Death Certificate - Ritcheson, James W_7/13/2015 IS_IS'AN:OFFICIAL COPPrOF NECORD.OFtOEATWORIGINALFCOPY:ON FILE'AT(IND •t'I•' - i ' ' y' 1 • yI
• • TATE DEPA}2TIJIENT"OF•FIEACTH 1092517
CERTIFICATE OF DEATH
' f Local No 000134 EDR No 000000334389 State No 033810
1.Decade;rs Legal Name(Fee.I.b die,Last) Ia.Maiden Name(If lema:e) 2.Sex 3. Time Of Death 4. Date Of Death(:-bnrt'DaylYear)
JAMES W RITCHESON MALE 05:20 PM 07/20/2013
61 Monte (Days _ Noise Minutes
Hospeal
0 Hospice Fealty 0 Decedent's Home 0 Nursing kane&Ong-term Care Fealty
®Yes (]Na ❑Unknown ❑Inpatient 0 Emergency Department Outpatient 0 add on Arrival 0 Other(Specify)
II.Faculty Name(If Not Instanvl Give Sleet and Hurter)
218 WEST 3RD STREET
12.Ccy Or Town,Stax,And Zry Cade 13.County Of Dean 14. Manta)SOWS Atrme Of Deadt
0 Maned 0 Married.BLM1Separatel 0 Divorced
HAZELTON, IN,47640 GIBSON 0 Widowed 0 Neva Married 0 Unknom
15.Survhing Spouse's Name i5a. (If VAfe)Give Maiden Last Name 16.Decedents Usual Occupation 17.KIM 06 BusinessIIrdsBy
BEI IY RITCHESON WILLIAMS QUALITY CONTROL NAVAL BASE
18.Residence-Sttae 18a County 1ao.City Or Taw,
INDIANA GIBSON HAZELTON
18c sleet And Number 16d. ApL No. 18e. Zp Code 18f.Inside City Limits?
0 Yes 0 No
218 WEST 3RD STREET 47640
19.Decedents Eduaim 20.Decedent Of Hispanic Ongn 21. Decedent's Race
SOME COLLEGE CREDIT,BUT NOT A
DEGREE NOT HISPANIC White
22.Fathers Name(First Midde.Last) 23.Mothers Name(HrsL Middle.Last) 23a.Mother's Maiden Last Name
• JAMES E RITCHESON _BETTY R DYEHOUSE LINDSAY
24.Infrmants Name 24a.Relattionsrlp To Decedent 24o.Mating Address(Street And!hewer,City,State,Lp Code)
BE I I Y RITCHESON WIFE 218 WEST 3RD STREET,HAZELTON, IN 47640
25.Place Of Disposdon
25a.Method Of Disposcon 250.Race Of Disposison(Name Of Cemetery.Crematory,Other Place) 25c.Location-City.Tom,And State
0 Statist 0 Cremabon 0 Donason 0 Entombment
0 Femoral Fran Sate
0 Over(SPedyk GOODWIN CREMATORY VINCENNES, IN
26.Was Coroner Contacted? 27. Name And Complete Address 01 Funeral Fadsty 27a. Fteeal Halle License Number.
0 Yes 0 No GARDNER BROCKMAN FUNERAL HOME, 505 MAIN ST.,VINCENNES, IN 47591 FH11100023
275.5grtalre Of Indana Funeral Service Licensee: 27c.License Number(Of Licenseek
TIM R.GOODWIN ,BY ELECTRONIC SIGNATURE FD08900025
Cause Of Death (See Inso'uctons And Examples) Approximate
28.Part 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,Respirator/Arrest.Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Addi:inal Lines If Necessary.
e:led:ate Cause(anal Disease Or Condition Resulting In Death) A. HEPATIC ENCEPHALOPATHY UNKNOWN
oe a to Aa•c....p Oct
Sequentially List Conditions, If Any.Leading To me Cause Listed On B. CIRRHOSIS OF THE LIVER UNKNOWN
bun I
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated - G a.��.M
The Events Resulting In Death)Last C. ALCOHOLIC LIVER DISEASE UNKNOWN
onto,id•c...aara Oh
D.
Patti.Enter Other ScnSpaLCaihyts CondiblYt,o to Death Sin Not Resulting In the Underlying Cause GMn In Pan I 29.Was An Autopsy Pertamred? 0 Yes 0 No
30.Were Autopsy Fitton Available To Complete The Cause Of Deah? 0 Yes 0 No
31.Did Toloacoo Use ComlWte To Death? 32. If Female: 33.Manner Of Death:
0 me P.sawa.,Pa Ya. 0 Pv.n.v CI Tee or Death O,a Prr..&deca t win,.roes a De.. 0 Natural 0 Homicide 0 Acodent 0 Pendng Inves•gatlon
❑Yes ❑Probably 0NO ®Unknown 0 xn Tor.lt to Persil of rev,..Bette o.m 0tain,ePea.v en,n.Pa la 05uicide 0 Could Not Be Determined
34.Date Of lnNy(MondVDaytYear) 35.Time Of Injury 36. Place Of opry(E.G.,Decedents Home.Construction Site,Restaurant.Wooded Area) 37.Ir{rry At Work?
0 Yes 0 No
33.Location Of Injury-Sate 38a.City Or Town 380. Street 8 Nutter 38c.Apt.No. 38d. Zip ••^a
39.Describe Nov L ury Occurred 40.If Transporaoen Injuy.5 f
nj- Don.ew O '-'-c- .-'0 on-1sRVn
41.Signature,CI Person Cerytg Cause Of Death: •2.Cattier(Check Only One)
JOHNNY BEAR. BY ELECTRONIC SIGNATURE Cattier r 0 e°tAing Physician 0 Coroner 0 Heath O'Scer
43.Name,Address And Lp Code Of Person Cemfytg Cauca Of Death: 44. license Number 45.Date Ce:aed
JOHNNY BEAR ,406 N. 1ST ST., PO BOX 806,VINCENNES, IN 47531 _ 01036151A 07/24/2013
46.AddSnnai Ewen]Service Provider Pe� 47. •AFas'
48. Signature of Local He=Officer - 49. For Registrar Only -Date Feed(MotYDayrY ear
k
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE JUL 24 2013
AMENDMENT TO CERTIFiC ATE OF DEATH;ENTRY OR ORIGINAL)
ar6-Da -SR- 03a- 000 ' 330 -DI q
State Form 53395 ATTENTION ESTATE:The Social Security is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary and there via be no penalty for refusal.
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