Death Certificate - Koberstein, Alvin L_9/8/2014 T 'I A 1 F I 1• 1 '' 1 • Iii ( Y. •• L• 1fe 1•.,I1 i 1, 1 ) , I . . II , , 1 . 1. , •
_'<�' INDIANA STATE DEPARTMENT OF HEALTH'. - ' • 10.9 2 37 3
. „I CERTIFICATE OF DEATH
` 1 Local No 002144 EDR No 000000351314 A State•No 050033 . .
1.Decedents Legal Name(Frst.Middle,Last) 1a. Maiden Name(If female) 2.See 3. Time Of Death a. Data Of Der (MW/Day/Year)
ALVIN L KOBERSTEIN MALE 12:11 PM 10/31/2013
A Hospital
❑Yes 0 No ❑Uriv»en
0 Hospice Fealty 0 Decedent's Home ❑Nursing Home/Long-term Care Facility
0 Inpatient 0 Emergency Department Outpatient 0 Dead on Areal fl cmle( ,)
11.Fealty Name Of Nrins:una,Give Sweet and Number) - -
SELECT SPECIALTY HOSPITAL-EVANSVILLE
12.Cry Or Town,State,Arad Zip Code 13. Canty Of Death It Mang Swan At Time Of Death
•EVANSVILLE, IN,47713 ®uM3afl Married,But sevaa:ed
VANDERBURGH ' 'O fl Nevei Mamed 0 UnFhown
15. Surviving Spouse's Name 15a. Of WVe)Glve Maiden Last Name 16. Decade-srs Usual Ocapaton 17. Kind Of Busnesvindusry
TRUCKING AND
DOROTHY KOBERSTEIN SHERMAN TRUCKING` CONCRETE
15. Residence-Sate 18a Canty 180. City Or Town - -
INDIANA GIBSON PRINCETON ,
1Bc. Sweet And Number 1Bd.Apt No. I9e. Zip Code 19f. Inside City Lanes?
214 SOUTH STORMONT STREET •
47670 ®ves ❑No
19.Decedent's Education 20. Decedent Of Hispanic Onpa1 21. Decedents Race
HIGH SCHOOL GRADUATE OR GED -
COMPLETED NOT HISPANIC White ' . -
22.Fames Name(Fist Mare,Last) 23.Mama's Name(Ant.Mq,9e,Last) •1 23a.Mother's Maiden Last Name
EMERY KOBERSTEIN HENRIETTA KOBERSTEIN BULTMAN
24.Informant's Name 24a Relationship To Decedent 24e.Meit,9 Adress(Sweet And Number,City,Stale,Zip Code)
In
DOROTHY KOBERSTEIN WIFE 214 SOUTH STORMONT STREET, PRINCETON, IN 47670 ' •
I 25.Place Of Disposer' e
25a.Method Of Depositors 25b.Place Of Depositors(Name Of Cemetery,Crematory.Other Place) 25c.Locaton•City,Town,And State
0 Boar' 0 Cremation 0 Donation 0 Entombment
0 Remove/Fran State • n •
fl Other(Specify). ST JOSEPH CEMETERY PRINCETON, IN :
26.Was Coroner Contacmed? '27. Name And Complete Address Of Funeral Facility 27a Funeral Home License Number.
Yes ®"° COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671
275_ Signature Of Indata Funeral Service licensee: 27c. License Number(Of Licensee): • . .
JOHN W WELLS, BY ELECTRONIC SIGNATURE FD01009940
Cause Of Death (See Instructions And Examples) Approximate
28.Pan I.Enter The Chain Of Events -Diseases,Iryunes,Or Complications-That Directly Caused The Death Do Not Enter Terminal Events ' Interval: Onset
Such As Cardiac Arrest,Respiratory Arrest,Or Vemmaifat Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Oriy One Cause On To Death
A Line_ Add Additinal Lines If Necessary.
immediate Cause(Final Disease Or Condition Resulting In Death) A CARDIAC ARREST
Don to tr A..Cwym en
Sequentially List Conditions, If My,Leading To The Cause Listed On B. RESPIRATORY FAILURE
Line A Enter The Underlying Cause(Disease Or Injury That Initiated D...IOaA w...,em
The Events Resulting In Death)Last C. ACUTE RENAL FAILURE
u to A.A ce..-e.en 0e -_
D.
Pan II.Enter Other Significant Condbons Corr bums to Deem But Not Resulting In The Undertyig Cause Grvin In Pan I 29. Was An Autopsy Performed?
0 Yes 0 No
30.Were Autopsy Fiidag Available To Complete The Cause Of Der? 0 Yes 0 No
31. Did Tobacco Use Contribute To Deets? 32. If Female. 33. Mather Of Death:
fl w naeadve.,e.0 rw fl N•wal At iona o tea. 0 to n.w ..eA P.n./CMS,42 Daps a tea 0 Natural 0 Homicide 0 Accident 0 Pending Investigation Yes ❑Probably❑No ®Unkfwvn
0.r',aut Si n.o..o Daps le t yew Wen teas 0 au...•p.a•eg Wein m.an vs. C Suede 0 Cold NO Be Determined
34. Date Of Inryry(MontwDayryear) 35. Time Of Injury 36. Place Of'nary(E.G.,Decedent's Home,Consm2cion Ste,Resatrant Wooded Area) 37, Injury At Won?
C yes C No
3e. Low n Of Injury-Sac 38a. City Or Town . 38b. Sweet&Number 38c.Apt No. 38d. Zip Code
39. Desmbe How Injury Occurred 40. If Traps
Ctena, r p. 5�'..aeee. rm.(ae-mi
41. Signature, Of Person Certfymp Cause Of Death: 42. Certifier(Check Only One) ,
RICHARD P. SLOAN , BY ELECTRONIC SIGNATURE 0 Cemfyig Plrysipan 0 Coroner 0 lieatOxer
43. Name,Address And Zip Code Of Person Cen:yig Cause Of Death • 44. License Number . 45. Data Crafted
RICHARD P. SLOAN , 1312 PROFESSINAL BLVD., SUITE 200, EVANSVILLE, IN 47714-8007 01042836A 11/01/2013
46.Aldit nal Funeral Service Provider 47. 'Akers:
48. Signature of Local Heath Officer. 49. For Registrar Only 'Date Filed (MonthIDayryew):
RAYMOND W. NICHOLSON, JR.,VIA ELECTRONIC SIGNATURE NOV 04 2013
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
State Form 53395 ATTENTION ESTATE:The Sooal Seemly it is being requested by this state agency in order to pursue responsibility. Disclosure is vohmary and there will be no penalty for refusal.
IVRA-20
. . (7/05)