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Death Certificate - Schmitt, Leroy J_4/6/2015 •$"�-'w4 ' IND1ANASTATE ETE . MENT OF;HEACTHV ''` r vii CERTIFICATE OF DEATH 'C t� ' 't� � .' L �..- -Local-Local : ' __..EDR No`000000413263 .?state No 050075. -- ' II 1:Decedere s Legal Name(First Middle.Last).-.. .. 1.Ia.Maiden Name (If femae) "-.. 2 Sax , 3 Jane Of Dean 4 Date Of Deatn(MOmhrlab 1• .+:.. ■ LEROY J SCHMITT '‘ • - - MALE, 12 00 PM 11/03/2014 E -I 10.1f Death Ocarred In A Hospital: " . 10a. It Death Occurred Somewhere OTC Than Th A Hospital. - Hezpce Faulty ®Dececer¢s Hone ❑Nursing Haren-C tem Care Fealty g y 0 Yes ❑No ❑Unknown Inpatient 0 Emergency Department Ouya4e 0 Dead on Arriv ❑cm.,(specify) C . I. It.Fealty Name(If Na InsYlah,Give Sleet and Number) 901 CHICKASAW DRIVE - 12 C y Or Town.State,And Zip Code 13. Cony Of Death 14.Mantel Status At Time Of Death ®Maned 0 Maned,But Sepaated 0 Divorced p FORT BRANCH, IN,47648 GIBSON ❑Wd a ❑Neer Married 0 Linkmen b 15. &raving Spouse's Name 15a. (If Wde)Give Maiden Last Name 16. Decedents UsualOcopY.an 17. Kind Of Business/Industry PHYLLIS SCHMITT - GRAY ' - INSURANCE AGENT - SERVICE INDUSTRY Is. Residence-State 19a. Coney - tear Cy Or Teen, _ • INDIANA GIBSON FORT BRANCH • t. 19c. Street And Number 18d. Apt No, • 18e. Zip Code . 18f. Inside Cy lards? . 901 CHICKASAW DRIVE • ' 47648 G Yes ❑No 19. Decedents Edtcacm 20. Decedent Of Hispanic Ongin 21. Decedents Race •• HIGH SCHOOL GRADUATE OR GED - ' COMPLETED NOT HISPANIC White - 22.Fathers Name(First Mae,Last) 23.Mothers Name(Fest,Made,Last) 23a.Maulers Maiden Last Name • HENRY V SCHMITT THERESA SCHMITT WEIS 24.Informant's Name 24a Relaomsaip To Decedent 24b.Ma9Tg Address (Street And Nunoer,Cy.State,Zip Code) „ PHYLLIS SCHMITT WIFE 901 CHICKASAW DRIVE, FORT BRANCH, IN 47648 I 25.Place IXDispose+m - 25a.Method Of Dispoaton 25b.Place Of Disposition(Name 01 Cemetery,Crematory.Omer Place) 25c.Locatm-Cy,Town,And State 0 Burial 0 Cremation 0 Donabon 0 Entombment 0 Removal From Sate • 0 Other(Spec•): HOLY CROSS CEMETERY FORT BRANCH, IN - 25.Was Comer Contacted? 27. Name And Complete Aodress Of Funeral Faintly 27a Finaal Mane Lice se Number. ❑Yes 0 No STODGHILL FUNERAL HOME INC, 500 E PARK ST HWY 168, FORT BRANCH, IN 47648 - FH10900013 . • 27o. Sgnatse Of Mary Funeral Senate Licensee: 27c license Number(Of Licensee): ANDREA LYNN VINCENT, BY ELECTRONIC SIGNATURE I FD21400005 . , • Cause Of Death (See Instructions And Examples) ,Approunzte 29.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 Attest.RespAatay Arrest,Or Ventricular Fien a:ion Without Showing The Etiology.Do Not Abbaviate.Enter Only One Cause On To Death A Line. Add Addinal Lines If Necessary. Immediate Cause(Final Disease Or Condition Restating In Death) A METASTATIC ESOPHAGEAL ADENOCARCINOMA 6 MONTH searo..AceYeee on Sequentially List Cawiions, h Any.Leading To The Cause Listed On B- 1 Line A Enter The Underlying Cause(Disease Or Injury That Initiated Da e `�ceY°'p m The Events Resutti g In Death)Last C toe NA.•Conlemen at - 0. Pan II.Enter Other Sin,W nt Corwin-1s Coorou:no to Dem But Not Rest/Prig In The Underlying Cause GMn In Pan I 29.Was An Acczpay Performed? 0 Yes 0 No ESOPHAGEAL CANCER 30.Were Autopsy Finding Avaiade To Camped The Cause Of Deem'! 0 Yes 0 No I 31. Dod Tobacco Use Cptrnbue To Death? 32. II Female- 33.blamer Of Death: ❑Yes ❑Prooaby®No ❑Unknown 0 ne n.rn vne eea The 0 ngea4 rm ao..n 0 r en.p.aaa P.a.n vac nom ao.e. 0 Habitat 0 Hmiiode 0 Awdea 0 Pending lnvestgation 0 r.4°.a...-se p..oa.corn r.t-i.e..ode, 0 ti-a."n.,n.a.'At.."n.peat... 0 Stickle 0 Could Na Be Determined 34.Date Of easy(Matwoay/yeary 35. Time Of Injury 38. Place Of Ir:pry(EC.,Decedents Home,Caubuf co Sae.Restaurant Wooded Area) 37. Injury At Work? D yes 0 No I 38. Loamn Of Iryuy-State 38a. Qty Or Town i 38b. Street d Nhnbs' 38c Apt.No. 38d.Zip Cone 39. Oesmde Now Iryury Omned -- .b. if Traaso em eer y Bpwy. Gp^ - 01'weree 0°....n= 00".13,...1) 41. Signature, a nature,Of Person Cyi g Cause Of Dean 42 Certifier ly Ore) I ERIK DEAN WOMELDORF, BY ELECTRONIC SIGNATURE - . - 0 r.Cendyirg Pysam D Comer •D Heath Ozer h? 43. Name,Address Am Zp Code Of Person Cam-tying Cause Of Dear 44. License Number <5. Dula CerS H ERIK DEAN WOMELDORF , 721 WEST 13TH. STREET, SUITE 205,JASPER. IN 47546 01062502k 11/06/2014 46.Add..ia,al Funeral Service Provider. 47. -Akas: 49. S acreaLOral NeaEm O°oer._ -- 49. For Registrar Only -Dab Filed(MmYVDay/Year)_ _ BRUCE BRINK JR;VIA-ELECTRONIC SIGNATURE . . - . NOV 07 2014 f;l r ' AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) - • - ' . . .I 1•� ''....2' '� � 9 �go � oo© � s oar .: . Ste eForm 53395 ATTENTION ESTATE The Social Security by is being reatested by this ice agency T order,to peasue responsibaw.i DsCOSure is voNMary and there wl4 De no perWy for re'usat. # . WARNING OR G YA DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE S_GURfTY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK HAT ' _hURNS FROM ORANGE TO YELI OW WHEN RIIRRFD nRIOINeI chin IMFNT.Hes HnnnneJvnunrw PaniucT ST a once me wu_e ounrn nrspmn! L