Death Certificate - Stence Sr, Reuben F_4/4/2016 fipilhillif 9111,1V7s1I111,110 a �; i, i,adl e z' IIVLoAr a " : , r ;',.r : 1078911
I -'- , `%1 CERTIFICATE OF DEATH
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Local No 000024 EDR No 000000367419 State No 004461
1.Decedent's Legal Na-.e(Fires,Male,Last) Ia. /Amain Nane(If femae) 2.Sex 3. Time Of Dean 4. Date Of Death(Mt/Day/Yeas)
REUBEN F STENCE SR MALE 10:45 AM 01/29/2014
69 erns Days I licurs ='s 07/19/1944 SALEM, IL
9. Ever in U.S.Anted For:es? 10.1:Death Occurred N A Hospital: 10a. If Dears Occurred Somewhere Otte Than A Hospital
❑:gscice Faaly @ Decedents Hama ❑Nursing H a.eJ_ag-term Care Faculty
❑Yes 0 No ❑uninom, 0 Inpaten Emergenry Deparunert Out.-gent Dead on Arrival o (Speedy)
11.Facility Name(If Not Nsaoa,Give Street and Number) .
317 SOUTH MAIN STREET
12.Cory Or Town,State.And lip Code 13.County Of Death 14. Marital S:ats At Time Of Death
0 Ma.ed 0 Married.But Separated 0 Divorced
HAUBSTADT, IN.47639 GIBSON 01'1dceed 0 Never Magid p Unknown
15.SureM g Spouse's Name 15a(If VA.e)Grae Maiden Lan Name 16.Decedents Usual Occupabon 17.Rio Of Bt nessAnousoy
GRACIE R STENCE COALE NURSE HEALTH CARE
18. Residence-State I lea. County lEd.City Or Town
INDIANA GIBSON HAUBSTADT
18th Sweet AMMtmoer 184. Apt No. 18e. Zip Code 181.Irntde city Lemts?
0 Yes 0 No
317 SOUTH MAIN STREET 47639
19. Decedents Educaten 20.Decedent Cf hispanic Ongin 21.Decedents Race
ASSOCIATE DEGREE(AA.AS) NOT HISPANIC White
22.Fathers Name(Firs:Middle.Last) 73.MCners Name(First.Mdae.Last) 23a.Mothers Maiden Last Name
CHARLES H STENCE LOIS E STENCE CLEMENTS
24.Informants Name 24a.Re!aoa:stip To Decedent 240.l.adng Address(Sweet And NUrtter,City.State.Zip Code)
GRACIE STENCE WIFE 317 SOUTH MAIN STREET, HAUBSTADT, IN 47639
25.Place Of Disoniton
25a.Mena Of Cispos.ta 25:.Face Of Disposa:cr.(Name Of Cemetery.Cre.airy,Other Place) 25c.Locaton-CM,Tom,And are
0 Banal 0 Cremation 0 Daaton C En:xcmen:
0 Removal From State
p Otter(specify): HIGHLAND MEMORIAL CEMETERY MOUNT CARMEL. IL
M.Was Cotner Contacted? 27. Name And Compere Address Of Funeral FadLty 27a. Funeral Hate License Number:
❑Yes ❑No FAMILY TRADITION FUNERAL HOME,2600 NORTH CHERRY ST., MOUNT CARMEL, IL
62863 N/A
27:. Sgnatu-re Of Libra Funeral Service Licensee: 27th License Number(Cf Licensee&
SHAUN WILLIAM KEEPES , BY ELECTRONIC SIGNATURE I FD21100019
Cause Of Death (See Instructions And Examples) Approximate
29.Pan I.Enter The Chain Of Fvents -Diseases.Injunes,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset
Such As Cardiac Arrest.Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Acoreviate.Enter Only One Cause On To Death
A Line. Ado Additinal Lines It Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. LIVER METASTASES EMANTHS
w..,ra ..Ca-neat pp
Sequentially Lis:Cond.WoCa, It Any,leading To Tre Cause Listed On B. a...io.a.rye at
Line A. Enter The Undying Cause(Disease Or Injury That Initiated
The Evens Resulting In Death)Last C.
Diu voce•a.._v'a>•a.Pi
O.
Par:II.Enter Omer icrrloant rondmpu Cent:icucno to Deals But Not ResWbng In The UrcMyvg Cause Gin In Pant 29.Was An Autopsy Performed: oYeS 0 N
PANCREATIC CANCER 30.Were Autopsy Finding Available To CCmc:e:e Tne Cause Of Dear?PANCREATIC Yes 0 No
31. Did Taaced Use Canute To Dean? 32. If Female: 33. Manner Of Deans:
O'e,ngw Wen Purr e• 0Air.+.,i,s.oc... 0. ,. ...we,as_,, 0NaturalCHomicide 0 Accident ❑Pending Invss;gaton
❑Yea ❑Probably 0 N 0 Unknown 0 wa,YR s40.v.fu can tar.-re.b. L ❑Suicide❑Could Not Be Determined
34.Date Of lrr_.y(ucnrJDayfYear) 35. Time Of Injury a In (E.G. -.Cdosovaon Site,Restaurant Wooded Area) 37. Iri-ry^:Wont?
`�' ❑Yes p No
39.Locaan Oflr{_ry,State 34a.Cry Or Town 36o. Sweet&Number 38c.h^L No. 39th it CSe
APR 4 2016
39.Descte How Injury Occurred 40. It Transcdra:o.I�Nry.Specify-.
0on.nowne p.. p: ., por.ts�,l•II
41. Sgnature. Of Person Cerfyug Cause Of Dears 'fir y,r gorgp' 42.Cer.S«(Check On One)
JERRY L LIKE,BY ELECTRONIC SIGNATURE GIBSON COUNTY AUDITO.$ Ce` ng Physician 0 um"' 0 Heart Oster
Code Name,Adcess And Zip Ce Of Person Cer'rvg Cause Cf Death: 44.License N_m0er 45. Date Car-reed
JERRY L LIKE . 110 W.SYCAMORE ST, ELBERFELD, IN 47613 02000254A 01/31/2014
46. Additional Funeral Serice Provider.
45.Signature of Local Hearn Ofleen 49. For Registrar Only -Date Filed(MatruDayfYear&
BRUCE BRINK JR.VIA ELECTRONIC SIGNATURE FEB 03 2014
AMENDMENT TO CERTIFiCATE OF DEATH(ENTRY OR ORIGINAL)
abHIQ-31-303 . 0ooaa Li 3 . �
.,:,../'to Form 5r33� ATTENTION ESTATE:The Social Security u is berg recuested by this slate agency in order to pursue respors:Litt .Disclosure is voluntary and mere'will be no penalty to refusal.
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