Death Certificate - Bazer, Regina E_4/17/2018 �' '.• - �m ���T^ . ;,...:1-INDIANA STATE.DEPARTMENT OF HEALTH_�. __. _ _. s. .. .�,_.�. 2,
CERTIFICATE OF DEATH „
.r' .Local No 000097 EDR No 000000639415 State No 019577-:1.
1.(dcaderts Legal Name(Fit,Middle.Last) Ia. Maiden Name(If female) 2.Sex 3. Time Of Death '' t.•Data a Death(Mcntuvaytyear)
II! r.,';
REGINA ETHEL BAZER MIGHT FEMALE 04:37 AM 04/17/2018
10.11 Death Owned In A Haspdat TOai If Death Occurred Somewhere Dar Then A Hospital 4-• t•
• tc,-4
pHospim Fealty 0 Decedents Home ❑Nursing HarcAnpeerm Can FaaSry
❑Yes 10 No ❑Unknown ❑Iryedrt ❑Ema9eq'Department Oitpadent El Mmfvdl. ❑Other(may) ,.it' i
11.Faulty Name(If Not!autumn,Give Sava and Number)
811 SOUTH PRINCE STREET "'jam, . -it '•'F'`r , .. •
12.Cary Or Town Stae,And La Cad J .r ' 13. Cony Of Death..,!. 14. Manta Stand At Tome Of Death
I ,•(nl j'p.' 0 Marred❑Manned.BO Separated.❑,Divmred
PRINCETON,IN,47670 ' • GIBBON r ❑Weaved ❑New Warned;`❑Unknown
15. SuvMng Spade's Name 15a.Last Name Before Ent Manage 16. Decedents Usual Ocdnaton •!-. 17. Kaid Of arsi esNm,aiy
•
MICHAEL BAZER .4-" CNA 1 e:• HEALTHCARE
18.Residene-Stab 18a.Carey p 16*.City Or Tom
INDIANA GIBBON • PRINCETON •.1
18c.Street And Number -`. 1.. led_Apt No. 18a. lip Cod 1e1:trans Coy Lines?
811 SOUTH PRINCE STREET �,`'.�t'''t, ' 47670 y"®Yes ❑No
19.Decedents Edumaon - 20. Decedent a Hispanic Ongn t c ;.• 21. Decedents Race I
HIGH SCHOOL GRADUATE OR GED ' ' ' ^,i -
COMPLETED NOT HISPANIC White _ r
22.Parents Nene(Fast Midme,Last) '. a 23.Paints Name(Fast Milk.Las) t';,i• 23a.Paints Last Name Been Fret Manage
1 ` al i.. ff,
DAVID ROBERT MIGHT SR . RUTH JEAN SHELDON MILLER .
24.Irt marts Name ,, 24a.Raab:nags To Decedent - 24t.Main;Address(S_a es And Matte,City.State,Zip Code) ..•`•
1•Tfi
MICHAEL GAZER _ HUSBAND 811 SOUTHFPRINCE STREET, PRINCETON, IN 47670 I.,c•A
n'S •, . 25.Race a Disoddaan - -
25a.Method aGSposxn 258.Race Oisposian'Names Cemaay.Cnnnxry.Ott et Race) 25c.Larsen-Cary.Tan,Ant Starts- .� 7 -- -
❑Burial,®',Crtmaion ❑Dnatcn❑Entombment k1
t
-0,.`--ST---p Removal From State .cF-4 i:_ ' •
3 F •❑ome<(SeeoMN: EVANSVILLE'CREMATORY. - EVANSVILLE, IN;it-::.•1."••'
• I '
26.Was Coroner Contacted? 27:Name And Complete Address 01 Fderel Fecitty
h 27a. Fulani'Hor ne e.License Nunbd
° :( - v-
ll
®Yes ❑No .; COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH8300567.1-,,u
2715. Signets,01'Mad Fier Service Licensee: 27c License Number(a Licensee): t 1'•MARK R.WALTER, BY ELECTRONIC SIGNATURE :'•t.. i'• 41 i FD01013010..1. ) ,
+Cause Of Death (See Instructlona And Examples) •y • '
28:P. .. 1 - us- s4C ' triunes.Or COm Terminal •.. 3- Approvanate
p&alions-lip .g The Caused The Deem. re Not Ertel lOn Cause To Interval:t Onset
SW1 As i R- ss"� . Vermhnaa FbrTatm VnYJnan Showing The Etiology.Do Not Abbreviate.Ertel Only One Catve On '• A•c- To Death ALre. iL I e a.' .{tat
Immediate Cause(Foal Disease Or Condition Resitting In Death)'"ti•' A RESPIRATORY FAILURE r .-t 41: MINUTES
.- onto sac _e_- O _
SequenaIy LAPoRladv7B 2rg 118adi g To The Clue Listed On B. CHRONIC OBSTRUCTIVE PULMONARY DISEASE • - t
Line A Enter The Underlying Case(Disease Or Injury That Initiated r5'x w.roae��os
The Events Resuti,gnDeam)Lail'6- C , •t i• " -+1 ,(=-•
W e N a Canseq eOG
e.t Lnlrn2
Pat I �aaala Iry are Not Resulting In The Underlying Cause Given In Pan I 29. Was M Autopsy Performed? H'--
1i.•,w�. .al v ❑Yes 0 No
30. Were Autopsy FsEVq Avaiabk To Campine The Cause Of Death?
RECURRENT PNEUMONIA ❑Yes ❑No
31.Did Tobacco Use Gmmboa To Death?.:r..' 32. If Female: }. -Tin'. 33. Mama a Elea.'M1 •. t\..S' •
•i i• 0 w,nw.+wM no v.. ❑Nw..M m'-acwe ❑ 1e N.ese:ei 11,,•.ves view a ce.as-e 0 Natml Hassid
❑Yes 0 Probably❑No ❑,UlWew'n ❑ ❑Accident ❑Pa,brng M'asagaaan
.I •b ' ❑w lrw.M1 m rrwas 4 on T.n few Moen ❑tab..•rintavan,n.Pad Y.' ❑Sande❑Cored NO Be Daermakd .",'1;':l"
34. Dab 011/Wry(MondYDaytYear) ' - 35.Tine Cr Injury ( 38. Pace Of Injury(E.G.Decedents Hans,Cansttnion Site,Restavat,Wooded Arm) 37.'Irytry At Wan?
:I. !): A:- .¢.1.'i __d
..' `❑'Yen ❑No
33 Laation Of Injury-Stab - 38e City Or Teen 380. Sava b Number .:'. f 38c. Apt No. 384.Zip Cod
39. Describe How'read Occurred 3;.'.,. m. a rransportaticnee , y
41. Sgenve,Of Person Cdvyng Cause Of Death: - - 42.CertSer(Check Only One) •- )-
MISTY G..HOKE , BY ELECTRONIC SIGNATURE .•rt.,' _ ❑uttering Ptysidan ta Carver ❑HaaNOSUr
43.Nave,Address And by Cod Of Person Cet tyiig Cave a Death Ri 44. License Mende 45. Date Canted
MISTY G.•HOKE ,203 S. PRINCE ST.,PRINCETON;IN 47670 L •- 04/17/2018
'48.Addaa'antra Savior Provider. ;c• 1 \. 1 - �47.'•Akas:
Lu•
48.Sigeare of Lod Heath 0.YS. : '•y._ 49. For Registrar Only Dab Feed Ptonm•Daylea):
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE APR 18 2018 ..t 1•`•
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) .
g -goo . s �9 oar $
-ioa i = ,
State Form 53395 ATTENTION ESTATE:Tte Social Seamly a is be4•S requested by this state agency in order to pursue respomblly. Disclosure is'voMiary and'ten w171 be no penny for refossL j.
WARNING: TIR lS ROOM ORANGE TO MULTICOLORED
RUBBED. RIG NO ONSPECIAL T HAGS ASECURITY EN VOID ON FRONT THAT APPEARS WHEN HOTOCOPIEDµ.EOyBACK THAT