Death Certificate - Whitehouse, Rex S_3/14/2014 �- �� -' s 635416
IS 'Li CERTIFICATE OF DEATH
�`�_,. �! Local No 000167 EDR No 000000278873 State No 040024
1.Decedents Legal Name(First MOSe,Lest) la. Maiden Name(If female) 2.Se. 3. Time Of Death 4. Date Of Death(MmpWay7Year)
REX STEVEN WHITEHOUSE MALE 06:45 AM 09/10/2012
10.If Death Occurred In A liosptal: 10a. If Death Occurred Sanewhere Other Than A Hospital
0 Finegan.Fealty IN Decedents Hose 0 Nursing HanelLUg-mn Care Fealty
0 Yes 0 No 0 Unknown 0 Inpatient 0 Emergency Department Ouv<.m 0 Dead on Antral 0 Other(Speoy)
11.Facility Name Of Not Insterton,GNe Street and Number)
1172 OLD HIGHWAY 41 NORTH
12.Cry Or Town,State,And Zip Code 13.County 01 Death 14.Martial Stabs At Time Of Death
0 Maned 0 Married,But Separated 0 ae W
PRINCETON, IN,47670 GIBSON 0 Widowed 0 Never Named 0 Unknown
15.Stunwg Spouse's Name 15a.(if Wde) ere Maiden Last Name 16. Decedents Usual Oco uzaon 17. Kind Of Busiesvindusty
DONNABELL WHITEHOUSE JONES STEAMFITTER INDUSTRIAL
18.Residence-State lea County 180. City Or Town
INDIANA GIBSON PRINCETON
1&.Street And Number I 1&. Apt No. 16e. Lp Code I 18f.Inside City Limns?
1172 OLD HIGHWAY 41 NORTH I 47670 I 0 Yes 0 Nn
19.Decedents Edkabn 20. Decedent Of Hnpaiic Origin 21. Decede ri Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Fathers Name(First Mdse.Last) 23.Mother's Name(First Middle,Lail 23a.Mothers Maiden Last Name
WILBURN BIB WHITEHOUSE EDITH WHITEHOUSE UNKNOWN
24.Inbmunts Name 24a.RNato slvp To Decedent 24b.Matbg Address(Street And Number.Gay.State.Zip Code)
DONNABEL WHITEHOUSE WIFE 1172 OLD HIGHWAY 41 NORTH, PRINCETON, IN 47670
25.Place Of Disoovtai
25a.Method Of Dapositto 25e.Place Of Disposition(Name Of Cemetery.Crematory,Other Place) 25c.Location-Coy.Town.And State
0 Burial 0 Cremation 0 noncan 0 Entombment
0 Renal Front State
0 Other(Seedy): WALNUT HILL CEMETERY FORT BRANCH, IN
26.Was Canner Contacted? 27. Name And Compete Address Of Funeral Facikty 27a. Funeral Hone License Number.
0 Yes 0 No STODGHILL FUNERAL HOME INC. 500 E PARK ST HWY 168, FORT BRANCH, IN 47648 FH10900013
270. Sunaame Of Indiana Fumed Service Licensee: 27c.License Number(Of Li-enter
ROBERT S STODGHILL, BY ELECTRONIC SIGNATURE FD01024378
Cause Of Death (See Instructions And Examples) Approximate
28.Pan I.Enter The Chain Of Event{ -Diseases.(Nunes,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset
Such As Cardiac Arrest Respiratory Arrest.Or Ventricular Ratan tan Without Snowing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Additnal Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resuttrg In Death) A. RESPIRATORY FAILURE 30 MINUTES
D..eta A.,r -04
Sequentiaty List Conditions. If Any.Leading To The Cause Listed On B. METASTATIC RECTAL CANCER 8 MONTHS
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated ow eta ••• Cass....on
The Events Resulting In Death)Last C.
pawta A.,Gra-e04
D.
Pat U.Enter Other$'rip 9nd..ions Contributive to Death But Not Resulting In The Underlying Cause Ginn In Part I 29.Was An Autopsy Performed?
0 Yes 0 No
SEVERE AORTIC STENOS'S.CORONARY ARTERY DISEASE 30.were Autopsy Foxing Avarape To Complete The Cause Of Death? 0 Yes 0 No
31.Did Tooacoo Use Coabious To Death? 32. tf Female: 33. Manner Of Dent:
Yes ❑%a0apy®No ❑Unknown
0 etin.e...wa..P.M r- 0 n.e..e,mr..a ova, 0 een.a..t aen.a..ewe.i 42oaw Of Ow* 0 Nabna 0 Nonitide 0 Accident 0 Penang Inestgabn
0 0 etn....,t e.r..t..no o.v.T.u-e.r.D.... 0 cave.,en.e.nw...nor e.a r- 0 SUkke 0 Coup Na Be Determined
34. Date Of Injury(Month/Day/Year) 35. Time Of iyvry 36. Place Of Inlay(E.G..Decedents Horne.Construction Site,Restaurant Wooded Area) 37. Ir t y At Work?
0 Yes 0 No
38.Locator Of'glory-Sfax 38a. City Or Town 380. Street B Number 38c. Apt NO. 38d.Zip Code
39.Desabe How Injury Occurred 40. IfTransparratdn tryury,5
Qon.ia..v Qo•..v ...Qow.ewrl
41.Sgnaune.01 Person Cer•Syvg Came Of Death: 42.CerkSu(Check Oc.y One)
MICHELLE L.SNYDER,BY ELECTRONIC SIGNATURE 0 C 'Cyin Physician 0 Coroner 0 Heats Oboes
43. Name,Address And Lp Code Of Person Certifying Cause Of Death: 44.License Number 45.Ors CetSed
MICHELLE L.SNYDER , 1808 SHERMAN DRIVE, PRINCETON, IN 47670 02001984A 09/11/2012
46.Addincal Funeral Serece Pnwidec • 47. 'Akas:
48.Signature of Local Heath Ot5cec 49. For Registrar Only -Date Filed(MabVDayn'earj
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE SEP 12 2012
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
der I I '01- ion-. Coy-?9 g oat
d ��i.ia.
:47 State Farts Silos ATTENTION ESTATE:The Social Sewnry e a Deng requested by this state agency In order to pursue mspomhsiD&ty. Disclosure is voluntary and mere will be no peaty for refusal.
.C.St, IVRA-20
.72. -0!•••,. (7/05) 1