Death Certificate - Besing, Judith Ann_5/25/2017 . -
! ('ice 'ire, it ..'- S INDIANA STATE DEPARTMENT OF HEALTH' i tlti -i - • ,
` CERTIFICATE OF DEATH
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�:' Le Loyal NO:0001.13:.' "EDIT No<000000561902 state.No 010084`
,.Decedents Legal Name(First,Middle:Lag)„ !ter MaidenName:Of female)• •„;N. .� - 2.Sex 3.Time Of Dear'..,,,. 4. Date 01 Deals;(MentlYDaylYeyr)
JUDITH ANN BESING , - `• MILLER c l r 7. iFEMALE 18.Bi AM " �° -02/19120no
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Armed Forces? ter.if Death Occurred In A Hospitat lea.If Death Occurred Somewhere Other Than A Hospital
• ❑Hospice Fatty ❑Decedent's Home ❑Nursing Home/Long-term Care Fealty.
❑Yes 0 No ❑Unsnoan 0 Inpatient 0 Enr,.,y.,..y Department OutpaCent ❑Dead on Arrival
❑other(Bpevfy)
11. Fddity Ndme(If Not InLV,Give Street and Number)
THE HEART HOSPITAL AT DEACONESS GATEWAY
12.City Or Town.State.MO Zip CCOe 13,County Ol Deem 14. Mewl Steen At Time Of Death
NEWBURGH, IN,47630 O Marred❑Marred.BU Y.e
Separd ❑Divorced WARRICK ❑%,wowed ❑New Married ❑Unknwn
15. Survwp Spouse's Name 15a.Last Name Before First Alamage 16. Decedents Usual Occupation 17, Knd Of Bud nessnmassoy
LARRY BESING HOMEMAKER HOME
18.Residence-State - 18a. County 180.Gay Or Town
INDIANA GIBSON ELBERFELD
tic. Spttt And Number 1Bd. Apt.No. the.Zip Code ( 181.Inside City host?_
8910 SOUTH 950 EAST, l-_ _ _ 47613 O Yes 0 No
19.Decedents Education 20. Decedent 01 Hispanic Ongn w 21. Decedent's Race .
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White •
22.Parents Name(First,Mdpe,Lazo 23,Parents Name(Fist,Maddle.last) 23a.Parents Last Name Before Fist Marriage
WILBUR MILLER BERNICE MILLER REAGON
' 24.Informants Name 24a.Relationship To Decedent 24b.Maing Address,(Street And Number.City,State.Ti0 Code)
LARRY BESING HUSBAND 8910 SOUTH 950 EAST, ELBERFELD, IN 47613 .
25.Place 25a.Method Cl Disposition 250.Face Of Disposition(Name Of Cemetery,Creme I Dispose
0 Burial ❑Cremation ❑Donaboon❑Entombment ry. toy,Other Place) 25c.Location-Cry.Town,And State
❑Removal From State
0Other(Specify): ST JOHN'S CEMETERY BUCKSKIN BUCKSKIN, IN
26,Was Coroner Contacted? 27. Name And Complete Address Of Funeral Fealty 27a. Funeral Home License Hunan
DV es 0 No CORN-COLVIN FUNERAL HOME, INC., 323 N.MAIN ST. PO BOX 278, OAKLAND CITY, IN
47660-0278 FH19400002
Did. Signature Of Indiana Funeral Service licensee: 27c.License Number(Of licenseep
MARK R WALTER, BY ELECTRONIC SIGNATURE 13
Cause Of Death (See Instructions And Examples) Approximate
28.Part I.Enter The Chain Of Events -Diseases.Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Term' en • Interval: Onset
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Snowing The Etiology.Do Not Abbreviate.Enter Only ie fan 9J YYY/// To Death
A Line. Add Additional lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. ISCHEMIC CARDIOMYOPATHV i�tAY r 5 2017 4 YRS
b.e1P..Ac_
Sequentially List Conditions. II Any,Leading To The Cause Listed On B' ..Ia•' .c....,...pn
line Events nts Resulting TM In Underlying Death)Lase(Disease Or iqury Tnal Iptiated .A.
Tne Events r The th Death)Last C i
•b( .a•
D. GIBSON COUNTY AUDITOR t
Pant].Enter Other$iortncam Condtions Contrlbypno to Death But Not Resuttig In The Underlying Cause Given In Part I 29. Was An Autopsy Performed?
❑Yes 0 No
•^--___ -- - Je.Were Autopsy Finding Am/table To Complete The Cause Of Death? ❑yes-❑NO ,
31.Did Tobacco Use Conm3ute To Death? 32.if Female: 33. Manner Of Dean:
❑,..n.r..we,.e.ur..- ❑ n...do... ❑w.n.e.H ew w.wwe We.,•do,owns, {
❑Yes ❑Probably 0 No ❑Unknown yw,s,,.n a�,n.c.w.s o.n*.,run e.b.O..w Suicide❑Could Not Be Determined❑Pending InveStga'Jgrn
❑ ❑uxw.wian.w.a wen Ti.TV r.uru. [
34. Date a ijury(MontNDay(Year) 35. Time 011
MurY 36. Place Q Injury(E.G..E6- Oecedentt Home.Construction Site,Restaurant Wooded Area) 37.Injury At Work? )
❑Yes ❑No
38.Location Of Injury.State 38a.Cry Or Town 38b. Sweet 8 Number 38c. Apt No. 38d.lip Code
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39, Describe How injury Occurred
40.If TranS,ronxan eyury,_ rilr.
41. Signature.Of Person Certifying Cause Of Death: 142. CerfSer(Check Only One)
FRANCIS PAMELIA, BY•ELECTRONIC SIGNATURE 0 Certifying Physician eo ❑Coroner ❑Health Officer j
43.Name,Address And lip Code IN Person CerMyig Cause Of Dean: 44. Lkertse Number 45. Dare Certified
FRANCIS PAMELIA ,4007 GATEWAY BOULEVARD, NEWBURGH. IN 47630 01060164A 02/28/2017 E
46.Ad6;b Funeral nal Fb Service Provider:er: 47. -Alia5: -
48. Signature of Local Heath Offcs - - - 49. For Registrar Only -Date Fled(MontwDay/Yearj . _ • b•
RICKY B YEAGER,VIA ELECTRONIC SIGNATURE - .. MAR`Oti 2017
AMENDMENT TO CERTIFICATE OF,DEATH(ENTRY OR ORIGINAL) ' - r . - - y
°&G-a0-a6- boo-000 044.1 V W' .aG-ao c2 a-woo-oo 1 :132-onv .:••
a' o % too - goo oyg tics 3
. State Farm 533955 ATTENTION ESTATE:The Social Security a is ben requested by thisjslate agericy m order to pursue resppnsibety.:Disclosure Is voluntary and there wil be no penalty tat refusal -.
-...WARNING ..TURNS FROM DOCUMENT ANGETO YELLOW MULTICOLORED
RUBBED.OOAIIGINA1'DOCUMENT HAS HIDDEN OID ON FRONT THAGAPPFARS SEAL OF punrnEre...cre ON fig.. .-. -