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Death Certificate - Ritcheson, Robert L_9/5/2017
-aTn�.'�-v a�.1ur. w - ri`-.i_, A ERTIFI ATE •F DEATH V..-. .i, ., -. ere.:.it%�u1�,.ia✓-, _ e�I• 0 'eI INDIANA STATE DEPARTMENT OF HEALTH - � ,1 ` CERTIFICATE OF DEATH - RESUBMIT 1 (tC , , . (}}1,__ '� Local No 000277 EDR No-000000394986 - State No:031745 '. -. - 0 - 1.Decedent's Legal None(Fest M .Last) fa. Ma den Name NLe,nalel a Sex a Tone a Deal 4.'Data Of Death(NadVDay/Yea) `� � -, tYr ROBERT L RITCHESON ,1 �-, , .. MALE. _ 08:05 AM .-07/12/2014' " 91 Hospital ..: - ,�.-' - 1 , O Hospice Facility - 0 Decedent's Hare 0 Nursing Hare oVmml Cue Featly ,. ` ial 0 Yes 0 No 0 Unknawn 0 Inpabert O Emergency Deportment Cem O Dead ai Anal p one,{sway)' ' i 11. Fairy Name(h Not Instant Give Seal ad Number)• . ) hit GOOD SAMARITAN HOSPITAL f fl 12.City Cr Tae.Stab,And Zip Cade 1-Cwmy Ot Deti 14.Maned Siam At Tree a Death c..l -0 Maned0 Maned,But Sepaabd 0 Divorced 7,1 VINCENNES IN 47591 - l KNOX , I ,0"^dosed ❑Neva hand,:❑unhaen '-, C. 15.Stamm Spouse's Name • 15a tam Name Bee Fit Manage 16.Decedents Usual Omj i i].Red Of BusnessitrOustry 1_ I 0 KATHY RITCHESON - HUNT FARMER " AGRICULTURE �0 18 Rm1aa.State 18a Cwiy 180 City Or Town _ ) 1 7' INDIANA GIBSON' - HAZLETON - .1 ` - �` er. a Seat And Hunter I led Apt NO 18e Zq Code 18L bade CayLnits, ) I f CC 111 MILLL STREET r-• -.1 ` 47640 ®Yes O No ?B -t 19. Decedent's Education 20 Derederta Htapar[pgn 21. De®dad'x Race - ) I • HIGH SCHOOL GRADUATE OR GED VVhite COMPLETED 2 Nane .st Male,Laa NOT HISPANIC 23 Paris Marne(Frst Melde,Lest - 23a Pacers Last Mane Bete Fm Manage ?.1 i - y t• JAMES RITCHESON I 1 BETTY RITCHESON LINDSAY x0 a 24.Informants Name 24a.Ralmvatip To Decedent - 24b.Mating Manna(Street And Hunter,Cdy.Stab,rd,Code) N KATHY RITCHESON WIFE '. 111 MILLL STREET, HAZLETON, IN 47640 2 4 '2S PMmd van(., Cr 25a.Meted a Daposaei 258.Place a Dispaatan(Name a Cemetery.Cremebry.Odes Rae) 25c Locabai-City.Town.A't Std Cl W 0 Bina 0 Cremator O Doran O Eaamnaa = Er 0 Re aFiun Slate A O 0 Ober(Speedy). - GOODWIN CREMATORY- VINCENNES,IN to O 26.Was Cages Contacted? 2T Mane Ait Cass a Address a Fugal Fatally 27a. Fund Home Lease Minter. - (t ❑Yes 0 No GARDNER BROCKMAN FUNERAL HOME, 505 MAIN STt;VINCENNES, IN 47591 FH11100023'i -C QW L 27b. Samar,a name FUaal Service Licensee. 27c, Lane NUMB(Cl Licensee) ' �, - 0 L.CHRISTOPHER SIEVERS, BY ELECTRONIC SIGNATURE ' .--' �` FD09000039 70 Cause Of Death (See Instruction And Examples) , App�p�p T LL 28.Part I.Enter The Chan Of Events -Diseases.trjaes,Or Canpecatmi-That Deadly Caused The Dealt Do Not Enter Tainted Events - btevat Onset 71• Sudr As Cardiac Arrest,Respratory hest.Or Ventricular Ftmllalni Weiout Showing The Etiology.Do Not Abbreviate.Enter Orly One Cause On , = i >To Death _ 'D - A Line Add Addboal Ines t Nernerl ), •' v. CD • Immediate Cause(Foal Disease Or Cmaaidn Resting In Death) ,' A METASTATIC SMALL BOWEL ADENOCARCINOMA - 1 YEAR - Q . -- b.aPw.mTe© 1. ) • Sequentially List Ca tens, U My,Leading To The Case Listed On B. MALIGNANT ASCrTES 1 3 MONRHS P Lne A Eider The(Iitleys9 Curse(Dsease a trpay Teat hMaled p.ep w.r�apas f . r� ) 1� The Events Rasullig n Dean)let C. ', r it 0 Pat 0 Eras Odra Significant Gannet Cattnno n Death Si Not Resitting In The Urdey*9 Case Given In Pat l = - 29.Wa An Autopsy Performed? , � _ N � .❑Yes A®NO �. - . SI.N9r0 Autopsy Fsdiig Available To Complete The Curse p Dean] ,❑Yes ❑No . ), 31. Do Toba ORGAN txn FAILURE 31. Oid Tpba®Ua CatrWeTO D®nV >2.UFemala. 33 Manna Orah � • (C ❑Yes ❑Probably❑No 0 unenown' 0 wnwa e4mo..o. l o.r, lg - rwv=.vale a bosom... 9 Mates❑IHa. ❑Aaadei ❑Paas9levaapWOn �' • r..,m.n.♦ 0 SUOde O Caid Nd Be Deteriorate," -i•I • 34. D a l e a hpay(MadeDyfeat 3 5.lane of beery ,Ire )ea EEG..Decedents HOns.Casmumbn See.Remora*VAOad Area) 37-npry At Vbrki .1 a-' S'n d,' �a ( ` J I I alvsry ••! 38a City Or Tam sEs t $Matra ` 38e.Apt No. ]8d Zip Code rn ry v C r `` t (.14, s A °vim' may-y..f•0...-.7.....4,_-.-*•;--;' � rt'� , - �,L' q pa..b::, Oe.�w pwan.i.pc...awn L"..I, 0,42"‘"t t D'Pli °Pei C2N COUNT` 1 ' • 42 Certae,(Check OtyOne) 91 ge� '- I N E $1jL.EE� ieao rSIGN RE ®calryrt9�m 1 ❑I:aane ❑Healeante ,g 1 ]w- v Lys LAOa a OmT K license Mager 45 Dole Caked `L >;EkRPW %HIRPENSTEEL'' :1. NORTH FIRST STREET-VINCENNES IN 47591 ( ' 01025674A 07/16/2014 - '� Prtva Se mPov 47 'Ala'. P IV 46 .'.- ti L.n 'M.qc�A' ;., *i " ; , 49. FmRa err Qtly`Date Fb0(MadivyrYea). _ )" (E RALP' r!iLily, </IA.ELECT:•NIC SIGNATURE - - - JUL 18 2014' ( . sr . . AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) ) L 4A 07)17RDI4 ,e 25e-Maths:BURIAL I �� < Gib- oar- q =:03a- 000�D - plq >A 1'.L State Fain 53395 ATTENTION ESTATE The Sacral Sporty D s bang requested by this slate agency in ceder to pursue responsibility..Disclosure is voluntary and then will be no penalty la refusal.' b' ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT y WARNING TURNS FROM ORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUMENT HAS A HIDDEN VOID ON FRONT THAT APPEARS WHEN PHOTOCOPIED. - ✓ -+tsv Ali^,•- .5-2-nri��-vcl'`rr"d1-v '`r -v- _ • L , _ L . cti;'1JJ'`,-ltd .�..J.:'r ti!_;Jr`"r�v j '7- =�j':'rT 1