Death Certificate - Schmidt, Rocky Van_6/9/2015 °
INV : da A •Yrs( 88:unser 1 Year ft.. unser I stors-..id Snow 1 Day I se unser:Hots: '7. Date al Ertl(Morei/DaylYear) 9:134,..epesca..(City,and Slate or'Reece Ccoraryll —3.-1
r 15a IINA8e)Ove Maslen Last Name • , 18, Deceaerts Usual Occupance . ' -17. Kasa Of aspnessinasay,- .. :
•
,t".. .19.Decedent 4 Eaucaeon : . . . — , 20 ceceaentor wssanc OnGcn 21 Decedents Race
'.4". ASSOCIATE DEGREE(AA.AS) - NOT HISPANIC . I ,
'- a Father'sName(First Mrole Lau) - 23 Malsers Name(F1131,Vied.kast) I 28a Mothers Mairlan last Name ' 'a
.244 Relalsansto ta Decetent - 24-br Maeng Roans(Street Ana NUMDer.C.iy,Stn.ZIII Cod)
4 . :25a matna Cf.Diseteren L< ; . i . .I 250 Race Of Dtsoosmon(Name Cf.Cemetery.Cramer-4r;Omer Place). 35c.icanon•Cay.Tom,.Ana Sten.... . ' t
. Cause Of Death (See InstivetIons And Examples) ..
--28 Fort L Enter:The Dhatn Of',ants -Diseases:44uries.Or Compecatrone-That Directly Cause°The Death.Do Not Enter Term:nal Events
' r.Sien As Careiac"Arrest.Rest:eatery Arres-L'Or Vertstular FibnlIattn'ANF(cut ShovAng The Etiology Do Not AbOraviate Enter Only One Cause On - .
eitmeaiate Ciao/FS Disease Or 6onetton R4:suting In Deeli) A MECHANICAL ASPHYXIA MINUTES
It ' --. Sequeready UV Coo:Mmes. It Any,Leading To The Cauie Listed On El CHEST COMPRESSION '
it, .line Ar Enter The time-lying Caiee(Disease Or liguy That Initiated '
3. .11.10DERArTE TO SEVERE AORTIC AND CORONARY ARTERIOSCLEROSIS ' . 30 Were ALtotsy Enema Ayala:ale To Complete The Cause Of Dea017 0 yes 0 isio ,..
CO 3:D'.4ia Cr' injury' ' ManAH'Day.'r;ear)•: ' 35- lineeri " "' 35 Place DI'Nu/(EC,Ds:aeon's Home,Consamtace Ste,Reramant Alcoaea Area) 37- Irfur/81'8;011 - -' -
4' I 41.Spnasre..01 Person Cerr.lyng Cause Of Dean. . . I 42.Cortese(ChOCIC CI*One) . • , ' '4
-rg I BARRETT W.DOYLE. BY ELECTRONIC SIGNATURE 0 Car--8/11,9 PnYsrZial , 2 Caoner 0 risen Carer ' 't.tr.
. 43 Name.Address.Ana IA C030 POrSOn CS;Cals./Cr Dent 44 Loves NutlItoit 45 Date Centred . :...
'Yr.': BA,RRETTW.DOYLE ;520 SOUTH MAIN ST. PRINCETON, IN 47670 , 12/29/2014 . 5y
. I 49 FOC Ripsaw Only -Cate=ilea,(MeriveDayff sari , -. . .. , ., ,e
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