Death Certificate - Schumacher, Genevia J_4/28/2014 -. "`- 1078781
i b* i _� INDIANA STATE DEPARTMENT OF HEALTH
.`, ) CERTIFICATE OF DEATH
1 Nest/
Local No.000043 EDR No 000000371800 State No 008887
' ,.De ecenrs Legal Name(First Made.Lam) la. Maiden Name(If tamale) 2 Sex 3. Tone Of Death 4. Data Of Death(MateVaytTear)
GENEVIA JOAN SCHUMACHER JONES FEMALE 08:43 PM 02/24/2014
10.1f Death Omnd In A Hospital: Ida. a Dean Occurred Somewhere Omer Than A Hospital
1 ❑Yes 0 No ❑Unknown ❑beaten 0 Emergency Department Oupiera 0 Dead on Arrival O ow�) D[¢oans Hone ®Nursiro wneaaw-lerrm Care Facility
I ' 11.Farlty Name (If Not 1nsetstan,Give Street at Minter)
GIBSON GENERAL HOSPITAL-SNF
12.-Cay Cr Town,Stay.And Zip Cade 13. Canty Of Death 14.Manta Stain N Tine Of Death
/ 0 Mamd 0 Manned.But Separated ❑Divorced
PRINCETON, IN.47670 GIBSON ®YAdawd ❑New Pwned ❑Unknown
15.Suns og Spouse's Name 15a.Of WRe)Give Mitten ten Name 16.Decedents Usual Omrpaom 17. Kind Of Bussesslnaaty
NURSE MEDICAL
18.Residence-State 18a.County 18b. City Or Tom
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INDIANA - GIBSON PRINCETON
18e,Street And Hunter 150. Apt No. 18e. Zip Cede 181.Inside City Lam?
1808 SHERMAN DRIVE 47670 ®Ys 0 No
19.Dececenrs Education 20. Decedent Of Hispanic Orgrt 21. Decedents Race
ASSOCIATE DEGREE(AA,AS) NOT HISPANIC White
22.Fetters Name(First Mona.Last) 23.street Name(Fist Mole,Last) 23a.Mother's Mean Lan Name
AUSTIN JONES ONA JONES MARVEL
24.Informants Name 24a.Relationship To Decedent 245.Mang Address (Seer And Mmtr.Cay.Slate,Zip Code)
DAVID SCHUMACHER SON P.O.BOX 23, MACKEY, IN 47654
25.Place Of Dispovman J
25a.Memo,Of Disposition 250.Rare Of Dispositon(Name Of Cemetery.Crrnbt r.Other Place) 25c.Loran-Coy.Tom.AM State
®Baal 0 Canaan 0 Donatan 0 Entombment
❑Removal From State
0 Other(Specify): TOWNSLEY CEMETERY MACKEY, IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Fine-S Facility 27a. Final Hone License Number.
Yes I No CORN-COLVIN FUNERAL HOME, INC.,323 N. MAIN ST. PO BOX 278, OAKLAND CITY, IN
47660-0278 FH19400002
27b.Signature Of Indiana Famaat Service Licensee: 27c.License Master(Of Licensee):
MARK R WALTER, BY ELECTRONIC SIGNATURE FD01013010
Cause Of Death (See Instructions And Examples) Apawinbte
28.Part I.Enter The Chain Of Events -Diseases.hyunes.Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval:Onset
Sufi As Cardiac Arrest Respiratory Arrest,Or Venmadar Faitation Vhtrtout Snowing The Etiology.Do Not Atbeviale.Enter Only One Caine On To Death
A Line. Add Additinal Lines Y Necessary. .
Immediate Cause(Final Disease Or Condition Resulting In Death) A. CONGESTIVE HEART FAILURE 3 MONTHS
Ding.Si•Cowen a,
Sequentially List Conditions, H Cause Any.Leading To The e Listed On B. ATRIAL FIBRILLATION 4 YEARS
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated orwia...�pat
The Events Resulting In beam)Last C. ARTERIOSCLEROTIC HEART DISEASE MANY YEARS
a.wick kiscwwwwn 00
Pa IL Enter Other ;4 . . 1 . .,. _ m._.,..• •s__w But Na Resulting In The Untie lYb9 Cause awn In Pan I 29.Was An Autopsy Performed' 0 Yes 0 No
i WE 2 INSULJN.OEPENDENT DIABETES.PREVIOUS STROKE WITH DENSE LEFT HEMIPARESIS were Autopsy Ending Available To Complete The Cause Of D¢xi? 0 Yes 0 No
31.Did Tobacco Use Contrite To Death? 32. H Female: 33. Manner Of Death:
❑vs ❑Pmvandy 0 No ®Unitdwn 0 Hskw:-.ww-Perm.', ❑Pere,inn°rows ❑r.P....a a.Pa i wow..2 ow.ao-r ®Natural❑Honidde ❑Accident ❑Prdrg Investigation
❑,.se_at enw.t,w-.n ow.7e f r a.d.ern O Unman e P,.wm wee n.Pa Yr ❑Suicide O Cold Na Be Determined
34. Date Of Injury(MaietDaylyear) 35. Time Of injury 36. Place Of'nary(E.G.,Decedents Hone.Construction Site.Remnant Wooded Area) 37.Injury At Wok?
0 Yes ❑No
38.Intim Of Irpury-State 38a. City Or Toes Sao. Suer B Miner Sac.Apt_No. 38d. Zip Code
39. Deanne Ho,Injury Occurred 40. if Transportation Injury.
Qm-c OPT.. OF,9OW.raP u,1
41.Signature. Of Person Certfyeg Cause Of Death: 42.Certifier(Chalk tidy One)
WILLIAM R. WELLS , BY ELECTRONIC SIGNATURE 0 Certifying PS ❑Coroner ❑Heat Officer
43.Name,Address And Zip Cote Of Person Certdyhg Cane Of Death: 44. License Number 45. Dale Ceni'ed
WILLIAM R.WELLS ,510 NORTH MAIN STREET, PRINCETON, IN 47670 01017790A 02/26/2014
•6.AdarnnS Funeral Sena Framper - 47. *Alas:
4E.Sombre of Local Heath Officer. 49. For Registrar Only -Date Find(Mo mfDay/Yeark-
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE FEB 27 2014
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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State Fan 53395 ATTENTION ESTATE:The Serial Security E is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary and Mere will be no penalty for refusal.
;IVO)DYIF_ALTERED OR EASEDNOT VAL_ID UNLES&.CERTIFIED`BC HEALTH DEPARTMENTc