Death Certificate - Goebel, Ronald G_3/14/2016 ' aY r5 "r'� ri ' INDIANA STATE DE ENTOF 1EATT v ��
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' S%\ )F' ,h` '' 3 p •I CERTIFICATE.'OFDEATH r _ ,, 3:".:'4,,` . ,\
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?s ,\yy' Local No OOOOOH - ,EDR No 000000489518-• - Sratejo 001227 -L `
y 1.Decedent' Legal Name(Fist Made.LM).. ly. f tat Madan Name (U r a ) .1 2 Sae ,• 3.,Tutu°Damn '4" par 9,D"th ?:tt:r
RONALD G GOEBEL - : ` .-_ ;• _ , o MALE nt '16 50. 01/12/2016
• I 78: Math -' Days Hoar Mwras - '• 03/05/1937 INGLEFIELD IN -
L• 9 Ever in U.S.Armed Fares?. 10.If Death Oaunnad In A Hosgtat • I • 10a. If Death Occurred Sonewnere Other Than A Hospital •...
._ 0 Hospies Fartty 0 Decedent's Home 0 Nurshg Hmwlong-term Care Fealty'
❑yes 0.N6 ❑unknown ❑,lcpatea❑Emerge ey Doper nerd Oun ea ❑Dead on Arrival - • ..
P( '❑Other lSPedN)
a! 11.Fatty Name(II Na Inscaaart Give Street etl NIande0 --
9 RIVEROAKS HEALTH CAMPUS
6 12.City Or Town State.And Zip Code • _13.County Of Death 14.Mama,Status At Tune Of Death• •
k ❑clam M
ed❑Maed,But Separated ❑Diiorce0
Y PRINCETON,IN,47670 GIBSON ®`Mdosad 0 Never Marled ❑Witham)
15.SrrvMng Spouses Name 15a. (II NLte)Giva Maiden test Name 16. Decedents Usual Occupation 17. Kind Of Busi esalndustry
3
LOCKSMITH SERVICE
IS.Residerca-Sae lee. County 16O. City Or Town
• INDIANA GIBSON FRANCISCO
19< Sheet And Number 160. Apt N0. lee.ZIP Code let inside Cdy Units/
6100 EAST STATE 64 ROAD ®Yes ❑No
18 Deceoenrs Educaton 20. Decadent Of Hispatic Origin 21. Decedents Race 47649
i HIGH SCHOOL GRADUATE ORGED
COMPLETED NOT HISPANIC White
22.Fathers Name(First Sadie Last) 23.Mothers Name(Fist Middle,Last) 23a.Mothers M.aioen Last Name
LEO GOEBEL ZELMA GOEBEL GLOVER
Zs.I,0°mom s Name 24e.Relations/0 To Decedent 246.Mang Address (Street And Number,City,State,Zip Code) -
NANCY HASENOUR SISTER 3498 EAST STATE 68 ROAD, HAUBSTADT, IN 47639
' 25.PMCe Of Dispositcn •
25a.Meted Of Disposition 250.Place Of Dsposiaon(Name 01 Cemetery.Crematory,Other Place) 25c.Loradcn-City,Town.And Sae
❑Baia, 0 Crenw.im ❑De anon❑Emanement
' ❑Removal Fran State
O other(Spasm: EVANSVILLE CREMATORY EVANSVILLE, IN
' 26.Was Comma Contacted? 27. Name Ara Complete Address Of Funeral Fealty • 270. Funeral Horne License Number.
❑Yes 0 N STODGHILL FUNERAL HOME INC, 500 E PARK ST HWY 168, FORT BRANCH, IN 47648 FH10900013
27b. Signature Of Indent Funeral Service Licensee: 27c License Number(Of Licensee). '
ANDREA LYNN VINCENT, BY ELECTRONIC SIGNATURE FD21400005
Cause Of Death (See Instructions And Examples)
2B.Pat I.Enter The Chain Of Events •Diseases,Injuries, Approximate
rguries,Or Complications-That Directly Caused The Death Do Not Enter Terminal Events Interval Onset
A Line.As Cardiac Arrest,Lines Arrest,Or Vearic ular Fibrillation Wihotn Stowing The EliClogy.Do Not Abbreviate.Enter Only One Cause On To Death
A Lie. Add Addti,al Lines a Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. METASTATIC ADINOCARCINOMA OF SIGMOID COLON YEARS
tow la ii A Caen.os:
Sequentially List Casd4iols, B Any,Leading To The Cause Listed On B.
Line A Enter The Undeeyihp Cause(Disease Or lrhjasy That Initiated wan°"•e°•••• e'Da
The Events Resulting In Death)Last
C.
Dee.Ste AS.ce..,.mw
D.
Pan IL Ever Other Sat Caa C t. Death But Not Resaarnc In The Underlying Cause Gavin In Pan I 29.Was An Autopsy Partmaed?
T 'p'� ❑Yes 0 N •
ISCEN.IC HEART DISEASES,HYPERLIPIOEMN u`viR'„■p■T !■ppssss5®riot 30. Were Autopsy Finding Available To Complete The Cause Of Deam7 1
O Yes 0No I
31. Did Tobacco Use Carndhfa io Death? 32. If Fe ale. 33.Maurer Of peach.
a" tern.:0.na0.L1 ❑ enyg Investigation
❑Yes ❑Pnvbaby❑No ®Unknown
0 m we a e Own 0 we.pne se n. 0 Natural❑Homicide ❑Accide0. P
❑rel yhewt eu maw/43 De's To,her Mtn D..e ___0 thew eMn a vaa.ne Pte rut ❑Suds❑Gald Not Be Determined
34. Dux Of Injury(MaOyDayMea4 35. Tine'VAR 1 4 2016" alt. pia!,Of piny Nall
)YI F11S st Irytry,lEG..Decedent's Home.Cmsvhrtm 5'a,ResatranL Wooded Areal 3]. Al i
0 yes 0 No
38. LocaXn Of blue-State Sea City Or 8 Street e'Ntmtm
sec. Apt_No. 38e. Zip Code
3B Deeame How Injury Oc rred GIBSON COUNTY.AUDITOR .• w. If Trat'wa'5on Inert'. eayy .•,
41.Sidsayre,Of Person Candying Cause Of Dean -_ --- 42.Certifier(Check Cm Du)
RAMESHBHAI P PATEL, BY ELECTRONIC SIGNATURE- D andyigvty,oa, 0 Canner 0 Heath Ozer
43.Name.Address And Zip Code 01 Person Cattyi g Cause Of Death t:' 61. License Nunber 45. Data CeM1.Sed
RAMESHBHAI P PATEL ,685 VAIL ST.,PRINCETON, IN-47670_ .- :. 01040266A 01/13/2016
. 45:Additional Funeral Senior Presider.'. . - 47. 'Akan:
• _ ;\' •
b.Slpfanae alLOCaI Xee Obot: 49. For Registrar Only -Din Flee(Month/Day/Year): •
Lr BRUCE:BRINK JR,VIA ELECTRONIC SIGNATURE
_ ` ' L T .' JANt13:2016 :i
i-e-.I i ';.' t�.0 y _ - - , t AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL): - • - ,
1 . a t,,,� 3 J2 t 1Q3 000 ► 3 c bas f H:?:'• � :.
State Farm 53395 ATTENTION ESTATE:.Tbe Saaa15et:Onry a ii being requested by Ras'state agency-n crdey to pursue responstbdity i)isclosirets vW Wary era there WI ba no panty(cc refusal 1;4 ;
.WARN I NG•,OR(GtNAL-DOCUMENT. sNDt Y-'V L G..it.r
-Y HAS A`MULTICOLOAE,BACKGROUND D CUMEN HAS IDDEN V ID ON FRDN TTH GREAT SEAL OF THE STATEOFINDUVA.. BACK....--? 6
• TURN�Ffl°MMORANG13 TrE.LLAN'WHE,- N rBL gIOINAC....cg ENT HAS HIDDEN VOID ON FRONT THAT•AEPEARS WHEN PHOTO rthown n_ . ':sue- .-•