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Death Certificate - Mizeur, Roger P_6/4/2015 i-.•'•=21•..�7.fate-. - '=47fr: Veirai�13N:V ,:iCn4'N • • • ]ll417�i-`ill.:.a9ct W>Y.''inC�wU.; ' €\t lY: n.."`" "'a '' .• - -`idrANA-STAItUtta7 a .• _ �,. _ °•" _,r \ °� � CERTIFI. " z. F DEATH RESUBMIT 1 > _ * ' / 'Local No 001-146 A EDR'No 000000450604±.--,(ii state No'025730. ``� . ` - �, 1 Deaden(!Legal Name•(FtSLMgdle.last),,,.•' \. :.,t. -' '1a.Maiden Nane,(If female).,,, „„ Z Sex,,„...; ,3.Tune Of Dea^I._•„' 4. Date Of Death(MorcltaywYear)„r ROGER PAUL MIZEUR `` i "'.. _ ." MALE 1620 AM -."/ 05/23/2015 •5. ; i months• Days • Hers Minutes, -] `\ 05/ IL 9'Ever n U.S.Armed Forces? 10-If?earn Occurred In A Meseta l: • • • Ida. If Dram Occurted SometMere Omer Than A Hospital (s]HospzeFarity-. U Oerredenrs He U Nursing Horne/Long-term Care Faotty -U Yes El No ❑Unknown 0 Irpabera U Emagmry Depa-.'ner Wgatera 9 Deaf on Amval D Otter(thy) , 11.Fault'Name (If Not Instanon,Give Sweet and Number) VISITING NURSE ASSOCIATION HOSPICE - 12.City Or Town State.AM Zip Code 13. County Of Death 14.Mental Status At Time 01 Death 0 Maned U Married,But Separated 0 Divorced EVANSVILLE, IN 47734 VANDERBURGH. D Wsdowed D Never Married D unknown 15. Suaveg Spouse's Name 15a. it WL•e)Give Maiden Last Name . 16. Decedents Usual Occupy n 17. Kind Ol Busnessendustry JANE MIZEUR VIEBACK . MANUFACTURING 16. Residence-Stave 18a.County Igo. Or Town INDIANA GIBSON PRINCETON _ sac. Street And Number 190. Apt No. 13e- Zip Code 101. Inside City tints? U Yes E)No 817 NORTH 275 EAST 47670 ! 19. Decedents Educator 20. Decedent co Hispanic Ongn 21. Decedents Race . ASSOCIATE DEGREE(AA,AS) NOT HISPANIC White ' 22.Fathers Name(Fist Middle.Last) 23.Mafefs Rame(Fist.MgTe,Last) 23a Mothers Maiden Last Name ORVILLE F MIZEUR NORMA T.MIZEUR WADDINGTON - • 24.Irtbmaas Name 24a.Rela•.ionsrip To Decedent 24b.Maine Adores! (Street And NunDer,City,State,Zip Code) JANE MIZEUR WIFE 817 NORTH 275 EAST. PRINCETON. IN 47670 25.Place Of Disoosisn 25a.Meted Of Disposition 25b.Place Cl Disposition(Name Of Cemetery.Crematory,Other Place) 25c.Loason-City.Town And State 0 Baal U Cremation O Demon 0 Entombment U Removal From State 0 Omer(Spear): COLUMBIA WHITE CHURCH CEMETERY PRINCETON, IN 25:Was Coroner Contacted? 27. Name AM Compete Address 01 Funeral Fealty 27a. Funeral Home License Number: ❑Yes 0 No COLVIN FUNERAL HOME INC.425 N MAIN ST.. PRINCETON, IN 47670 FH83005671 27b. Sigrabre 01 Indiana Funeral Service licensee: v 27c. License Number(Of licensee): JOHN W WELLS. BY ELECTRONIC SIGNATURE FD01009940 Cause Of Death (See Instructions And Examples) Approximate 28.Pan I.Enter The Chain 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 Fitvifetlm Wlthdut Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death A Line. Add Addltnal Lines It Necessary. Immediate Cause(Final Disease Or Condition Resulting In Death) A. NONSMALL CELL LUNG CARCINOMA WITH BONE AND BRAIN METASTASES oath ia...e,..w..e.m Sequentially List Conditions. If Any,Leadig To The Cause Listed On B. UPPER GASTROINTESTINAL BLEED Lite A. Enter The Underlying Cause(Disease Or Injury That Initiated Dan}As.da.eone m The Events Resuttng In Death)Last C tie wla...car,OI. D. Par.II.Enter Otter�+ncan De Bm Na Resatng In The Underlying Cause Givin In Pan I 29.Was An Atit sY Pedamed? D Yes 0 No 30.Were Aiebpsy Feting Avaiade To Complete The Cause 01 Death? . U Yes 0 No 31.DM Tobacoo Use Canribute To Death? 32. If Female: 33. Marner Ol Death: ©Yes ❑Probably Na unknown 0 Na ar.tvaiw'ee.that 0.r.w:n Al n..Co D..P 0 wi went e4 Pn eva..a o.nopee> 0 Natural 0 Homicide 0 Accident D Pandang lnvesbpatidn D..i nor .aa Prey.*o Den To m yew a.d.o.ci D ate.n.ewwew U.earl..., 0 Suicide 0 Card Not Be Detemineo 34.bas Of Injury(Mcntn•Dayffear) 35. Time Of Iryury 36. Place Of Irpry(E G..Der-eider-CS Home,Construction Ste,Restaurant Wooded Area) 37. Irynry At Won? DYes ONo 38.La2von Of Irauy-State 38a. City Or Town 38D. Street&Number 3EC. Apt No. 38d. Zip Code 39.Desrnbe How lrypry O.xned a O. It Transpcuam lr#ry, y: Do-..•,a.nsu Un..,e'LI^.0 ,., pme..ise.wm 41. &please,Of Person Cen yi g Cause Of Dear 42. Cer_Ier(Check Orgy One) JULIE K.GERHARDT. BY ELECTRONIC SIGNATURE 0 Cenyirg Pnysirian D Corona 0 Heath Ori:er 43.Name,Address And Lp Code 01 Person Cenilryg Cause Of Death: 44. License Number 45. Dave Ceram ed JULIE K.GERHARDT .600 MARY ST.. EVANSVILLE, IN 47713 01057271A 05/26/2015 48.Amdm.s Funeral Service Provider- 47. 'Alas-: ? 48.Sgnet re of Local Meats Ottcer ' . ' - 49. For Registrar Only -Date Filed (Month/Day/Year): ' • ROBERT KENNETH.SPEAR,.VIA ELECTRONIC SIGNATURE • -. : • : ' JUN 02 2015. x • , •- • AMENDMENT TO CERTIFICATE OE DEATH(ENTRY OR ORIGINAL) 49 0529/2015 "' . is<B mt 7 5 ., 1k.s.. :725 a b-ia'03-300-000---- �ii orb oat < i_ `: 2465u M:725,' / ,i' State Form 53395: ATTENTION ESTATE:The Social Seardy#is being requested by this stave agency,ei Oder to pursue rasponsibdty:OtsElosure Is voluntary ahc Pere won be no penalty to retusat .•WARNING: ORIGINAL DiMOURMAENGE OYELLOW�LEN RUBBEC. Oa I DOCUMENT M�DENV ID ON FRONTT THAT APPEARSW WHEN PHOTO COP EDINDIANA ON BACK THAT .