Death Certificate - Braun, Mildred M_12/29/2016 sr� st INDIANA STATE DE RTMENT;OF HEALTH
• 1 y CERTIFICATE OF DEATH -
. 0 1
c�-.,. S \ _ �! 'Local No 000636 -'�EDR No:000000541487 State No
k;, 1 Decedent's Legal Name(Fest Middle;Last) .,. 1d: Maiden Na a(If(e tale) 2•Sex 3. Time Of Death <. Dace Of Death(McnlMDaynear) _
L[(YgY7! MILDRED M BRAUN METER FEMALE 08:17 AM 11/05/2016
80 Months Days Hours ii.ies' 03/05/1936 SOMERVILLE. IN -
(L�ryay 9. Evers U.S.Armed Forces? 10.Il DeathOzuned InAHOSPtat: 10a.If Death Occurred Soewnere Other Than A Hospital
�I ❑Hospice Facility ❑Decedents Home ❑Nursing HorneJL og-term Care Facility
epRpy-7e,
0 Yes No 0 Unknown (]lnpaoenl Emergency Deoadment Outpatient Dead on Arrival Omer(SpeG!y)
C
to ::.Faulty Name(If Nct Institution.Give Street and Number)
- DEACONESS GATEWAY
12. City Or Town.State.Ma Zip Code 13-Cam:y Of Death
14.Mancal Status At Time Of Death
❑Married 0 Marred.But Separated ❑Div«ced
NEINBURGH, IN.47630 WARRICK
0 Whdowed ❑Never Marred ❑Unknown f.
15.Sunreg Spouse's Name 15a.Last Name Before First Mamage :6. Decedents Usual Occupation A. Kano Of Business/Industry
ASSEMBLER MANUFACTURING
:fir Residence-Sate tear County ;Bo. City Or Town
INDIANA GIBSON PRINCETON __
q lac. Street And Numoer 18d.Apt.No. lee. Zip Code 181. Inside CityLint?
`0 Yes 0 No
1001 SOUTH HALL STREET 47670
t9-Decedent's EducaU 20. Decedent Of Hispanic Origin 21. Decedent's Race
4 UNKNOWN NOT HISPANIC White I e
9 22.Parents Name(First Muocle.taz;) 23.Parents Name(First lucae.Last) 23a.Parents Last Name Before First Mamaye
IFLOYD METER EVA MEIER ALSMAN
2 .4.for ants Name 24a.Relationship To Decedent 24b.waling ACd:ess (Street And Number.City.State.Zip Code) I ,
ta
' KERRY BRAUN SON 309 SOUTH MILL STREET. HAZLETON. IN 47640
25.Place Of Disposition n
25a.MCthoo Of Disposit> 25o.Place Cl Disposition(Name Of Cemetery.Crematory.Other Place) 25c.Location-City.Town.And State I
0 Burial ❑Cremation ❑Donation 0 Entombment
❑Removal From State
❑Other(Specify): COLUMBIA WHITE CHURCH CEMETERY PRINCETON, IN
26.'•'/as Coroner Contacted? 27. Name And Complete Address Of Funeral Facility 27a. Funeral Hone License Numbe-
❑Yes No DOYLE FUNERAL HOME, 520 S MAIN ST. PRINCETON, IN 47670 1 FH iIF'11 j e
27o. Signature Of Indiana Funeral Sevice Licensee: 27c. License Numo.E(0.Lic sed , �'(
BARRETT W. DOYLE . BY ELECTRONIC SIGNATURE FD2950000• -
Cause Of Death (See Instructions And Examples) Approximate
2S-Part I.Enter The Chain Of Events -Diseases.Injuries.Or Complications-That Directly Caused The Dean.Do Not Enter Terminal Events . Onset
Su on As Cardiac Arrest,Respiratory Arrest.Or Ventricular Fibrillation VAtnout Shoving The Etiology.Do No:Abbreviate.Enter Only One Cause On DEC 2 9 20 o To Death
A Line. Add Additional Lines If Necessary.
s Immediate Cause(Final Disease Or Condition Resulting In Death) A. CARDIO RESPIRATORY FAILURE a t.Mr ra,:.:■-...ea
Sequentially List Conditions. If Any,Leading To The Cause Listed On B. CARDIO RESPIRATORY FAILURE Di .e« ,c on IOCfl COU TY Al UI I(../H R
Line A. Enter The UnCedyi g Cause(Disease Or Injury That Initiated G O
-. The Events Resuain;In Death)Last C.
Ore a Ins .e Crier.+ve on
t
A D. v.
Pane.Enter Omer Senecant Conacons Conmoutm o to pea?.But Not Resulting In The Undenyv-.g Cause Geen In Pans 29_Was A.^.Autopsy Performed? ❑Yes 0 N I ?
30.e „x r 29_Ware n Autopsy
Finding rmed?le To Complete Inc Cause Of Dean? yes ❑No I 0
CARDIO RESPIRATORY FAILURE
31.Dic Tobacco Use CS.r.Eute To Death? 32. if Female: 33.Manner Of Deam:1 ❑w .v..w...•..0...• ❑Pie ..ovo e ❑N.-le-w+t ss F...• s,v 0eoe w n Natural(]Homicide ❑Accident ❑Pe:.cog Investigator _
❑Yes []Pmbadly'iN No ❑Unxnawn 0•ee ,ere..ea Pier.,Nr p...:.t renter.v..: ❑trs eerer,.+'•w•�ow ❑Suicide 0 Could Not Be Determine^.
34.Date Of Injury(M:r4rOarYeat) 35. fume Of l..ry 36- Place Ofr{ry(E.G..Decedent's Home.Construction Site.Restaurant Wooded Area) 37.Injury At Work?
D Yes 0 N
111pPPFFF 36-Locator.Of Injury-State Ma. City Or Town 350. Sete b No^_e:
3 8c. Apt No. 380. ho Cade -
139.Describe How Injury Occurred 0If,Transportation mjuri Sceuy.
Qo.e+0.n.s ❑eery.. ❑re«:w,QM•e.I3:.rn1 '
41.Signature,Of Person Certifying Cause Cl Death: d2.CeaSer(Cnec:.Ore'One) I '
ii NANDAKISHORE AKULA, BY ELECTRONIC SIGNATURE I G'Ceniying Physician ❑Coroner ❑Heated Officer
43.Name.Address And Zip Code Of Person Certifying Cause Of Death: 44. License Number e5. Date Certified
1 E
NANDAKISHORE AKULA . 600 MARY STREET, EVANSVILLE, IN 47747 01075418A 11/09/2016
45.Addtional Funeral Semce Procter I 40. .Akas:
1 <8. 55nawa of Local heath Officer lag. For Registrar Only Date Filed(MonWDaylYeark
�' NOV 14 2016
RICKY B YEAGER.VIA ELECTRONIC SIGNATURE
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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E GG
Stale Form 53395 ATTENTION RSGINAL TDO(A Social NAA,S Security MULTICOLORED eBACKG(iDUffdD ON SPECIAL WHI E SECURITY SPAPER Disclosure
ND THE GREAT SEAL OFtTHE STATE OF INDIANA rONUBACK THAT 'L
.,..WARNING•.TURNS FROM ORANGE.TO YELLOW WHEN RUBBEDORIGINAL DOCUMENT HAS HIDDEN VOID ON FRONT THAT APPEARS WHEN PHOTO COPIED y
u krizglaNWaalVii STATE OF,INDIANA P t