Death Certificate - Hirsch, Edward_5/7/2014 •:'.'?'•o INDIANA STATE DEPARTMENT OF HEALTH U O U O J U
`i'` "• CERTIFICATE OF DEATH
Local No 000066 EDR No 000000318468 State No 018342
1.Decedents Legal Name(First Middle,Last) la.Maiden Name(If female) 2.Se. 3. Time Of Death 4.Date Of Death(Mont/Day/ear)
EDWARD FRANK HIRSCH MALE 03:20 PM 04/11/2013
65 Months Days Hours Minutes
Hospital
0 Hospice Facility 0 Decedents Hare 0 Nursing Hometong-term Care Fanity
0 Yes 0 No 0 Unknown 0 Inpatient 0 Emergency Department Oumasent 0 Dean on Arrival U Omer(Speedy)
11. Facaty Name(II Not 4stuton,Give Street and Number)
10133 SOUTH 350 EAST
12.City Or Town.State.And bp Code t3.County Of Death 14. Mantel Status At Time Of Dean
0 Married 0 Named.But Separated 0 Divorced
HAUBSTADT, IN.47639 GIBSON 0 moaned 0 Never Married 0 Unknown
15. Surviving Spouse's Name Isa.of Wfe)Give Maiden Last Name 16. Decedents Usual Occupation 17. Kind Of BusmesLVeYisry
LINDA F HIRSCH LAMEY OPERATING ENGINEER COAL MINER
18. Residence-Sate ida.County IB.n. CM Or Town
INDIANA GIBSON HAUBSTADT
18c.Steel And Number 18d. AOL No 18e. Zip Code 181.Insbe City Lints?
10133 SOUTH 350 EAST 47639 0 Yes 0 No
19.Decedents Eoucaton 20. Decedent Of Hispanic Ong+. 21. Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Fathers Name(First Wilde,Last) 23,Mothers Name(First.Middle,Last) 23a.Mother's Maiden Last Name
ROY HIRSCH MARY HIRSCH MARTIN
24.Irdomant's Name 24a.Reatonsr p To Decedent 24 b.Mating Address(Street Ant Number.City.State.bp Code)
LINDA HIRSCH SPOUSE 10133 SOUTH 350 EAST, HAUBSTADT, IN 47639
25.Pace Of Dispos.ton
25a.Method Of Dsposiaon 25o.Race Of Disrosison(Name Of Cemetery.Crematory.Omer Race) 25c.Location-City.Tom,And State
O Bowl 0 Cremation 0 Donator.0 Entombment
0 Removal From State STS PETER AND PAUL CATHOLIC
0 Other(Specify): CEMETERY HAUBSTADT, IN
26.Was Coroner Contacted? 27. Name Ala Complete Address Of Funeral Facility 27a. Funeral Home License Number.
0 Yes 0 No STODGHILL FUNERAL HOME INC, 500 E PARK ST HWY 168, FORT BRANCH, IN 47648 FH10900013
275. Signature Of Indiana Funeral Service Licensee: 27c. License Number(Of Licensee)'.
ROBERT S STODGHILL, BY ELECTRONIC SIGNATURE FD01024378
Cause Of Death (See Instructions And Examples)
AP Proximate
28.Pan I.Enter The Chain Of Events -Diseases.Injunes,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset
Such As Cardiac Arrest Resoiramry Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Additinal Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resultng In Death) A. METASTATIC ESOPHAGEAL CANCER 3 YEARS
a.eo ..tae.,.....a,
Sequentially list Conditions, If Any.Leading To The Cause Listed On 9'
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated w.eio•,.riot>....a,
The Events Resulting In Death)Last C
0..big.
•s•Cmssae..pn
D.
Pan II.Enter Omer 5gndKant Condpons contibutro to Death But Not Resulting In The Underlying Cause GW,In Parl 29.Was An Autopsy Performed?
❑Yes 0 N
30.Were Autopsy Prolog Available To Complete The Cause Of beam? 0 Yes 0 No
31.Dal Tobacoo Use Contribute To Deam? 32. II Female: 33. Manner Of Death:
0 Yes 0 Probably 0 No 0 Unknown
0 wen,a 5'eeW.uv.e 0 e.y.. i,J...orp..e U xaP..rea 0.eP..7..,i Aee..,:b.n Oib..e 0 Natural U Homicide 0 Accident 0 Pendvg Inveslgaaon
El wrv.P.n a.P,.r in t.pter re e.s..ouse ❑Late.+en.>w wan.-n.van.... O Stacide O Could Not Be Determined
34. Dam Of Inlury(MonmiDaytYear) 35. Time Of Injury 36. Place Of Injury(E.G..Decedent's Home,Construct on Site.Restaurant Wooded Area) ` 37. Ijury At Work?
0 Yes 0 No
35.Laaton Of Injury-Sate 38a. City Or Tovm 380. Street 8 Number 38c. Apt.No. 384 Lb Code
39.Describe How Injury Occurred 40. If Transpona r:InlurYtfipecit,
al. Signature.Of Person Cerfyng Cause Of Death: 42. Cenfer(Check Only One) ---- _
EDWARD PATRICK FOX ,BY ELECTRONIC SIGNATURE , 0 Cengiig Physician 0 coroner 0 Heats officer
43. Name.Address And bp row Of Person Cemyvg Cause Of Death: 44,License Number 45. Dam Ceried
EDWARD PATRICK FOX , 3699 EPWORTH ROAD,NEWBLIRCH, IN 47630 01038620A _ 04/16/2013
45.AddPalal Funeral Service Provider: 47. 'Alias:
48.Signature of Local Heaton Oftcer 49. For Registrar Only •Date Filed(MontJDaylyear)
BRUCE BRINK JR, VIA ELECTRONIC SIGNATURE APR 16 2013
AMENDMErf 10 CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
C4'.-
State.Fmn 53395 ATTENTION ESTATE:The Social Seamy=is being requested by this state agency in order to pursue responsipeity. Disclosure is voluntary are mere will be no cena!y for refusal.
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