Death Certificate - Stone, Ruth_10/10/2013 nun • • - ' ,• ,..�u..:..
4-4-"1-'•4. D `A • I EPARTWIENT OF"HEACTH 89 7 016
'k � CERTIFICATE OF DEATH
ire, :WI
\` Local No 000152 EDR No 000000340436 State No 039720
1.De edenfs legal Name(First Md1e.Last) _a?Jet e,Name(If female) 2.Se. 1. Tare Of Der A. Data Of Des(MceavDayNee)
RUTH G STONE HARMON FEMALE 07:00 AM 08/27/2013
86 Mars Dan Haas Moan 0723/1927 GIBSON COUNTY, IN
9 Ever ei U.S.Amrd Faces? 10.11 Dear Oconee In A Hero tor: _Oa. if Death Occurred Somewhere Other Titan A Hooey
0 Nonce ®Decedents Hone ❑Nvny.gnelaq_em care F>aty 0 Yes 0 No 0 Unknown p Inoeent p Emergency Deoemren Outpatient 0 Dead on Arrival 0 ogne(9per fy)
1I. Fay Name(if Na hada1.Give Shea s+d Number)
501 NORTH HULL STREET
12.Cr Or Town.Star.AM Zp Code C.Carey Of Des IA. Mersa Saba Al The Of Dent
0 ware 0 Man But Serrated 0 Di.acsf
FORT BRANCH, IN,47648 GIBSON 0 Widowed 0 Never Married 0 to nosh
15.Sashay Spcuse's Name I5x.(if Wde)Give Staden Lao Nam* 16 Decedents Usual O¢Vpaton 17.Nat Of Buseasi oday
HOUSEWIFE DOMESTIC
18. Reveence-Store tea. County 1116 City Or Tom
INDIANA GIBSON FORT BRANCH
18c. Sweet An Nunn ISa. Are No. 18e. Zo Code lea.lone Cry Lena?
501 NORTH HULL STREET 47648 ®Yes 0 No
19. Daepnh Educasn 20. Decent Of rays Omen 21. Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
-
I.
22.Fathers Nane(Fa e,Last)
st 23.Alters Name(First Loose Intl 23a.Mothers I o n Last Nape
MELBOURNE HARMON GRETEL HARMON SLOVER
24.Infamrs Name he a.Relata,SNP To Decedent tae.Mary Adaess(Sweet AM Nun ..City.Sate.Zip Code)
JANICE OSTRANDER DAUGHTER 805 EAST ULEN STREET, FORT BRANCH, IN 47648
25.Race Of OOe
25a.Merd Of Disarm 25e.Place Of Daemon(Name Of Cemetery.Cre rtMCry,Other
Piece) 25c.Lacer-cr.Ton.AM State 0 Bur 0 Cremators 0 Doran p Efranonem
0 Removal Fran State
0 Ore(Spectra WALNUT HILL CEMETERY FORT BRANCH, IN
26 was Caen.Canaan? 27.Naar And Complete AMress Of F,awi Fee y 27a. Funeral Hone License Number;
❑Yes 0 No STODGHILL FUNERAL HOME INC,500 E PARK ST HWY 168, FORT BRANCH, IN 47648 FH10900013
2:6 Signer Of IMians Funeral Sent,Licensee: 27c. License Number(Of Lcerlseey
ROBERT S STODGHILL, BY ELECTRONIC SIGNATURE �FD01024378
Cause Of Death (See Instructbns And Examples) Appmei:nele
29.Pan I.Enter The C•an Of Even4 -Diseases.runes.Or Compbcaliae-That Overtly Caused The Des.Do Na Enter Tennal Events Interval: One_(
Such As Caron Arrest.Respiratory MesL Or Venbno4ar F,aasatian W 5'eut Snowing The Etdopy.Do Not Abater.Err Only One Cause On To Dear
A Lim. Aso Addarl Lines a Necessary.
L reclare Cause(Foul Disease Or Cottuon Resll:ng In Death) A. RESPIRATORY FAILURE HOURS
D.•n0..A!...0000 a,
SMueraaav List Carbons, if My.Leann To TM Cause(send On B. NEUROMUSCULAR DISORDER MONTHS
Line A. Enter The Undepiry Cause(Disease Or Injury That rated i'ei0
..'"'O^•°1
The Events ResWpng In Death)Last C. MENINGIOAU OF THE BRAIN YEARS
°+ess Is 4 CSwv 0,,
D.
PY.II.Enter Other aSceScnt Cantors Cottuo.V to Cern But Na Reran;In Tee unease Case or In Pan 29.Was M ArMosy Ran.•
pYes 0No
ATRIAL FIBRILUATION.CONGESTTVE HEART FAILURE.OLD AGE ])-were Awdpsy cirauq Avaalae to paMae Tae Cause Of Dear? p Yes 0 No
31. Do Toba000 Use Canters To Data? 32. If Female: 33 Manner Of Dear:
0 v>.a,..we.=.•._ 0 'tr..a:twn 0'-...err error.en..2 On de.., 0 Nasaral Hlm.rade
❑yet ❑P:oSapy❑No ®lAU7c.v:a 0•-•""•••••••A.e.._.0 On.T. ._re.c.+. ❑a•.�..w.....wen 7_._•_ ❑sonde 0 Corn Na eDeele 0 Penare u�esagebdan
34.Dar Cr ray(MotesRry/Yar) 35. Tame Of Inaary 36. Place Of min(E.G..Decadenrs Hane.Co stucoon Sr Restaurant Wooded Area) 37. Injury As Won?
0 Yes 0 No
I 38.Lash Cf Irywy-5ta Ma. Coy Or Town 385. Sort a M.Tiei_ 38a Ze Con
39 Dane Jr dry Oconee • 130 .1 on.'- %n l aev•
41.SQnawe.Of Rion Canny Cause Of Deal`
RAMESHBHAI P PATEL, BY ELECTRONIC SIGNATURE - - - Az.e.n.5ea (cnecs Only One)
0 Cenfyve Rhine/an 0 Coroner 0 Heat Dyer
43. Name.Arians Ma Zo Cote Of Person Cerro C ase Of Der -� -� - Aar. Larne Ninon as. Dal CM4d
RAMESHBHAI P PATEL .685 VAIL ST.. PRINCETON, IN 47670 01040266A 08/29/2013
AE. Ara Funeral Sawa Poorer; • 4 7_ 'Alas
.s. Senahne of LOral Head O!Mer. -_ 19. For Registrar Only -Date Far°(Mam✓Day7Yeay
BRUCE BRINK JR.VIA ELECTRONIC SIGNATURE - - - - AUG 29 2013
AMENDMENT TO CERTIFICATE OF LEA Di(ENTRY OR ORIGINAL)
9 krigLig ,31542-000 • 1135-va4
Sine Earn 53395 ATTENTION ESTATE:The Social Security a is berg mounted by Pus su1e agency in order to pursue reapOnrbihry. Onrbsure H voluntary and there.tie be no Cranny for refusal.
IVRA.20
(2/05)