Death Certificate - Becker, David J_4/1/2015 t,� CJ i c-. \ , ; INDIAN ' • tin ? i
a �i CERTIFICATE OF DEATH ` a \t.
` � 6ocal.No 000057 : `EDR No 000000439698� -. , SState No 014464'\, 4
r .t,DeceEec's Legal Neme'(Frst,Mp¢e last).::: - +' ta-Maiaen.Name'Dlfarab), ," 2 Sex 3.J'°°01Deah a. Daa Orocath,'”,%„I)ay
DAVID J BECKER\� ``'•. ' z. ..•• w MALE= .01 55 PM ,, 03123/2015
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'` 'i. 66 Mann. . Drys ' .J Hours 'M? • `+- . '. 09/20/1948- • �EVANSVILLE; IN
M 9 Ever at U.S Armed to If Death Occurred In A Hospital. f Pik L - '.
10a. If Deem Orcurtad Somewlbn Omer Than A Hospital
1. .. . ', ,. ❑/loupes FaaSry. ®'OestleMS Home -❑Niasvg HamdLagmrm Can Fao6ly .
...tt 0 Yes 0,No 0 Unknown 0 1ma:en 0 Emegescy Deparunem OCyaaen 0 Dead On Amval. 0 omer(spaa"»: t ,
3' 11'F•dty Name(If Not Instboe,Give Sheet and Number) s.
3 357 EAST 925 SOUTH • - . '. ,'
F12•G.y Or Torn SlayAnd Zip Code 13'CanY Of Death .14 Mamdstatus At Tune Of Dead '•
I _ _ ` ®Mooned❑Martied Bd Sepaated ❑Divoaea
ji (FORT BRANCH;'IN,47648 .. : GIBSON. . 0 Hboeed O'Nestr Mamed,0 Unknown •
IS Surdsvg 9p,vn^s Name : - 15a. Of Y.Ye)G'e Maiden Last Name .,,15 Decxet's Usual Ocupadan •17,:Kid Of Bueimssrindetty,
PEGGY BECKER NUEBLING% FACTORY WORKER WHIRLPOOL -
d 'IS Residerre Sae tea. Coaiy - �' t6b tam \ '(
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•- INDIANA �- ' - GIBBON "` FORT BRANCH`''
4 1St Shed ASd thumbs - " / ♦ , 19d. APL NO. ..•Ito Zip Code tat'b'eide Cdy lather?
357 EAST 925 ROAD SOUTH i 47648• , - Yes ❑No 1•Q 19.Decedents Education ',. 20. Decedent m Hispmuc Onpn 21 Decedents Rao _ . ,
HIGH: CHOOL GRADUATE OR GED ' - ' t
i COMPLETED '' '. ' - • - NOT.HISPANIC ,''� White ' -,
3 22,Feelers Nate(Fist MEde,Last 23.MCeefs Name(Pint Midda,Last) 23a Mothers Maiden Lass Name
A .' . :
•
BERNARD T BECKER i , : < MARY FRANCES BECKER SNYDER
O 24.Irtbmats Name• - 24a.Rdaavutip To Decedent i,,A 24o.mating Addess(Street And Number,City,Stan Zip Cade) '. " ' - ' -
• ' PEGGY BECKER- SPOUSE--. _ -- 357 EAST925 ROAD SOUTH, FORT.BRANCH,^IN 47648
. , , .,
25a.Retied Of Disposition , 25o.Place Of Disposition(Name Of Cemetery,Cremaay,Other Place) 25c Locaeon,City,Tom Arid Star
0 Bind 0 Cremes.= 0 Denaxn 0 EmaneMem .
'ORemwd Fmm stag ST PAUL UNITED CHURCHOE CHRIST'' ./' _ - ' •
0 Om«(Spet;N):. .,'' : . .. '' CEMETERY:... >. a.. '' :"P FORT.BRANCH, IN ,
e 26.Was Comdr Contacted? 2). Name Ard Complda Address Of Fined Faulty . .j .. •\\ .. ., 2]a..Ftneal Hone license Number.
O ves 0 No STODGHILL FUNERAL HOME INC., 500 E PARK ST HWY 168, FORT.BRANCH, IN 47648 , FH10900013 •
275.Sgrban Of Indara Ftneal Service Licensee 27c License Minter(Of Licensee):
ANDREA LYNN VINCENT, BY ELECTRONIC SIGNATURE - . FD21400005.' , ' `. ..
. .. ' ,,.-Cause Of Death`(See Inm:oedema And Examples): i. ) • . 'Hpprozvnate ._
20.Part I.Enter The Chan Of Even4 -Diseases,InAties,Or CC nplications=That Ofeaty Caused The Deathh.Do Na Enter Terminal Events `- Interval Onset
Still As Cardiac Ajrest'Respvacry Melt Or Ventricular Fibrillation W4JwA Shoes g The Etiology.Do Not Abbreviate:.Enter Only One Cause On ' - TO Deatn ,
A Line. Add Addldal Lines If Necessary. VC-): - - ' .
Immedtate Cause(Final Disease_Or Condition Resulting In Death) A CARDIAC FAILURE' - m�y cap- •+wn . - - - MINUTES
I
f 4 . B. RESPIRATORY FAILURE } ' - MINUTES-.
r Lie A. Enter a nderlyb ICause(Disea a Or Inj CamatInitiated'edOrl _ - .s It' re.•e."'Frc -•The A. Enter The Underhyrg Cause(Disease Or Injury That s '
J, The Events Resultvig In Death)Last , C. -CONGESTIVE HEART FAILURE , M4 .. . \-. li t - 2 - WEEKS" . -
..dumta.•..v..wsar
D.` :CHRONIC OBSTRUCTIVE PULMONARY DISEASE • _ , - - . , - YEARS
3 Pan IL Enbr Omer - a^� ^n^ De But Not Resdtng In The USdetyic Cause Gcen In Pan I + 29_Was An Autopsy Pertamed? 0 Yes .0 A-6- y-
.. ' /•." "`"- 3Dr Were AC.apsy FiMbg AVadablgTo Campb:e The Cause Ol Dean?\ Oyes ❑NO'`
rNONE% .''� ;...: . ' ... ., -
' 31.Did Tobacco Use Omelette To Death? - 32. If Female. _ 33.:Macro O(Death:
- 0.:n•a-. ..0 0 ta nrnaora 0.e,.a'+e�.n•e,•.vicenun.ao.se ' to Natal O HOnidde 0 Awden ❑ mdrg Inv ageaon
Q Ye O�Pr"oomly 0 N O unk,a.;, 0 '--e.e` ❑i...::;.444:7.:1".”.1",* 0 st;eide 0 Cod Na Be Detemsned
wN.p.n vn.p..•avm Tel o.ai G.. ..,
3a,Date 01 Injury(Month'Dayffear) ' ' . 35.Time Of Injury 36-Place Of Injury(EG..Decedents llae.Cc tamwon Ste,Restaurant Waded Area):. 3].-Irytry At Nbrlc?
$ ,� �... ..p Yes ❑No •
'� 3B Lorshonml!Iury-S:ab 3Ba. Ccyd Tom 360- Shedb Nanber . . 36c. Apt NO. s ,33d. Zrp Code..,
L. , 3 a
•3nred . i - \ `
9.,Dire/How Maury Om 40 ItT ab^•■•••••Clue..pa'IS.eun
A - e1.Sgtmte,Of Person Cdt''e Cause 0:Death- w . M •2.Cestifs(Check OCJy One) .. .
J. MARK ALAN MARTIN , BY ELECTRONIC SIGNATURE\ • \ ✓' ` 0 Corablrle Phntaan ■ 0 Caw-: 0 Heath0CCe
(43. Name,Aiteess And Zip Caod Or Pandn Ceafyig Case IX Dean: - - - N. License Ntmioa 45. Da.s CereSed
MARKALAN'MARTIN 4405 BELLEMEADE AVENUE SUITE 102,-EVANSVILLE IN 47714. 02002206A 03/25/2015 - .
e6-Addamal Fungal Settee Pnpy�er - e] Alas-.
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s6 ypsdme M Loch Hey s 0ttcer " r ': - s 4 For Registrar OMY Dab Filed (MondvDaytYea).
a BRUCE BRINK JR;VIA ELECTRONIC SIGNATURE . ,..--- - e ":MAR25 2015
'{ , _ „ _ , AMENDMENT TO GERT1FICATE OF DEATH(ENTRY OR ORIGINAL) . , , -
:. 111 30 0 Oo 3 s L
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:i. State Perm 53395 ATTENTION ESTATE:The Stoat Security?a loo requested by ttis slate egenty d ordef tg W!aufe resf3onstEi,6ty o1scbsue a vohnfary aii0 Core wi Ce no penally fl;......re fusaL�
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TURNS F10l,9R G QAMIILTI WHENCtUBACKGROINACOSPECIAL HAS HIDDEN Y PAPERRONTRHGREAT,SFL5 HEMP 0T.co INDIANA'. ON OACICTl1AATtt
WARNING TURNS FROM ORANGE TO • WHETRUBREO:ORG NAL DOCUME lL HAS HIDDEN Y` ' ,, ",e a-'PPEARS-. EN PHOT•COPIED v'+ -I
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