Death Certificate - Wolfe, Margaret M_12/20/2013 IiID1N19T1a17IIrI111491 4112115Ynns7rII11 Wrath Ii ito R n 1 M I y as Id.q.r
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1092587
s . , CERTIFICATE OF DEATH(} ,)
" Local No 000216 EDR No 000000358546 State No 057522
1.Deceoerls Legal Name(Fast Miod,e,Last) 1a. Maiden Name(if feriae) 2.Sex 3. Time Of Death 4. Date Of Death(Month/Day/Year)
MARGARET M WOLFE MEYER FEMALE 02:40 PM 12/13/2013
91 Months Days Hours !Mutes 06/04/1922 HAUBSTADT, IN
9. Ever in U.S.Dinned Forces? 10.11 Death Occurred In A Hospital: 10a. H Death Occurred Somewhere Omer Than A Hospital
O Hospice Facial/ 0 Decedents Hans 0 Nursing Home to g-xrm Care Faoity
0 Yes 0 No 0 Unknown 0 It' atent 0 Emergency Department Ouvatent 0 Dead on Amval 0 one,(Speedy)
11. Facity Name(If Not nsttacn,Give Sweet and Number)
RIVEROAKS HEALTH CAMPUS
12.City Or Town,Sate,And Zip Code 13. County Dl Death 14. Maned Status At Time Of Death
0 Named 0 Mamed,But Separated 0 Divorced
PRINCETON, IN, 47670 GIBSON 0 Vldowsd 0 Never mimed 0 Unknown
1 15.SurNwrg Spouses Name ISa. of Wfe)Give Maiden Last Name 16. Decedents Usual Ocivpaton 17.Kind Of Busne55llndusy
POSTAL CLERK US POSTAL SERVICE
18.Residence-State 18a. County 180. City Or Town
INDIANA GIBSON PRINCETON
18c. Sweet And Number 180. Apt No. 18e. Zip Code 181.Inside City limits?
1244 VAIL STREET 47670 Ores 0 No
19.Decedent's Education 20. Decedent Of Hispanic Ongn 21. Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Father's Name(First Middle.Last) 23.Mothers Name(First,Middle.Last) 23a.mothers Macen Last Name
GEORGE MEYER ROSA MEYER MAYER
24.nfon-ants Name 24a.Relationship To Decedent 240.Malrg Adtress(Steel And Number.City.State.Zip Code)
VON N WOLFE SON 307 WEST MAPLE STREET, HAUBSTADT, IN 47639
25.Place Of Disposition
25a,Method 01 Dspositon 255.Face Of Disposition (Name Of Cemetery.Crematory.Other Place) 25c.Locator,-City.Town.And State
0 Burial 0 Crernatvon 0 Donator 0 Entombment
0 Removal From State
0 Other(SDeafyI STS PETER AND PAUL CEMETERY HAUBSTADT, IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Faulty 27a. Funeral Hare License NLmoec
❑Yes 0 No WADE FUNERAL HOME INC, 119 S.VINE STREET, HAUBSTADT, IN 47639 FH83002990
27o. Signature Of Indiana Funeral Service Licensee: 270.license Number(01 Licensee):
ALAN J.WADE, BY ELECTRONIC SIGNATURE FD01017080
Cause Of Death (See Instructions And Examples) Approximate
25.Pan I.Enter The Cain Of Events -Diseases,Injuries,Or Complications-That Duecoy Caused The Death.Do Not Enter Terminal Events hnterval: Onset
Such As Cardiac Purest.Respiratory Arrest.Or Ventricular Fibrifattidn Whthout 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 Resulting In Death) A. RESPIRATORY FAILURE FEW DAYS
D.w no-...Ca.w.e 09
Sequentially List Conditions. If Any,Leading To The Cause listed On B. RECURRENT ASPIRATIONS WEEKS
Line A. Enter The Underlying Cause(Disease Or Injury at Initiated w.era...reeve.-eon
That
The Events Res•lydrg In Death)Last C. ADVANCE DEMENTIA YEARS AND
Oa error 4..cor444ee09
D.
Pan It.Enter Other Sidnfoant Condro ns Contnbltrc to Death But Not Resulting In The Underlying Cause Gavin In Pan I 29. Was An Autopsy Performed?
❑Yes 0 No
OLD AGE.ATRIAL FIBRILLATION
30.Were Au,^,opsy Fetcag Available To Complete The Cause Of Death? 0 Yes 0 No
31. Did Tobacco Use Conotbux To Death? 32.If Female: 33.Manner Of Death:
❑Yes ❑Probably❑No ®Unrnovn 0"'r"'°•.e w..,Pre v.. 0 n.wt Az yen Cr c...r ❑......wt.e.w.a.iwc.,.2an here.. ®Natural 0 Homicide 0 Accident 0 Pe dtg Invesagatce
O.ve,w,es e..w..,...a o.n Tel r=err..erne O u..- ew.w.caw.t....avv 0 Suicide O Coda Not Be Dexmind
34.Data 011nryry(MdnovoayNear) 35. Time Of njury I36. Place Of Injury(E.G..Decedents Home.Caswvction'Stte,Restaurant.Wooded Area) 37. friary At wort?
0 Yes 0 No
38.Ldraton Of Injury-Sat 38a.Cry Or Twos 385. Street 8 Number f 38c. Apt No. 384.Lp Code
39.Describe How Ii iry()cameo j •40.If Transpdratan Injury.5 fit
1 1 co-- O..ry �..,,One.ne.nr
41.Sgnat4re,Of Person Ger-lying Cause Of Death: - 42.Cenifer(Check Only One)
RAMESHBHAI P PATEL, BY ELECTRONIC SIGNATURE _ 0 CenrMng Physician ❑Coroner 0 Hes+O`•ticer
43.Name,Address And Lis Code Of Person Ce tf ng Cause Of Death: 44. License Number 45. Date Centred
RAMESHBHAI P PATEL .685 VAIL ST., PRINCETON, IN 47670 _ 01040266A 12/17/2013
46.Add,to al Funeral Service Ptwtler. 47. -Alas:
48. Sgnawre of Local Heath Officer. 49. For Registrar Only y--Dad Filed(MdnftDayfearj
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE DEC 18 2013
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
v
3 :.i ai•.
'sSate Form 53395 ATTENTION ESTATE:The Social Security a is being requested oy this state agency in order to pursue responsibBty. Disclosure is voluntary and there will be no penalty for refusal.
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