Death Certificate_Thompson w...r..e., tv<r<i._„� .e. :ien.r.�.-r, - :• • {. it' ..n.h�.ii�-.. .i� a.T- �..ilTi,�
ma '13 INDIANA STATE DEPARTMENT OF HEALTH
� CERTIFICATE)OFDEATH
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''' Local No 000141 EDR No 000000571537 State No 01871.23_ ` \-____i
1.Decedents Legal Name(Fast.Middle.Last)
la. Maiden Name Of female) 2.Sex 3. Time Ol Death V 4.Date Of Death(MurJVDaynear)
v- :3
JOE THOMPSON " '. y :MALE 08:49 PM
04/07/2017
10.II Grath Oosred In Hospital: t0a. If Death Occurred SameAhere Other Than A Hosal "�
r ' }+ ❑Ibzpira Faatty ❑peudmi's Hvre ❑Horsing Hor JLatptem Care Fealty Yes 0 No..0 Unluwn 0 Inpatient 0 Emergency Depanmem Oipa'4ert 0 Dead on A uv i'. 0 Other(Specify) s"
r4,N is
11. Fealty Name(If Not tiusY.on,Give Street and NumGQ
GOOD SAMARITAN HOSPITA t• w � ...cc.
` >..'"
12.CMQTPAn Stew,And lip Cede y 13 corn Of Death ts"y 14 Ma WSta•4a At TyreaDeaVu S
VINCENNES, IN,47591 ` " I Y �'d ( 0 Married0 Marred,Edsepaaed'p Diverted:
I CENNES,I ,4e .•z', " KNOX :5.,, , ❑Wdowed ❑Never Mamed:�p Unknown
15a.Last Name Before First&teeng 16. Decedents Usual Oon aaias ,r4 17. Kind Of BusinnessaMusby
SEP 182018 ,A .;:
ELIZABETH THOMPSON STERCZER TRUCK DRIVER . FOOD
f8.'Residerce-Sate bl
1. �j 18a.Coumy % :y i8b. CiyQTam '`�a11er,...•a
INDIANA XI6�EG1855, 'i.*'.. " FRANCISCO
18c Street And Number ' '...
sG113SOP1 COU�I?Y ALIDITOR ed AptNo ere Zip Code sI:lmoepy :v
6296 EAST 500 NORTH'.4 {is t,p ! p,ves p No
19:.Decmays Edueabm \. . 20. Decedent Of Q7649 '
Hlspauc Ongn _ 21. Decedents Race.. HIGH SCHOOL GRADUATE OR GED " •`-`4 ';•j"
ty COMPLETED NOT HISPANIC White .VA.- 5
22.Parents Name(First Mi ege,Last) 23.Parents Name(First.Wide,Last) 1,,,...-.' 23a.Parent's Last Name Before Fist Marriage
ELDEN THOMPSON - MARJORIE THOMPSON ' `P. DAWSON ,:a?1
24,Informant's Name c I 24a.Retationshp To Decedent
;4se .
"ul• 25b.Rau Of Disposrbon(Name Of Cemetery,Cremaay,Other Race) 25c Loraron-City,Town,And State 0 Baal p'Gemaru p ovation p 6aernemeA r`,•'1r1 t. 4.. --__L3rt.v
p:Remoai From State s t
70
�1�i tea � t�f:
pOdar(SPeriy): MOUNT OLIVE CEMETERY MOUNT OLYMPUS INf"25'.Was Corona Contacted? 7..Name And Complete Address Ol Rneral Faoesy _
'I;I'r:. 27a. Fsnazl Hone License Nutlrs
❑Yes 0No Al .:irt. .1� j 7.
,..-i'. COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 74'1,1I. ��. i 27b Synave Of teams Funeral Service Licensee:
_ 27c FH8300567,1°•1 '
RICHARD DEAN HICKROD• BY ELECTRONIC SIGNATURE (:'-.:'- D 1012153er(ol licensee): +y
- FD01012153•;t . S?s"'
. s' " .r. Cause Of Death (See Instructions And Examples)
1/428 Par,I.Enter The Chain Of Events -Diseases Irm,,es,Or Complicati •11ons':= "'d r'.^I Approximate
Such As Cardiac Arrest,RespiratoryP T•hat Directly Caused The Death.Do Not Enter Terminal Events •, ,t ',....I.:" Interval. Onset
<' A Line. Add Additionalres LinesNece�est.Or VeKrivear Fibrillation'i itlioul`Slwug The Etiology.Do Not Abbreviate.Enter Only One Cause On,r.I
Necessary.
.,l,t To Death
•r''r Lr.
Immediate Cause(Final Disease Or Condulon Rev1Ng In Death) it: A SEVERE SEPTICEMIA V,TTH SEPTIC SHOCK 4wSl
`tt,,t a b.ero...G.,.q: UNKNOWN ./ _I
-rsng to LITHIA � W Y5.
Ent List Undo ns If Arry'Leadrg To The Cause Listed On B. ACUTE CHOLECYSTliI$AND CHOLELITHUf51S UNKNOWT!
Line
A. Enter The Underlying Cause(Disease Or INtrY That Initiated
bass,4•c„wwww dry: _
The E setts ResettingNpeaty)Last'' 'DISEASE
WITH METABOLIC ACIDOSIS AlkUNKNOVVN
•x`{,ni1`. _, As*to a.r oce a�
"-c1:yt�'- .D.'_'ATRIAL FIBRILATION r'• J UNKNOWN
Pori e:Ereer Other Saac5cam Con65ons Ceneb bnd to Death But NOt Reassrg In The Underlying Cause Given In Pat I 29.Was An Autopsy Palannod7.tl�a•"
.�y.. ar Iu`le. p Yes 0 No
DIABETES MELLITUS TYPE II 'i 1(. s 30.Wars Autopsy Finding A`v alade To Compete The Cause rid Death? D Yes. D No
31. Qd Tobacco Use Contribute TO Dear?PP:'. 32. It.Female: •.• 33.Manner Of Death:
p Yea 0 Probity 0 No 0 Unb,oxxn 0 P'm en..ao...n p w^•w!A_eu n•s�rvne•xam aorta Stidde 0 p HgNddF p Accidentp P jg Imes:gabOn
❑rn npu,t eun.#a.aoP.r=,r.,,son.am pax ,, ^:�:: s u vas,ire Paw yaw ❑Studs❑Could Not Be Determined�i};�I}-4'34, Date Of Injury(Mm'Npayfyear).' 35. Tare Of Injury 38. Paces_ s• it., . Injury,( ..Decedents Here,Construction Ste.Restaurant Weeded Area) 37._Ir�ury At Won'?
• s s❑Yes ❑NoL .I 3 Vt3w3B Laaam Oltrnry-Sax 38a. City Or Town ',-',
3e15. Sven S.Number :mi a:} 38c.API No 3e.',. Zip Code
Y
,' h '-.1-I, ' f
39 Describe How Ir*ry Occurred
( 40:It. ceeat ua d,ocn In - say „: S
(.' pb•ew.m OP•swyn UP•e.ew,pm.tsa.nl
41. Sy walu Ol Person Cenfyng Cane Of.Deadc f' \ .Tj(. 1 s'T --1
FELICITAS GATCHALIAN tBY ELECTRONIC SIGNATURE J ® 40Cemt)i (cneptpyQ'e) 'if,„'4L
al. Na're Address And Ip Code a?ersvl c q i t' 0 Cen:Mrg Plsysidan ❑Coroner ❑Resits Orsav
arnfyig Cause 01 Dead:' L :" °at' 44 ticerise ll,w,riter 45. Dore Cn:.5ed
FELICITAS GATCHALIAN ,520 S.7TH ST,VINCENNES;IN 47591 01069188A 04/13/2017
48.Adeaal l Funeral Service Provider. .^,1'ii:. A]. •A}- 'v • .
q A" i h:a ll
48.Signature dLocal Health Meet-. :jF•. •,. P 49. For Registrar Only -Date Feed (MontlVDay/Year):
RALPH JACQMAIN VIA:ELECTRONIC SIGNATURE I )` :1 APR 132017 !'':` T>u
l4•1. AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) 0..3 11
O. at°g- 2,0•
r -000 g ',: ; 13- .
Slate Form 53395 ATTENTION ESTATEf.The Social Severity#is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary and there will be no penalty for refusal';'. •
WARNING. ORIGINel rrl IMENT HA A MULTICOLORED BACKGROUND ON SPECIA WH T E$ECUR Y PAPER AND THE GREAT SEAL OF THE STATE OF IND A in ON fi4CK THAT
M lV lY\.7• TURNS FROM ORANGE TO YELLOW WHFN Dimacn nevauer rw',nrc•�,:.�.s,.,...-.............__".-_.._ "