Death Certificate - Kruse, Verda M_8/3/2017 TNISIS AN OFFICIALCOPYLOFHECORD'OF DEATH .ORIGINAL COPY ON FILE AT INDIANA STATE DEPARTMENT OF HEALTH S-
o INDIANA STATE DEPARTMENT OF HEALTH 351114
(\`--• i •�} CERTIFICATE OF DEATH
� '!• Local No 000007 EDR No 000000177638 State No 002421
I.Decent's Legal Name(Firs.Middle,Last) 1a. Maiden Name(If female) 2.Sex a Time Of Death 4. Dave Of Death(MdntrJOayNear)
VERDA M KRUSE_ KUESTER FEMALE 04:10 AM 01/18/2011 _
93 Montle Days Hours Ambles FORT BRANCH, IN
9. Ever in U.S.Armed Forces? 10.If Dear Occurred In A Hospial: 10a. U Death Occurred Somewhere Other Than A Hoseal
❑Yes 0 N p ❑Emergency Department 0 Hospice Fealty 0 Decedents Home 0 Nursug Home/Long-term Care Facility
❑Unknown 0 L abent erg cy eparment Outpatent 0 Dead on Arrival D Other(Specfy)
11. Facility Name(If Not Instvton,Give Street and Number)
RIVEROAKS HEALTH CAMPUS
' 12. City Or Tow..Sate,And Lb Code 13. County Of Dean 14. Manal Status At Tune Of Death
0 Marred 0 Mamed,But Separated 0 Divorced
PRINCETON, IN,47670 GIBSON 0 V.doeed 0 Never Married 0 Unknown
15. SunMng Spouses Name 15a. (If Wife)Give Maiden Last Name 16. Decedents Usual t Tete Of D
County tab. Ciy Or Town
INDIANA GIBSON FORT BRANCH
13c. Street And Number 180. Apt.No. 18e. Zip Code laf. Inside City Lent?
306 E JOHN ST STREET 47648 0 Yes 0 No
19. Decedents Education 20. Decedent Of HSpanic Orign 21. Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Fathers Name(First Mode,Last) 23.Mothers Name(Firs.Mace.Last) 23a.Mower's Maiden Last Name
WILLIAM KUESTER ANNA KUESTER HASSELBRINK
24.Informant's Name 24a.ReationsWp To Decedent 24b.Mailing Address(Street And Number.City.State.Zip Code)
ALAN KRUSE SON 802 CREEK DR, FORT BRANCH, IN 47648
25.Place Of Deposition
25a.Method Of Otsposibon 250.Place Of Disposition (Name Of Cemetery,Crematory,Omer Place) 25c.Locasen-City.Town,And State
0 Bu tal 0 Cremation 0 Donation 0 Entombment
0 Re:noral From State
D Other(Speceyk ST LUCAS CEMETERY FORT BRANCH, IN
26.Was Cotner Contacted? 27. Name And Complete Address Of Funeral Facility 27a. Funeral Home License Number.
0 res 0 N STODGHILL FUNERAL HOME INC.500 E PARK ST HWY 168,FORT BRANCH, IN 47648 FH10900013 . -
270. Signature 01 Indiana Funeral Service Licensee: c �
ROBERT S STODGHILL, BY ELECTRONIC SIGNATURE I f - 8 '
Cause Of Death (See Instructions And Examples) l Approximate
28.Part I.Enter The Cna'm Of Events -Diseases.Injunes.Or Complications-That Directly Caused The Death.Do Not Enter Terminal Eve Interval: Onset
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Snowing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Addalnal Lines H Necessary. p
Immediate Cause(Final Disease Or Condition Re<Wdng In Death) A. RESPIRATORY FAILURE AUG 0320 (2017
FEW DAYS
M.5101...p.a.r.une
Sequentially List Conditions. If Any,Leading To The Cause Listed On B. PNEUMONIA FEW DAYS
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
a..51a...ra..a�oR
The Events Resulting In Death)Last C.
0. vlot y.
.rtn:IS COON)Y Au,:T f
D.
P a r t 1 1.Enter Other ••n.. one,. • • o•-.y BN Not Resulting In The Underlying Cause CNn In Pan I 29.Was An Autopsy Perfarmed?
0 Yes 0 No
OLD AGE.HIP REPLACEMENT. 30.Were Autopsy Finding Aradable To Complete The Cause Of Dear? 0 yes 0 No
31. Did Tobacco Use Co tibute To Death? 32. If Female: 33. Marne Of Dean: .
❑Yes ❑PtMaNy❑Nc ®Unknown 0 luny..weer rue v.., 0 etfl' 4 At n..a t..e 0.a,>.wt an r•.e..a wan a2 On.a Doter. 0 Natural 0 Homicide 0 Accident 0 Penang investigation
❑a P,y...a ennwa.sw.t.I-e.s..one 0 u......,eawwwee riw en r.. D Suicide 0 Ca.0 Not Be Determined
34.Date Of Inryry(MdntVDay(Year) 35. Tune Of Injury 36. Pace Of Injury(E.G.,Decedents Home,Constriction Site.Resauran.Wooded Area) 37. Ltay Al Work?
0 Yes 0 No
38.Location Of Maury-Stale 38a. City Or Town 380. Street&Number 38c. Apt.No. 384. Zrp Code
39.Descnbe How Irplry Occurred .8.0.1f Transooratm Injury.s eoty
..,ce-.w D C).4.ee. Dte.lss.ev)
41.Sgnatue.Of Person Centyi g Cause Of Death: 42. Ce.Ser(Check Ony One)
RAMESHBHAI P PATEL, BY ELECTRONIC SIGNATURE 0 Ge.fying Physician 0 Coroner 0 Heath Officer
43.Name,Address And Lo Code Of Person Ce.fying Cause Of Death: 44.License Number 45. Data Cetfied
RAMESHBHAI P PATEL ,685 VAIL ST., PRINCETON, IN 47670 01040266A 01/21/2011
46.Addtional Funeral Service Provider. 47. 'Akas:
48. Signature of Local Heat,Older 49. For Registrar Only -Date Feed(MoneeDayfYexk
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE JAN 24 2011
` AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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Stara Fenn_ 5r1ht2tifTENTKDN ESTATE:The Social Sewry t is being requested by this state agency in order to pursue responsibBy. Disclosure is voluntary and there will De no penalty for refusal.
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