Death Certificate - Decker, John Pascel_10/29/2018 .1. _,...,. is .r•�_ .�)...4-z_i i. e'i.t� 1 . .. . . °. °. . .7 it".in n'..(Fe .r. �) �..✓ C) St,lJ:�_
4�a INDIANA STATE DEPARTMENT OF HEALTH
flC i CERTIFICATE OF DEATH ' ,
•
No EDR No 000000670958 State No 051035 'i
is � Local 002125 3. Time Of Dear 4. Date Of Dear(Month/Day/Year) - - �
J:Decedent's Legal Name(Ent Middle,Last) , - Ia. Maiden Name(II female) 2.Sex
/ JOHN PASCEL DECKER ' MALE ' 21:16 10/16/2018 1
ri
10.1f Dear Oa Bred In A Hospital \ lea.'a Dear O jnad Sanev here Omer That A Hospital `v/
Hospie Fatly ❑Decedents Home ❑Nurses;Hone)Laglenn Care Fa ity
04.7 Yes ®No .❑Unknown 0 Impabet❑Emergency Depertmem OutptSa"' ❑Dead onAmv l 0 Otter(Specify)
11.Fealty Name(If Not Insttnat,Give Street and Numbed .l-e
ST=VINCENT-EVANSVILLE ` J
12 Cry Or Town Star An Zp Code 13.Canty Of Dear u. Man1al51aou At Tree Of Gear r
0 Man n Married❑Mauled,But m Sepated ❑paced+
q. EVANSVILLE IN 47750 VANDERBURGH 1. ❑Weed ❑Never Marred ❑Unuman
15.Stamina Spouse's Name 15a.last Name Before Fin Manage 16. Decedents Usual Ooapeodil 17. lend CI WsnessAndtalry '�_ l)
M ROCHELLE JUNE DECKER . STONE ' DIESEL MECHANIC • COAL MINE )a
//� lab.'G Or Town P
18 Residence Slav teaJCeuny,` y
'1��1r INDIANA GIBSON PRINCETON - - .
N• 18c,Street And Number. 180. Apt No. 18e.Zip Code 181 Inside City lens? '1
'C Oy .r'. ❑Yes 0 No-- e
1042 WEST 400 ROAD SOUTH - 47670
19. Decedents Eduraoan 20.Decedent Of Hispanic Onpn 21. Decedents Race ",r
yy� HIGH SCHOOL GRADUATE OR GED -
l'r COMPLETED NOT HISPANIC . White
22 Parents Name(First,Middle,Iasi, - 2,3.Parents Name(Feat Middle,last) 23a.Parents Last Name Betas Fen Mamage )/
'r JESSE WILLARD DECKER - LUCY LENORA DECKER MIDKIF � rl
O 24.4b'atnats Name 24a.Ralelivutap To Decedent 24b.Mang Address(Street AM Number,City.State,Zip Code) '
Q ROCHELLE JUNE DECKER " WIFE - 1042 WEST 400 ROAD SOUTH PRINCETON IN 47670 a
CC 25a.Metre Of Dispovm 250-Place Of Gseasibon(Name 01 Cemetery,Cremezxy.Other Place) 25c Loratat-City.Town.And State
W 0 9uw ❑Cremators ❑Daaatton❑ErdantC n CC ,
❑Removal From Slate
O 0 Other(specs): FAIRVEIW CHURCH CEMETERY J PRINCETON, IN r -
O 28-Was Corona Contacted? 27.Name AM Complete Address Of Funeral Facility 27a. Frnaal Home Lrense Number. s
Ui
CC ❑Yes 0 No DOYLE FUNERAL HOME, 520 S MAIN ST PRINCETON 'IN 47670 FH10400010"
J .
2?b.Signature 01 Indiana Funeral Service lxensee:..-� 27c License Number(Of Licensee): 0
a BARRETT W. DOYLE BY ELECTRONIC SIGNATURE FD29500009 -
LL Cause Of Death (See Instructions And Examples) Approximate
28:Part I Enter The Chan 01 Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events ' Melva,'Onset r
CI Sur As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrieafion VAUwl Showing The Etldogy.Do Not Abbreviate.Enter Ormy One Cause On To Death'A line. Add Additional
s If Necessary. I
a f"
7 bnmedate Cause(Final Disease Or Conitian ResdtBg In Death) A. CROHNS DISEASE WITH BOWEL OBSTRUCTION LONG STANDING
amaiaa,*ca..a.004
d Lead' To The Cause Listed On B- RESPIRATORY FAILURE AND CARDIAC ARREST SUDDEN ONSET 'e!
• Sequelta%List Conditions, Any,Leading Nato a,.wew are.
l�( use A. Enter The Underlying Case(Disease Or Injury That Wta �
ted )
The Events Resuen;In Death)last - C. SEPSIS
us N SUDDEN ONSET ,1
aeaiN.e.e.-aim ' D%
•�- Pat U.Eno Ora Sirnt5cat Cavuin,CIXRnb..o to Death But Not Restitng n The Urdel)g Cause Given In Part I 29.Was An Aunpsy Performed? ❑Yes ®No
.75
•r 30.Were Ateorey Friona Avaiable To Complete The Cause Of Death? (]Yes No:,..
NONE , )/
/`s 31:P 'O Tobacco Use Connate To Dear? . 32.If Ferrule \ - 33. Mama 01 Dent
M+: '❑Yes 0 PrMady®No 0 Unknown
(� 0 noP tit rye., 0 nvam.s,rwea ors 0 wPgae.Pnow wire mi. reipmao o 0 Natural 0 Hadde 0 Accident ❑Paidxglmestgaton 9.t
`y 34.Da Cf ❑wnyw at n.ew re Ti.o o I rs ruse No 0 Wm.,a n.i.s.urn ln.P re, ❑Suicide 0 Card Not Be Detemened - )
el
Ora Injury(MonfvDayfVeeil 15-Time Of Injury 38. Place Of Inery(E.G.:Decedents Hone,Costncv tt Site,Restaurant Wooded Area) 37. bitty At Work!
_ _ ❑Yes- ❑No 65
' 38'Lomilon Of!miry-Stab 38a. City Or Town 38b. Street A Nanber 19c Apt.No. 380 ZetCode )
GC
.
t 39 Desanbe How injury Occurred t .. 40. II Tramponauon Iryvy,,<�rro-n-7
❑ane.N`eew Or....... 0 Madan Doe I5c ,I -
- A
Pr -41.Sguase,Of Penn Cendysg Cause Of Death - - 42.CeitSer(Check pNy One) - j�i
KARL WAYNE SASH BY ELECTRONIC SIGNATURE . GI Certifying ysid
ig Pten ❑Corona m❑Hira Ottcen " ,�
• 43.Name,Address AM bp Code p Person Certfyag Cause Of Death 44. License terser t 45. Date Carded D,-.
? KARL WAYNE SASH 3801 BELLEMEADE AVENUE.SUITE'200E a -1,I.! 1J - 01050566A 10/18/2018
biz 48 Adldo al Faecal Saaiu PTwEer. 1 I art ) t l 47. Alas
all
l r 48.Signature of Local Heath°Seer For Registrar Only -Dora Fled(MontVDay/YeaT '94
G< ROBERT KENNETH SPEAR VIA ELECTRONIC SIGNATURE : . - _ OCT 19 2018 c>
r e( ill tit. i
I -a,th.- 11-30 -I DO .- Ior �-1y3 agy:iti n s
tit>State Form 53395 ATTENTION ESTATE:The Social Senility#is being requested by this state agency in ode to pursue espcin;bility7 a isclosure is voluntary and there wd8 be no pearly for refusal: i t.
WARNING. TURNS FROORIGINAL M ORANGE TO YELLOW WHEEN RUBBED.ORIIMENT HAS A MULTICOLORED GND ON SPECIAL GNA DOCUMENT HAS ASECURITY PAPER AND THE GREAT HIDDE VOID ON FRONT THATAPPEARS OF WH WHENTHE
STATE OF PHOTOCOPIEDINDIANA ONBACK THAT �+
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