Death Certificate - Stoll, James R_10/21/2014 THIS ISANI IAL IP' I • I ' I ( Ii• '. I' ' • 1•• t. r• • I • 1 , I
%1 ''4th INDIANA STATE-DEPATRTMENT"OF-FIE-AC•T• 635006
t
a ''` CERTIFICATE OF DEATH
51 ,
Local No 000076 EDR No 000000257905 state No 019234
I.Decedents legal Name(First.Mole,Last) 1a. Maiden Name(If female) 2.Sea 3. Time Or Death 4. Date Of Death(Mon/Day/Year)
JAMES RAY STOLL MALE 03:30 PM 04/26/2012
47 Moms Days Hours Mnnxes 04/28/1964 PRINCETON, IN
9. Ever n US.Armed Faces? 10.11 Death Occurred In A Hospital: 10a. If Death Occurred Somewhere Omer Than A Hospital
0 0 Yes 0 No 0 Unknown 0 Inpatient 0 Emergency Delon ment Oumatent 0 Dead on Amval 0 Hospice(Speed:y ®Decedem's Nome ❑Nursing HpMAmgtem Care Fealty
❑Otha(Spec2y)
11.Factry Name(If Not Instslbbn,Give Street and Number)
4294 SOUTH SR 65
12.City Or Town,State,And Zip Code 13.Canny Of Death 14. Mara)Scan At Time Of Death
0 Mamed0 Mamed,But Separated 0 DNoced
OWENSVILLE, IN,47665 GIBSON 0 Widowed 0 Never Married 0 Unkstovn
15.SuMWg Spouse's Name 15a. (If Wde)Give Maiden Last Name 16. Decedents Usual Omvpaon 17.Maid Of Bush.es rdusay
GIBSON COUNTY
RACHAEL C. STOLL KRIEG LAW ENFORCEMENT SHERIFF DEPARTMENT
18. Residence-State lea. County lab. City Or Town
INDIANA GIBSON OWENSVILLE
18c. Sleet And Number 180. ApL No. tae. lip Code let Inside City Limas?
4294 SOUTH SR 65 47665 0 Yes 0 No
19.Decedents Educator 20.Decedent Of Hispanic Orgit 21. Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Fames Name(First.Wide,Last) 23.Mothers Name(First.Middle.Last) 23a.Mother's Maiden Last Name
JOHN DAVID STOLL JUDITH ELLEN STOLL ABBOTT
24.Inthcmarta Name 24a.RelamsJp To Decedem 245.Wang Address (Street And Number.City.State.Zip Cade)
RACHAEL STOLL SPOUSE 4294 SOUTH SR 65,OWENSVILLE, IN 47665
25.Place Of Oisposidm
25a.Method Of Dispositon 250.Place Of Ditpoaiton(Name Of Cemetery,Crematory.Other Place) 25c.locasco-City.Town.AM State
0 Bunal 0 Cremation 0 Donation 0 Entombment
0 Removal From Slate
0 Omer(Speotyk OAK HILL CEMETERY PATOKA, IN .
-
26.Was Cancer Contacted? 27.Name And Compete Address Of Funeral Facility 27a. Funeral Home License Number:
0 Yes 0 No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671
275. Signature 01 Inaba Funeral Service licensee: 27c.License Number(Of Licensee?
RICHARD DEAN HICKROD,BY ELECTRONIC SIGNATURE FD01012153
Cause Of Death (See Instructions And Examples)
APProvimate
n
Su.had I.Enter
rdia The Clain pi ratory r Diseases.Injuries. ib Or Complications-That Directly g The Caused The Death.re Do late Enter Terminal my One Cause Interval: Orel
Such Line. Add Add in l Lines Respiratory any. Or Vemutvlar FibnOation Without Slowing The Etiology.Do Not Abbreviate.Enter Only O Cause On To Death
A line. AOd Adtlrinal Lines If Necessary.
Immediate Cause(Final Disease Or Condition Rest/Ong In Death) A. RESPIRATORY ARREST MINS
nano,r+4iewvy
Sequentially List Conditions. If Any.Leading To The Cause Listed On B. ASPHYXIA MINS
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated dije•••02.44444-44 on
The Events Resulting In Death)Last C. HANGING
I$va elA 4aCewre�
D.
Pat II.Enter Omer .. - . -a. - -u - . But Not RestAti g In The Underlying Cause Gtai In Part I 29. Was An Autopsy Performed? 01 Yes 0 No
30. Were Autopsy Fxtlag Avaaable To Complete The Cause Of Death?
®Yes ❑No
31.Did Tobacco Use Contribute To Dean? 32. If Female: 33. Manner Of Death:
❑Yes ❑Probably❑No ®Unknown 0•aa•T'awe.•P..rw 0 p..swu r...d Dual 0,uw.r 0.t W..,.i Nn oust 0 Naamal 0 I M•w:.a. ❑Accident 0 PMdng Invesbgaion--
0wep,.,,.,,a. Dun r.+-e.w.owe. 0 univer re.e..0 wee,TM P..roe Sulfide 0 Could Net Be Determined
34.Date Of Injury(MatfvDayfYes) 35. Time Of Injury 36. Place Of mjuy(E.G.,Decedents Home,Construction Sate,Restaurant Wooded Area) 37.Lary At Work?
04/26/2012 03:30 PM RESIDENCE 0 Yes No
38.Laren Of Injury-State 38a. City Or Town 38h. Street 8 Number 38c.Apt,No. 380. Zip Code
INDIANA OWENSVILLE 4294 SOUTH STATE ROAD 65 ROAD 47665
39. Desulbe Haw Inryry Occurred 40. If Transpormot Immry,5 fy
SELF INFLICTED LIGATURE STRANGULATION
41.Signature.Of Person Certifying Cause Of Death: 42.Cede(Check Only One)
BARRETT W.DOYLE , BY ELECTRONIC SIGNATURE 0 Certifying Physician 0 COMM 0 HeahOSCer
43.Name.Address And Zip Code Of Person Cent yimy Cause Of Death: 44. License Number 45.Date CatSed
BARRETT W.DOYLE , 520 SOUTH MAIN ST, PRINCETON, IN 47670 05/01/2012
46. Addfimal Funeral Service Provider. 47. 'Akan:
48.Signature of Local Hearers Offerer. 49. For Registrar Only -Date Filed(MmbJDey/Yearj
BRUCE BRINK JR.VIA ELECTRONIC SIGNATURE MAY 01 2012
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
2(0-I � -31 -300 -004' 3S&-& (
Sate Form 53395 ATTENTCN ESTATE:The Social Seventy a is being requested by this sate agency in order to pursue responsibility. Disclosure is vounary and there will be no penalty for refusal.
IVRA-20
(7705)