice Facility ❑Decedent's Moms ❑Nursing Hanen_ongre.-,Care Facoty O Emergency Depart-,era 0.Wxei 0 Dead on anvil 0 Omer(speedy) I11. Fatty Name(If Not Ins:anat Give S:eet and Number) ST MARY'S MEDICAL CENTER OF EVANSVILLE, INC 12. Goy Or Town,Sate,Ann Lp Code 4.T 13. Canty Ol Dead II. Matsu SSTs A:Tre Of Death EVANSVILLE, IN,47750 �,. VANDERBURGH 0 Maned❑Marna.0 eer Separated 0 U ki Divorced Wcowee ❑Never Sepia 15. Sur-ming Spouse's Name 15a (I:W/e)Grie Maiden Last Name 16. Deadens Usual Occupation 17. IC=Of BusinessAnentry BRENDA FIELD - HARGRAVE COAL MINER COAL MINING 18. Residence-Stale ) 18at County tee. Cay Or Town INDIANA GIBSON HAUBSTADT 18c. Street And Number • 180. Apt No. lee.Zip Code 160.Inside City lirv6? 409 WEST ELM STREET . 47639 0 Yes ❑No 19. Decedent's Education 20. Decedent Of Hispanic Ongn 21. Decedent's Race . HIGH SCHOOL GRADUATE OR GED COMPLETED NOT HISPANIC White 22.Fa'teis Name(First Middle,Last) 23.Mothers Name(First,Middle,Last) 23a.Mothers Maiden Last Name GENE W FIELD DOROTHY J FIELD GREUBEL 24.Informants Name 24a Relatmtiip To Decedera 246.Maing Andress (Street And Number,City,Sate,Lp Code) BRENDA FIELD WIFE 409 WEST ELM STREET, HAUBSTADT, IN 47639 25.Place Of Dapoarton 25a.Method Of Disposum 25o.Place Of Disposibon(Name Of Cemetery,Crematory.Omer Place) 25c.Locum-Qty,Town,And State 0 Renal ❑Cremation 0 Donation❑Erdmanmen ❑Removal From State ❑Other(Specify): STS PETER AND PAUL CEMETERY HAUBSTADT, IN 26.Was Coroner Conta:tee? 27. Name And Complete plete Address Of;vent Farley 27a. Funeral Horne License Number. O Yes 0 No WADE FUNERAL HOME INC, 119 S.VINE STREET, HAUBSTADT, IN 47639 FH83002990 276 Signature Of Indiana Funeral Semte Licensee: 27c Number Nu (Of licensee)' ALAN J.WADE, BY ELECTRONIC SIGNATURE IFD01017080 Cause Of Death (See Instructional And Examples) Approximate 28.Pan I.Enter The Cram Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events 4vervat Onset Such As Cardiac Arrest,Respiratory Arrest Or Very✓ioAar FibnI anion W,thout Snowing The Etiology.Do Not Abbrelate.Enter Only One Cause On To Death A Line. Add Addninal Lines It Necessary. Immediate Cause(Fetal Disease Or Cohition Resorting In Death) A ACUTE ON CHRONIC RESPIRATORY FAILURE DAYS TO WEEKS Paw Id a..c an.eM B. EXACERBATION OF INTERSTITIAL LUNG DISEASE c Sequentinly List Conditions, If Fury,Leading To Tne Cause Listed On DAYS TO WEEKS Line A. Enter The Underlying Cause(Disease Or Injury That Initiated a..maam..eraoc Tr*Events Resulting In Death)Last C. INTERSTITIAL LUNG DISEASE YEARS D. _ Pan II.Enter Other 5asnilcatl Conditions Conthbut'nq to Death But Not Result-no In Tne Underlying Cause Givin In Pan l 29. Was An Autopsy Performed? ®Yes ❑No NONE - 30. Were Autopsy Finding Available To Complete The Cause Of Death? ❑yes 0 No 1 31. Did Tobacco Use Contribute To Deaf? • 32,If Female. 32. Maurer OI Death: ❑yes © Papaly❑No ❑i Unitxvn' -( 0 w..a..w..e....., ❑e,w.u re..eD,n ❑w ne....u PEES,vm...a Din month El Nara! Homicide ❑Accident Pending lmeaugaCron 0 r«n.ww ea teams our.:e up..sort as ❑ue a..an.saave,.u.eta Yea, ❑Sucide❑Could Not Be Determined 34. Date Of Injuy(MonoVDay/Year) 35. Time Of Lryury 36. Race Of In/try(E.G.,Decedents Home,Construction Site Resauant Wooded Area) 37.Injury At Won? ❑Yes ❑No 38.Loam Of Injury-State 36a. Cary Or Town 355. Soeet S.Number 36c. Apt.No. 35d Lp Code 39. Describe How I ryury Occurred 40. If Transportation IV-Ty,Opacity po,..are.> ❑e...c.,Osman,DOVE(SEEM 41.Sgnioire. Of Person Certfyeg Cause Of Dean 42. Cerite(Check Orly One) ROGER F. JOHNSON , BY ELECTRONIC SIGNATURE I 0 Cer_ying Physician ❑Coroner .0 Her:o.-xer 43. Name,Andreas And.Zip Code Of Person Cer yet Cause CX Deaf: 44. License Number 45.Daa Cer4ed ROGER F.JOHNSON , 901 ST. MARY'S DRIVE STE.200. EVANSVILLE, IN 47714 01061986A 01/30/2013 146. Add:tonal Funeral Senate Provider. I 47. 'Akas: 45. Sgrietute of Local Heath Of5cer. 49. For Registrar Only Date Fled(Mont-flay/Yew): RAYMOND W. NICHOLSON,JR.,VIA ELECTRONIC SIGNATURE JAN 31 2013 I AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) ^.4 akpl- iS 36- 404- 000. 113 .009 , • Stale Form 53395 ATTENTION ESTATE:The Social Securely Si is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary and there veil be no penally ter refusal. .;,= • IVRA-20 s+'alai' (7/05)