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Death Certificate - Kissel, James R_7/18/2014 ,, .,;W:IL'41„; 4.:•''‘... "k. . •,'"'" t-, • - -‘. INIMANA bI A i t UtrAK I MtN I,V1-,11tAL I n -f: ;-- ••• : , -- , .:-:,.- ir -c. " - • , • :`;4:ti... .%-• il t c ; <-‘ t'. .• :c c z-- . • ' -: -• ' .' ..--• .-: • .: • - . . ", .., t : :-:7 '.:, ' k.-: .. - \ CERTIFICATE OF DEATH i RESUBMIT 1 'i r -.. :: ":-. 1 ?. . ; f '• \-:. .:- 7 ; ;.; ' ; ' ' ' ' ' . - t - ' ' • - • ' z' % ' .; 3 .. s. • e.....liii-g>" i:oalNo 0011.62 -c, - .i.":., --EDR No 000000389950 ."---.-4 .1: State No 026.574%. -1,:'I - ,9,..7,i..)th,,,,,,firstp.......ip,:; , , "-.;.:., , :....Maiden Name.Of remelt) " : P. ..::.' 2 Sex :.; 3:-Time Of Death -' -, ot Date Of Dean(MonevDaylyear) .:* . ,--",.....,''■ ' JAMES ft-KISSEL: ": -s.. ...H., f. .... ••11 ? ..-: . •• . .- ' „ .. . : ,'=. . '..MALE':. ... 0130AM, ,., .11 i 06/14/2014 i •.: .i . , .,' 59 :: monis' " , I Dan Haus • Minutes Hospital 0 Hospice Facility 0 Decedents Home 0 Nursinollomensng-terin Care Peaty '. • 0 Yes 0 No-0 Unknciwn- 0 Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival 0 Omer(speedy) 11. Facavy NaMe(if Not Insttutort Grve Street and Minter) ST MARY'S MEDICAL CENTER OF EVANSVILLE, INC 12 Or Town.State,And Z.,Code ,_ 13. County Of Death 14.Mantel Status At Time Of Death • .. 0 Maimed 0 Named,But Separated DDir..rceci EVANSVILLE, IN 47750 • VANDERBURGH 0 Wdoeted --0 Ne4r Married 0 Unknown 15. Surviving Spouse's Name 15a (It YAle)Give Maiden Las:Name 16. Decedent's Usual OCCUPY= 17.Kind 01BUS=S5/frld=1, • 16. R.esidence-.State INDIANA . I .1>c oveet Ar4 NurnDer . . . . 05 EAST STRAIN.STREET ' . _ G11313a-SC*jnO: Sty. City Or Town FORT BRANCH UNEMPLOYED . . . - . -• ltd Apt No. - tee. Zip Code --lit. Inside City Lends? 47648 - CEI Yes 0 No 19.Decedents Education ,- 29. Decedent Of Hispanic Ongth 21. Decedents Race . HIGH-SCHOOL GRADUATE OR GED . - . • - ' OMPLETED . . . . NOT HISPANIC White • .. . , 22.Fathers Name(First Midcle,Last) . 23.23 Mothers Name(First.Middle,Last) 23a.Mothers Maiden Last Name . .. . • CLARENCE KISSEL . . ROSELLA KISSEL SCHMITS .. '24.1.nfonnant's Name ' 24a Relabonshm To Decadent 24b.Mating Address (Street And ttrnlaer.City,State,Zip Code) ' . ' • • . , . ROY KISSEL ' • BROTHER P.O. BOX 232 NORRIS CITY IL 62869 .- . . - • . . . ' 25.Place Cf Eh ••515011 . 25a Method Of DISPUSQ011 25o.Place Of Disposition(Name Of Cemetery,Crematory.Other Place) 25c.Locators-Qty,Town,And State . . . 0 Donal 0 Cremation 0 Donation 0 Entombment 0 Ren;ovai From State . ' ' 0 Otter'ISpeary), .•'. ST.BERNARD'S CEMETERY , FORT BRANCH, IN . ..' .. . ..- 26 Was Coroner Contacted? • 27. Name Aro Complete Address Of Funeral Fatitty 275 Funeral Hone Ucense Number. 0 Yes 0 No .• STODGHILL FUNERAL HOME INC, 500 E PARK ST HWY 168, FORT BRANCH, IN 47648 . . FH10900013 . 27b. 5.one:ore Of Indiana FUllefil Service Licensee:- . 27c license Hinter(Of Licensee): - ROBERTS STODGHILL. BY ELECTRONIC SIGNATURE FD01024378 . Cause Of Death (See Instructions And Examples) -, .. , • _ u Approximate 2B:Pad I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset . Such As Cardiac Arrest;Respiratory Arrest,Or Ventricular FrOnllation Wthout Snowing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death •A Line.-Add Add.tinal Lines if Necessary. . Immediate Cause(Final Disease OrCond.tion Resulting In Death) A. SEPSIS 1 WEEK • . •• . . B. URINARY TRACT INFECTION . 1-2 WEEKS . Sequentially List Conddiats, If Any:Leading To The Cause listed On awe rc...•ceon..ox..00 ' Line A,'Enter The Underlying Cause(Disease Or'Injury That Initiated • . The Events Resultog In Death)Last ' C. - . . 0..blOr As A Cassuant•00 .. • - . D • • . . • ' • . • • - . . Part II En...t.r Other Siorefloa Cone.. ns nt..Staacta But Na Resutung In The Lh-cledlying Cause Gnu,In Pan I 29.Was An Autopsy Performed? • 0 Yes .-...0 No . - 30.Were Autopsy Finding Available To Complete The C.ause01Death?.. 0 Yes 0 No eEHYDRATION MALNUTRITION DOWNS SYNDROME 31 ID.c IntaODO Us.Ccnalbote To DeSh? - 32.1f Ffralaie: 33.Manner Of Death, - . :.. • . 0,,,,,;:-.-Eva-...,Ye. 9 P”prira Al ti,or o.ch 0 yes PUPPull,Id Prorvo=n•-2 Dns a ca.", El Natseat 0 Hocncide 0...cdtirt 0 Pr.- .;Investigation 0 Yes..0 Prober*, 0 No 0-Unkncan , 9 He eo-,..‘air Pup=C Dm I-.i milks.ono, 0...nee.,irRerattValim The nee nu 0 Suicide 0 Couto Not Be Determined .' 34. Date Of thiury(MotrOrinear) -3.5. Time Of Injury 38. Place Of'Nog(E.G..Decedents Home,Construction Ste.Restaurant Wooded Area) :37.Iraury At Work"?' • , - . 0 Yes 0 NO . . • , .. • ' 32.tocetionOf Injury•Stste .- 1 3E3 C4:y Or Town 36e. Street 5 Number ' - . _ 39. Denote How Injury Occuned i. - . . • . 00meriDoraltr. - • - OPostew Ferran OCer Mora-- S . . .. . . •. . •I. Signature.Of Person CM:4M Cause Of Death: : 42.Certifier(Check Orly One) • .. ' .- J - UNISH KLAPSIA;BY ELECTRONIC SIGNATURE 0 Certifying Pnyskian • 0 Coroner . 0 Heath Of5cer ' 43.Name,Address And Zea Code Of Person Cerefying Cause Of Death aa License Number - : as. Dee Certified . . . . ... - . - . I UNISH H LAPSIA:,3700 WASHINGTON AVENUE, EVANSVILLE, IN 47750 01068841A .--. : •.. - 06/15/2014..•At Adchtional Funeral Sautce Provider "7...;•.: . ., - . . .,... 46 Signa.ture of Lecel Health Offiasr: i'... i -- J. ; , r - 49. For Registrar Only -Date Filed(Montn,Day/YearY: ",.. ROBERT:KENNETH SPEAR,VIA ELECTRONIC SIGNATURE ' - . . - . , . -.. JUN 16-.2014 f. . . . „ . •. . . 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'._, :. :. !-'.-. --i ', j"., . . -J h.,' . 17'.Zip:42670 t;- : "'; :::. ;., ; .::,. . 1..j %.• ''..' ...; ' ".:- ' ': ' ) ,.: '.; ;- 1:...!:2:.: • ::.; :' :‘,. - 6-Stieeti lEni SHERMAN DRIVE ; ..• - :' : ,. i .- - '. : : ; ; :: ; : : ...-. • I : -.e Eon,,53395:•ATTEtf1-10:1 ESTATE:The Sobel Selcur?../.30.is..b. y_th s state gency_ stt%FeldE-D BACKGROUND GIVhSPEe6121WHullentallsgYaYP:A..Mk'AND THE GPO-SEA/10F oeso 01■B:4641A7^; W A RN MLR On " '' -D o ethsa------ -'• ' • -I 4.-TUTtN FROM ORANGE ie YELLOWWHEN RUBBED:ORIGINAL DOCUMENT HAS HIDDEN.V•lD FRONT THAT.APPEAFtS WHEN PH T .-..-..J,......, ■••,-......,. -;-‘...ff 11,Z,71VE„ . ... .14.11.-C-fl STATE OF INDIANA 1:-:;:=Th rtiJ-"I':•1==.3,:C=-?-1----;',cs=-a-llje.NsfE:=147)-%-::::':--;:a.111-•A=.-