Death Certificate - Weber, Stephen A_10/24/2013 . 516 1092772
:c?..-:ik i i, CERTIFICATE OF DEATH
Local No 000173 EDR No 000000347144 State No 048130
1.Decedents Legal Name(First.Midd'e.Last) la. Maiden Name(Iffeca'e) 2.Sex 3.I Time Of Death 4, Date Of Death(MOnttsDayNear)
STEPHEN A WEBER MALE 1 11:00 PM 10/05/2013
10.If Death Occurred In A Hospital 10a. Y.Death Occurred Somewhere Omer Than A Hospital
0 Hospice Fealty 0 Decedent's Home 0 Nursing HorneP_ong-term Care Fadfy
0 Yes 0 No 0 Unknown. 0 Inpatient 0 Emergency Department Ouyatent 0 Dead on Arrival 0 Other(Specify)
11.Fec&y Name(If Not Instmton,Gee Street and Number)
1017 WEST 150 NORTH
12.City Or Town,State.Na bp Code 13.County Of Death 14.Manta)Status Al Time Of Death
0 Marled 0 Manned,But Separated 0 Divorced
PRINCETON, IN, 47670 GIBSON 0 Widowed 0 Never Mated 0 Unknown
15.Surviving Spouse's Name 15a. (If WSfe)Give Maiden Last Name 16.Decedent's Usual Occupation 17. Kind Of BusinessA dustry
AUTOMOBILE
PAM WEBER BARRETT PAINT SHOP MANUFACTURING
1s. Residence-Sate 19a. County 1St. CM Or Town
INDIANA GIBSON PRINCETON
18c.SveetAt Number 1844 Apt No. 18e. Lp Code 185 Inside City Limits?
1017 WEST 150 NORTH 47670 ❑Yes 0 No
19.Decedents Educator. 20. Decedent Of Hispanic Organ 21. Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Fathers Name(First McIde.Last) 23.Mothers Name(First,Middle,Last) 23a.bothers Maiden Last Name
JAMES R.WEBER Sr. GERTRUDE M WEBER REXING
24.Informant's Name 24a.Relationship To Decedent 24b.Mang Address(Street And Number,Coy,Sate,Zip Code)
PAM WEBER SPOUSE 1017 WEST 150 NORTH, PRINCETON, IN 47670
25.Place Of Disposition
25a.Method Of Disposition 25b.Place Of Oispositon(Name Of Cemetery.Crematory.Omer Place) 25c.Locator-City.Town,Ard Sate
®'Burial 0 Cremation 0 Donation 0 Entombment
0 Removal From State
0 Omer ISpecfyb ODD FELLOW CEMETERY PRINCETON. IN
26-Was Coroner Contacted? 27. Name And Complete Address Of Funeral Peaty 27a. Funeral Home License Number.
0 Yes 0 No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671
27a 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) Approemate
25.Part I.Enter The Chain Of Events -Diseases.',Runes,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset
Such As Cardiac Arest,Respiratory Arrest,Or Ventricular Fionllalion Without Snowing The Etiology-Do Not Abore-ate.Enter ONy One Cause On To Death
A Line- Add Addilinal Lines If Necessary.
Immediate Cause(Final Disease Or Condition Reslting In Death) A. CEREBRAL DISRUPTION a. IMMED
..lr A.4:ee.o-ev 0'1
Sequentially List Conditions, Y Any.Leading To The Cause Listed On B. GUNSHOT WOUND TO HEAD a.4 uA.Ara+o.e..on IMMED
-Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last C.
0..<n1P.v A w.o-ev.ut
D.
Pan II.Enter Other Sgnficatt Conditions Contnbutino to Death but Not Resulting In The Underlying Cause Gem In Pan I 29. Was An Autopsy Performed? 0 Yes 0 No
30.Were Autauy Finding Available To Complete The Cause Of Death? 0 Yes 0 No
31. Did Tdbacoo Use Cotnbut To Death? 32.If Female' 33_ Manner Of Death:
❑Yes ❑Probably No 0 Urlmwan 0 rae.v..vwe.ewr1. 0 nexwru ri..oro..e 0 we.e 4%n A.aw w.n...Ut.eop.c 0 Natnal 0 Homicide 0 Accident 0 Pending Investigation
0wry a as NO m,r••'54,4•0444, 0 uu.ee-.a•4e,441wa4,r.•p..r.. 0 Suicide 0 Cox Not Be Determined
34.Date Of Injury(bontJDay7Year) 35. Time Of Injury 36. Place Of Injury(E.G.,Decedent's Home.Contrunion Sae.Restaurant.Wooded Area) 37. Injury At Work?
10/04/2013 11:00 PM RESIDENCE 0 Yes 0 No
38.Location O:Injury-State 38a Cry Or Town 380. Street a Number 39c. Apt.No. 38d. Lp Code
INDIANA PRINCETON 1017 WEST,150.ROAD NORTH 47670
' 3R Desmbe How Irfury Occurred - 40. If Transportation Infury.S iy
po" .. Qea...e. 0 «.�,1
SELF INFLICTED GUNSHOT WOUND TO HEAD
41. Sgnature, Of Person Cendyvg Cause Of Dead:: 42 Cen.Ser(Check ONy One)
BARRETT W.DOYLE ,BY ELECTRONIC SIGNATURE _. I 0 Cenying Physician El Coroner ❑Heath O.cer
43.Name.Address And Zip Code Of Person Certyi g Cause Of Death: 44. License Number 4R Date Cerded
t 10/22/2013
BARRETT W.DOYLE , 520 SOUTH MAIN ST, PRINCETON, IN 47670
46. Additonal Funeral Service Provider. 47. Plan'
45. Signature of Local Health O(5cer. For Registrar Only ••Date Filed (MorltVDayNeart
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE _I`^ OCT 22 2013
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
5 2‘.- I I-OI- ion'.oo0. 0 SCI O•2 '1
Ag State Fonn 53395 ATTENTION ESTATE The Social Secunty a is being requested by this state agency In order to pursue responsibi5y. Disclosure is voluntary and there'MO be no penalty for refusal.
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