Death Certificate - Siekman, Randall L_10/3/2013 ' A
INDIANA STATE DEPARTMENT OF HEALTH
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•I e '--_ CERTIFICATE OF DEATH - RESUBMIT
" y Local No 001047 EDR No 000000325162 State No 024507
1.Decedents Legal Name /First Middle,Last) tar Maiden Name(It temae) 2.Se. 3 Time 01 Death 4. Date Of Death(MonuvDay/Year)
RANDALL LEE SIEKMAN I MALE 09:50 PM 05/22/2013
s IC.If Deans Ocamec In A Hospital: Its If Death Occurred Somewhere Other Than A Hospital
0 Howiee Faddy 0 Decedents Home 0 Nursing hooe&On?term Care Fealty
0 Yes 0 No 0 Unknown 0 Inpatient 0 Emergency Deparrrent Oii^„t3beni 0 Dead on Arrival 0 other/specify)
11. Fealty Name (II Not Ins4Nnon,Give Street and Number)
CHARLIER HOSPICE CENTER
12.City Or Tom,State,And Zip Code 13. County Of Death 14.Mantel Status At Time 01 Death
0 Flamed 0 Marred,But Separated 0 Divorced
EVANSVILLE, IN,47715 VANDERBURGH 0 Mmowed 0 Never Mamed 0 umnoen
35 Smog Spouse's Name 15a (If VAM)Gne Maiden Last Name 16. Decedents Usuat Occ:patron 17. Kind 01 BuseessAraustry
HEAVY EQUIPMENT HIGHWAY
PAMELA M SIEKMAN GRAFF OPERATOR DEPARTMENT
16. Residence'State 18a County Ito Cry Or Town
INDIANA GIBSON OAKLAND CITY
113c. Sneer Ara Number lad Apt No The Zip Code 181. Inside City limits,
12047 EAST 1000 STREET SOUTH 47660 ❑Yes 0 No
19.Decedents Et:rcabon 20 Decedent Of Hispanic Oe.gn 21. Decedents Race
ASSOCIATE DEGREE(PA,AS) NOT HISPANIC White
22 Father's Name(First Madde,Last) 23.Mother's Name(First,Middle,Last) 23a Mother's Maiden Last Name
ORVAL SIEKMAN MANEDA SIEKMAN SCHMIDT
24.In.•pmair's Name 24a Relationship To Decedent 24b Mating Address (Street And Number,City,State.Zip Code)
PAMELA M SIEKMAN WIFE 12047 EAST 1000 STREET SOUTH,OAKLAND CITY, IN 47660
I 25.Place Of Disposition I
25a Method Of D,sposison 25o Place Of Disposmon(Name Of Cemetery,Crematory.Other Place) 25c Locator,-City.Town,And State
0 Banal 0 Cremation 0 Donation 0 Entombment
0 Removal From State ST JOHN'S CHURCH OF BUCKSKIN
0 Other Lspeoiyp CEMETERY BUCKSKIN, IN
26 Was Coroner Contacted? 27. Name And Complete Address Of Fiaieral Facility 27a. Funeral Home License Number
❑Yes p No PEMBERTON BRADLEY FUNERAL HOME, P 0 BOX 247, MAIN STREET, LYNNVILLE, IN
47619 FH19800018
27o Signature Of Innana Funeral Service Licensee: 27c. License Number(Ce Licensee).
ROBERT LELAND STEINHAGEN , BY ELECTRONIC SIGNATURE FD21200011
Cause Of Death (See Instructions And Examples) Approsibate
28.Pan I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events ntervat Onset
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation LMtnout Showing The Etiology.Do Not Abbreviate Enter Orgy One Cause On To Death
A Line Add Addrnal Lines 11 Necessary.
Immediate Cause(Final Disease Or Condition Resetting In Death) A METASTATIC ADENOCARCINOMA OF THE COLON 7 YEARS
Die Is td As•rauawnn.03
Sequentially List Conditions, II Any,Leading To The Cause Listed On B - b..nlD,s•ca eea.M
Line A. Enter The Underlying Cause(Disease Or togas'That Initiated
The Events Resulting In Death)Last C
Die i,IO.a a eavaw.en
D
Pan II Enter Omer Sun:ram Cond.bcosContr.btino to Death But Not Resulting In The Underlying Cause Chin In Pant NONE 29 Was An Autopsy Pedpnned7 Dyes 0 No
30. Were Autopsy Foot.;Available To Compile.IreCause 01 Death? OYes 0 No
31. Did Tobacco Use Contabule To Dean.? 32. If Female mr 33. Marries Of Deed'
0 nu Pump•Wimr 0 n V Ion.or ❑id Awe.MFeaM'Nm.2 pine aunt 0 Namral0 Homicide ❑/Modern 0 Pending lMesbga4M
0 Yes ❑wpbaby ONO ❑unkr.ow,i Ob irunun.eu anon c Dori to I roof winoem 0 L....a Aere,rvm,,,be cur re. 0 Sisode 0 Cote NM Be Determined
34. Date 01 Igor/(MontiDay:Year) 35 Time Of Inryry 36. Pau 01 Misty(E.G.,Decedents Home.Construction Ste,Restaurant Whooed Area) 37.Irpxy At Work?
0 Yes 0 No
38. Location Of Iryiry'Star 33a City Or Tam 360 Street B.Number 38c. Apt No. 33d Zip Code
39. Desc be How(Tay Occurred 40 II Transom bon I.•yry, ecity.
OD,. ... Oe..T• Pronsun Qa•.nuGt
41, Sgnature,01 Person Centric?Cause Of Death. 2. Certifier (Cluck Only One)
PATRICK C. FLAMION , BY ELECTRONIC SIGNATURE I 0 Cenyig Physician 0 Coroner 0 Heath Otncer
43.Name.Address And Zip Code 01 Person Ceni1 tg Cause Dl Death. 44. License Nimoer 45. Date Ceetted
PATRICK C. FLAMION , 801 ST. MARYS DRIVE# 110 EAST, EVANSVILLE, IN 47714 01027520A 05/23/2013
46 Adowna Funeral Service Promder. 147. 'Akas.
45. Signature el Local Heath Ottcer. 149 For Registrar Only -Date Feed(Monfoay(Yeap
RAYMOND NICHOLSON,VIA ELECTRONIC SIGNATURE MAY 25 2013
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
8-City:PRINCETON 3-City:PRINCETON
GIBSON COUNTY HEALTH DEPARTMENT
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GlB50N COUNT'EEALTH DEPARTMENT Vl�
I t e FDD,53395 ATTENTION DEGREE
Social State Fom 53335 gTTENTION ESTATE:The Social seomty a is oeig requested cy this state agency in order to pursue resxnsiabty. Disclosure is voluntary tic mere will be no penalty for refusal
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