Death Certificate - Bratcher, Natalie M_3/13/2015 INDIANA STATE DEPARTMENT OF HEALTH
€fie` CERTIFICATE OF DEATH -RESUBMIT
i,: ii
` '� Local No 000086 EDR No 000000434493 State No 009546
1.Decedents Legal Name(Fgst Middle,Last) - 1a.Maiden Name(II female) 2.Sex 3. Tine Of Death 4. Dale Of Death(Montl/Dayf war)
NATALIE MAE BRATCHER , FEMALE 05:51 AM 02/22/2015
10.I/Death Oavred In A Hosldat 10e. U Death Occurred Somewhere Other Than A Hospital
0 Hospice Fealty 0 Decedents Home 0 Nursing Home/Long-tarn Care Faatty
0 Yes 0 No 0 Un/rnown 0 inpatient 0 Emergercy Dapenment Oupallent 0 Dead on Arrival 0 Other(Spedry) PARENTS HOME
11.Featly Name Of Not Institution.Give Street and Number)
7284 SOUTH CHIMNEY PIER ROAD
12.Cay Or Town Sate.And Zip Code 13.County Of Death 14. Mental Status At Time OI Death
0 Marled 0 Married,But Separated 0 Divorced
VINCENNES,IN,47591 KNOX 0 KLdowed 0 Never Married 0 Unknown
IS Surviving Spouses Name lsa. ft Klle)GNe Maiden Last Name 16. Decedents Usual Occupation 17. Kind Of Businessandustry
NICHOLAS RYAN BRATCHER EMT MEDICAL
18.Resderce•State 18a County lab. City Or Tom
INDIANA GIBSON . FORT BRANCH
18c Street And Number led. Apt No. 18e. Zip Code 181. Inside City Limits?
0 Yes 0 No
7942 SOUTH ANDEE LANE 47648
19.Decedents Education 20. Decedent Of Hispanic Ongin 21. Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
23 Fathers Name(Fist Walt Last) 23.Mother's Name(Fist.Middle,Last) 23a.Mothers Malden Last Name
GARY KEITH FORTNER SUSAN MARIE FORTNER MARX
24 Informants Name 245.Relataulip To Decedent 24b.M.aiiy Address (Street And Ntrnber,City,State,Zip Code)
NICHOLAS BRATCHER HUSBAND 7942 SOUTH ANDEE LANE, FORT BRANCH, IN 47648
25.Place Of Disposition
25e.Method 01 Disposition 25b.Place Of Disposition(Name 01 Cemetery,Crematory,Other Place) 25c.Locetron-City,Town,And State
0 atrial 0 Cremation 0 Donation 0 Entombment
0 Removal Fran State
D other(Specify): STS PETER AND PAUL CEMETERY HAUBSTADT. IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Ftrwal Featly 27a. Funeral Home License Number:
D Yes 0 No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671
27b. Signahae a Incana Finical Service Licensee: 27c. License Number(a Licensee):
RICHARD DEAN HICKROD, BY ELECTRONIC SIGNATURE F001012153
Cause Of Death (See Instructions And Examples) Approximate
28.Part I.Enter The Chan 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 Fibrillation Wthout Slowv1g The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Add4iwl Lines U Necessary.
Immediate Cause(Fetal Disease Or Condition Resulting In Death) A END STAGE RENAL DISEASE 2 YEARS
Dos le pi A.A Ce...w.ev or.
Sequentially List Conditions, MAny.Leading To The Cause Listed On B. HEPATIC FAILURE 2 YEARS
Line A. Enter The Urderyilg Cause(Disease Or Injury That Initiated
oat.r aa.c.n.a'.
The Events Resitting N Death)Last C.
Pan N A.A v..a.b ors
D.
Pan II.Enter Other c..,.:tc Aesd;ions A+.wA6.il. to Death But Not Remitting In The Underlying Cause Gran In Peril 29.Was An Autopsy Performed? D Yes 0 N
30. Were Autopsy Finding Available To Complete The Cause Of Death? 0 yes 0 No
MULTISYSTEM ORGAN FAILURE
31. Did Tobacm Use Cortibte To Death? 32.II Female: 33. Manner Of Doe=
®
he n.p.nws Pea Sees 0 m5UfAt M.aoa 0 w e nn'.i.e Pmplall wM42 or.b .a 0 Natal 0 Homicide 0 Accident 0 Pending Inveslgaton
0 D Probably 0 No 2Unknom
0,er mp.n But ma,wa are T.r rem loo bee 0 atom a maweVana,m.Pea Yew 0 Suicide 0 Could Not Be Determined
34. Data 01 Our/(ManiNDay/Year) 35. Tine Of Injury 36. Place 01 gray(E.G..Decedents Home.Constaction Site,Restaurant Wooded Area) 37. Injury At Work?
0 yes 0 No
38.Location Ol Injury-State 38a. City Or Town 38b. Street d Number Sac. Apt.No. Sad.Zip Code
39.Describe Her,briny donned 40. 11 Transportation l 4 sy,B�Baf
Dpa..w w+. Da.e.cn 0P.sane Dm✓nsesrl
41.Signature,Or Person Candying Cause Of Death: 42. Certifier(Check Only One)
GERRY M. HIPPENSTEEL, BY ELECTRONIC SIGNATURE 0 Certirying Physician 0 Coroner 0 Heath Officer
43.Nerve,Address And Zip Code Ot Person CertfSvg Cause Of Death: 44. LIcense Number 45. Date Cemaed
GERRY M. HIPPENSTEEL ,406 NORTH FIRST STREET,VINCENNES, IN 47591 01025674A 03/02/2015
46.Additional Funeral Service Provider 47. *Akan:
48.Signature of Local Hearth Officer. 49. For Registrar Only •Dap Filed(Month/Day/Year):
RALPH JACOMAIN,VIA ELECTRONIC SIGNATURE MAR 02 2015
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
281-Intent]B:2 TEARS
45:226/2015 I2:00:00 AM
49:025262015
State Form 53395 ATTENTION ESTATE:The Social Security 9 is being requested by this slate agency In order to pursue responsibility. Disclosure is voluntary and there will be no penalty for refusal.