Death Certificate - Atchison, Joseph A_4/26/2016 r w;4�IIt1!1` 1 ' , If i f g NDIANATSTATE+DEP�ARTMENTOF HEALTH' V 11 9 51' III 1 +�
A` , - a'CS i. + �.j / CERnF AT if r ll l �j ~% r f�\1� r"0 v(
i1 > , �` - . --- . Atli . - , 1 :� 4,,lF�/ �. 0I -\ )1f,,,,,,� . . Local No.000014 �rvEDR No;00000042555:1 tistate Nti 001A40
". 1Decedenttsss Le9a/Nam!,( 1rsLwaie;Lesl)Ili HI .:,f'r�l. ;ry I /ter n�afaen am;(tlfen�ale);)t)r%911tC{�•':I y�.., "?i,,,:0lhaTl�/,. d:DakOf De, :(MCruJ�Yfiear)„
C:vltc, .` �!;i1.�'WW-�.,Ct`:�:1.<< its�.'�IV S i <'. ✓/ r' t'/e p.m!�+. .". �If / �y �r J%' �/ ,!I / II ice` II✓"i
�' `'-*nom -..Ri:r.ri ii4 In�i', �--itf.`�:truer ,'`�✓_trt'+-ifMALECi�19, 20P�M=.� ,..!k:',.:01/08/2015'''r
JOSEPH A'ATCHISON� ..
'I
.";. ..' 83\^ 1Mbnmsi i,�. . DaYS?..:�I.I., H°"!?i�:,.t. i? 6mb>e:'' � r - '� ,. �'.
_...._r1R,�.1r.�✓'04/27/1931 .. : .ROUND SPRING,.MO�%.' . ....
9 l Ever in U.S.Anne°Forces? :J10..11 DeYA Otto ed In r Hospital j ...:,,,;:„...,!:4,47::: :1Oa Il Death Oaun\d Saoewnere ONer lben A H°sgtal l ('_ j " '.7'
w, . r = w„ � E Hm Fadll } .y
Pica ry ;G DeceaenYS Hama ❑NUrsNp HarwJLOng krrn Care Far&ry Y'.
®Yes ❑No'❑Unknam ®Inpatient ❑Emapenry Depavaent OvoaSmt ❑
11. Fatty Name(if Not lnstituson,Give Street and Number) ;. :. i
• DEACONESS GATEWAY 'S z ^`
52/Qty Or Town,Stag,Ma Lp Cod. . • 13 County Of Deamri 1a. Martial Sa1s At Time Of Death
•. N Martled 0 Mamed BN Separated ❑Diwrcea:
NEWBURGH1IN, 47630 . ' . ' . WARRICK'' .'0viamed .0 Never,nlar.fed.•Duki wn_
15.Surviving Spwse's Name 15a (If vrfe)Give Malden Last Name It Decedent's Usual Occupeton '1] Kind Of BlsvlessAdustry '
1 S_
• GERALDINE ATCHISON ? • , - LEONBERGERC MACHINIST . . , : 3 % MANUFACTURING .
iS Residence:Sam' '• 1Ba;ea,my •. , ,, ----„v' - 1e° CdyO Toy.,, •_. - - :
' INDIANA ' GIBSON `.,' FORT BRANCH .
• ' 'L. .. T • ' ;
1&..SpeelAMNYmba - , .164 ApLNO• tie.Zip Cale j fBf.I.sside C571ere 7
.701;EASTLPARK STREETw�,�\�,,-'- ,. ,_ 7 y:iwg i 1a'� •: T ....,�-e ^ .-> 7648 ''s.®_:ves �
1 -19.Derederrs Eduraim- u. - 20 DecedentofHmpanlcong' 21 Decedents Race• -. ' - 4
„ HIGH SCHOOLGRADUATE OR GED '•` 47 C ` .$:-< `^,;'1' ~,:e•',' 1 `
;- COMPLETED : -. '_ .- NOT:HISPANIC �� �t White"L' t- :-?.` - .
22 Father's Name(First:kte,Last`+ .Y i 21 Mott Name(First,A9adIe Last) 23a MOmets Maiden Last Name
. ` F d
BENJAMIN`ATCHISON ,. ETHYUATCHISON e .%' . WEESE s C
2a.Infamy is Name - 24a.Reacwvub To Decedent: "240 maim Address (Street And Number,Cty,State,Zip Code) ¢
GERALDINE ATCHISON ' i SPOUSE„ . 701 EAST PARK'STREET, FORT BRA- NCH, IN 47648 + .- '1,,. •
i' w? '.-.1,.. 25.Race Of Q31>a1(IO . . .: •'I . ^ ._
• 25a.Method Of Disposition ' : - 250'Place Of Disposition,(Name Of Cemetery,Crematory:(3m�Pace), 25 Location Ory,Town Md State - - • y
, N Bunel 0 Cremation 0 Donatwn 0 entomdnen < t
0 Removal From Sale, ` ..• r4 ..`Y>+ a- ;x f
a 0Oiner.(SpecMt" - .• WALNUT HILL'CEMETERY... _ FORT BRANCH 4N'• ' "
26.Was Coroner Contacted/ 27. Name And Complete Address Of Funeral F qty y _ a' :;i 27a1F nerei Home License Number
p vas ®No • STODGHILL FUNERAL HOME INC;500 E PARK ST HWY.168,.FORT BRANCH,IN 47648 . FH10900013
: 27b. Signature Of Indiana Funeral Seaka Licemee'c '.y= •:% -' / - S. i` 1'? 27c:License NUrtEa(Of LaenseeY^. • t ii
ROBERT.S'STODGHILLTBY:ELECTRONIC SIGNATURE . . ^ ... .x FD01024378 ' - .
'*' -...ip".•:: '"+`v .xe: Cause Of Death:(See Instructions And Examples) • am'•'_ - `, r°umate
y.28chan 1 Enter The Cha n OI Events • iseasee Injurer Or Cani,ptions That Oireay Caused The Death Do Not Enter.Only O l Eventse Interval Onset
i Such As Cardiac Arrest;Respiratory Arrest.Oi VentriCular Fibrillation Without Showing The Etiology Do Not Abbreviate*Enter Only One Cause On
• A Una:Add Adddial Loosif Necessary. ;: ] . ' - o ` +
• 10:imedale Cause(Final Disease Or CafdiOOn Resulting In Deal)'% A ANOXIC BRAIN INJURY. s'fi • # 7 • `> t y ONE DAY: '
Sequentially List Conditions, B Any Leading To The Cause Listed On. . B CARDIACARREST r t !... `ONE DAY,: .
:The Even ( eO•l° 7. That Initiated
'•; ,tl ✓ , t 4 •'k } '
The Even R W. 31 Death) as 'C IBCHEMIC CAROIOMYOPATHY > - Y ` +. I •NINE YEARS •^ •
p..bt6 c ..eR.M
.0.--CARONARV ARTERY DISEASE: ` - ' 1 TEN YEARS
Par LL Enter Omer5gn:5canl cmdcims Conmbu rig o Dear But Not Resulting le Th Nis aPng Cause Ghin N PM I F,. •29..Was M Autpp.Y Pedormed? • r D Yes '0N.'°
:AP.R .2'6 2016 ,: f' - IcC v tmeyindugA4W`ieToCorwiniheCa,ae Of teats? '•`-Y> n�a,•..:.,-. _tea....,m,•..�J... DYes ❑NO _,
i 31•Dia ToBapo Use Conmbu a To Dear?,+
p n r...S V 31 If Female✓ I r." I! ~:. I f IllY%i --1 r! ,33 Mariner Of Deam •-
� 0' } ,l
,c t ' /f Y - a❑ ✓ ere. f i❑ ao3 0 y-C.u-..4•wr. - . ®Nor, e ❑ACci 0 Pe.Wug Nvesbgaeon
'Q Vey %oW ®Nor lU M i w p �\ . w % ., '- . . ,--, -' ',..%., / Ir▪ �0nnr t 1 t.O.. IQ ^+7 in.e ❑Strode Q Could Not Be De uiW s
r 34 Date Of MO•-"' 35 Time Of!Ivry 36 Place Of injury(E Z:.-Decegenrs Home Construction She'Restaurant,Wooded Area).. 37 Injury At Wyk? - -
'GIBSONCOUNTYAUDITOR '4 r � ' ' " >'` ', .,Dyes= 0Nci•
• 36.Lawson Of Injury:Sate 38a:Cry Dr Tam; 385.•Street&Number a 3&'Apt No.„' 38a.PP Coder '
s • `
1 .
• LL
39.,Describe;ow Injury Occurred e � �\\ < II T aataOm lnryry 5 F/..1 -
1r . , ,. _ . ...,.., , ' +; L.. fi. ?.yl..
S 41.Signature, Of Person Certtyog Cause()Meath:- - .0,-....,.1.42.Gender(Cheek Ore One)•
• DAVID RYON;`.BY ELECTRONIC$IGNATURE ' 0 CeniM g Physicia 0 Colorer • 0 Heels Of'ser •
T 1 43."Name AddressssAnd Zip Code Of Person Certiyi g Cause Of Death: 4s License Number 45 Date Certfed
5 DAVID RYON . .519 HARRIET STREET EVANSVILLE IN 47710 L"'f 01068608A _ 01/12/2015
i 46'Ad6uonalFuneral Service Provider , . - 'a7 ,AenC - . .
1 RLSgnameoftocIHWJsO^ICr liti/I vi▪ 1I :r/ it/AI .rte '" •' '7 - 1 t •;< 49 FoRpiamarO ly DaeFted IMOntOay1YearY/ _ „, it
RICKY B:YEAGER VIA ELECTRONICSIGNATUREUs'I:'c later) `V(-c•8 i�i+1t :4 '' - +L`' .JAN 1212015 .+ ,III .a1 f
j 1`9/w,t+�../Ii .�'h� '?/It Y•'"•'T i @.Yr/ AMENDMENTTO CERTIFICATE OFDEATH(ENTRY.OR ORIGINAL). ..7A` R�-i`t;.Y•' \� :;iR:y71.7„
I-. 'Pc7 i 11 t ./a Ci/. C✓ I I 1 i✓.i 1 ri 1 i ,111 ft :ill )t ..� ,j l; µ
1 i i„. 1r 'r�,l ;! j v , I%i
..;<;.„.
�ji IIil .. Y ll11 .r�)(ai<v.'I }� % 1 r,-; ! i!LJ /If.- i •-j,, ( r 11� .
,a..,19 i8y 3oa o_` 0 =�o. ,y am
. ool 0'3„4 a a� 1 Jar r R 11 Imo/ , �/
' Slate Fan 53395J ATTENTION ESTATE:The Sooal Sec`unty d 15 being redoes id by,Afs stale agency of order to pors4erespons4t iscosure sycdontaryand f(1re wA be ifopenagy far r ,isal(�4t1) �j
�����,,YY��``��iI{i tb� ' //±±'$ORIG1NAL"DOCUMENT-HAS A MU TICOLORED BACKGROUND ON SPECIAI:WHgE SECURrMPAPER AND THE GREAT SEAL OF E STATEOF1�OIANAON BACK THAT
`1C,I!.MYARNIN.l.11TURNSFROMORASTGETOYELL W.WHENRUBBED:ORIGINALDOCUMEN1NA8HIODEN-001E.ONFRONT-THATAPPEARSWHENPHOTOCOW-Dull sit. nt