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Death Certificate - Johanningsmeier, William R_11/13/2018 • • f7�P@ . r41.1, . -�i'- - ,; ! . 1 0 a it -&3) ' t1 ,"',iZ 4 it Ai'A. ' — '„, > i < INDIANA-STATE DEPA TMENT OF HEALTH . i , „-.. i.�. e 5 4 e - CERTIFICATE OF DEATH ` t , - • ) l ` .'‘Lo.6a1.No 001:2'72 ,, a";I . `EDR"No 0000004"53680. - stale No'028573, \` , 1 $$�� I t rarnOn(s Legal Name(Eisi AdWB Last),,,,,,,-,ii / is Maiden Name(II temal) ..2 Se .3 Jima Ol Death...,.‘, a Date Of Death(Mwrtiv fsDaylYea - Ti'J! 1W. WILLIAM R JOHANNINGSMEIER' -' l {.. 3 r.- S ^' . t `- MALE " 10 15,PM z /406/11/2015 r, tu - - '57 Mwws1 - Data .,.' xoa, Mean - ':, �/ t �I .ti •W \ .•'"."< `> ®Hospice Faelry El DecedentsH ❑;Nuraing Hamehmg"Iemr Care FaciGry Z, 1' ❑Yes ©No ❑Unknown), 0 lnpatent.O Ennage cy Depadm t oaaneb'.❑Dead nnnivel ❑os-er( ty) /,/_,. � ▪ :it.Faraty Name gl Not IlonaNcn Give So-eat and Numb y 4, •1 . e DEACONESS VNA PLUS-HOME CARE&,HOSPICE 3 • .. &, 12.City or5aesl State And Zip Cade i • . i i • . 13.County Of Death / 14. Marital Stabs At Tune GI Death 5 : . . / 1 ,: ,- .' -' „,. _ r - Mamee❑'M,Med.e�i Separa ed ❑oNorcad - " EVANSVILLE; IN,47713 , `'' .. VANDERBURGH'<:. ` - O 1AL?lkva? 0 NewrMamed .❑;udw;axn - J @ .15.Sumclo Spouses Name'` Wt-.15a..of e)Give Malden Lot Name's -16. Decedent's Usual Oodupatai. f 17. d oe eusnessNtltasy T ., 1 v s> ♦ + s1 MARCINJOHANNINGSMEIER e • . TERWISKE f _ ' ' EQUIPMENT OPERATOR", COAL MINING 7 18 Resdeee Sla ._ �.,. ^.185'CauntY lab t+tY OrT -> sS�: ✓' i "i ' Jf iBc.steetAndNumber s ` i - ! 184.-.ApttNo:- tee. ZJPCode ' 18f>4eide CUytircli 9962 SOUTH MISTY LANE ; # ; ' ❑Yes p"No G19,Decedents Educates 20. Decedent 01 Heparec pig - '21. Decedents Race <, ." A fi HIGH"SCHOOL GRADUATEOR.GED , _--` „- - e . . t '. gi COMPLETED - e. NOT HISPANIC. ' White - . + et' •-. ' r / -, -] 22Patters Name(Frst.Midge,Last) _- -' 4 23 Mot6es's None(Firs,Mbdie,Last) ,23a.Mothers Maiden Last flame •Y - .Ai S JOHN ANTHONY JOHANNINGSMEIER S ELSIE EISENHUT. SAMPSON ; �24.L emir rs Name' +� ,Ne Retatimsnp Ta Decedent -. 246.Miring P4tlress IsbeelAnd Nanber Coy Stale;2m Cade) -`+ -• 4' ` MARSHA'JOHANNINGSMEIER WIFE ''-- - 9962 SOUTH MISTY LANE HAUBSTADT, IN 47639- < _ - c s . -'♦ `. x •.2s Place a Drzpaze.n ; - ",, ',. s '� ` . s . ' , -25a Medad Of i pos t - ,` 25b Ram 01 Dispostwn(Name OI Cemetery.Cremapn,Other.flace) 25c,Lo etas City,Town,And State > z ' ' 0 0&anal ❑Cr maim 0 Donator 0 Eneanbmern - : ' ❑Renoval Ran Sta e ] ` w \ :- y t� m O'Ome'(Speoty) . ' .� STS PETER AND-PAUL CEMETERY , ; HAUBSTADT, IN • . D 26 Was Caroler Cantadedi, Z 2] Nameere Camplete Address Of Funeral Faulty . , - a > - 27a.Funeral Home Cense Number'-^ -4 - 'a 3 •,,,, , ."/ i] x .,`' . .. -s m ❑Yes ❑�No- WADE FUNERAL HOME'INC,"119 S:VINE STREET, HAUBSTADT,-IN 47639 : t . • FH83002990 i m 27b.'\tigtatne Of Dana Fingal Serviceucensee > s . - • 27c. license Number(01 Licensee) S : 0 ALAN Ji WADE -BY'ELECTRONIC SIGNATURE - <- FD01017080 .> . . O w - - w .! .Cause Ol Death (See Instructions And Examples), � Appoxunaa '' 28 Pan L ardta The Chair sp F en(e Diseases Irytaree tbnCattcei thou That ig The Caused The At Do Noe Enter Termnal Events �? � ry mtervar-erect 'm Stich les As Add Afrest,l Li RespeatcesArrest Or.Ventr-,i Fi0ri8ahm WAUroul Shown. Tire's, --. y Do Not Abbreviate Fitter Orly-One Cause On. ,-S/ r.: ' -,. Death? i, A Lne Add AddbnalL _ 'i Z Necessary.-. . g AAA--- i I rimedate Cause(Foul Disease Of Condition ResWtbg In Death) A •GLIOBLASTOMA OF THE BRAIN - - - N ,. nth/ NOV 13 2018 ;> v +Sequetaiagy List Corid'dtns,:If Arty,Leadig:To The Cause Listad On 5 B paw to 4.' ' m: _ .V/ Lgre A Enter The Underyag Cause(Disease Or Was Thal tiutu ad. 1. The Elients-Resulti g in Deals)Last g ce ` /l� _ p -<•y f 1 % 1 4 Da corm*tm.eeth •r(iln.IV,ss�P, 1 ` . : L x D, ‘ - A1fib'ON COUc ( 's Ij Pang Era Ddta SkvdfKannCond vm Cata4 to Deaf D Not ftespWg In Tire Unday+q C Grea Ln Pant ! - 29 W2 M Aubp y Pefla d_l ' : ._ ❑Yes ❑' Ne ..� < �'. ''-i - s_. t. a�^i ! \ N<.. 30 Woe Autopsy Finding Avadrle To Compere The Case OI Deathi \ �}i '• ❑Yes ❑,No .{ 31 Dig Ithaca,U Contnbade To Death? ' 32'I Female: > 1 33: memo Of Dean,e9l c - ,' • Y C ❑wrr. wvcnrmr ❑'444:a eo,m ❑ vr.aam-m�,P:.e We"u wnao.m ❑NaWral❑Hmnode:❑Accdem' 0 PaGgkrvesyaoon .a ❑ 0. Pbady©No ❑UnkvL Po ,; S , ❑m.;4v ..un.P,w...„ .,;4,..r.ex ' ❑ 4.�aan�ta. .r..s.x y ❑.Stiaddacdrid Nonce Oeu,Thsd 1 34. Date OfIryta mds y(M 'DayWear) -35.Tree 01 Injury ; --. a 38. Place lrgay(EG,Decedents Home:Ceaaudien Site Resulraµ Wooded-Area) 37.-IrasaYA1Wbnti, , ' 38 Location Of Injury'Ste . 38a City Dr Town 36b. Street&Ntmbe i. •,384 Ap.No 38d Zip Code it 39.Desrnce Hex IRrvy Oxwred i :.../ ., ., ,,.. goy a innspprudm GjaY' ' ,I a1 .5ipatae.i OLPesm Cettryeg Causeoe Death,' - . . d2 Ceotser:(CnxkOwQse),_ < st JULIE"K.GERHARDT:, BY'ELECTRONIC'SIGNATURE`; te s - "-_©Ca-f gPsysidan, :tO cuaoer q 0 H atboeicer J 43 Name Address And lip Cope 01 Pena,Certifying Cease OI Dead 44 License Nara ;45 Date Cemsed i s - .. . , • 1 JULIE K.,GERHARDT',600 MARY ST.,-EVANSVILL'E,-IN 47-713 :".---,-et.`I. ---; ': 01057271A: : +-06/15/2015 4fi AWLimal Funeral Service Pm+hr' '. -- .,. - ^.a]. Aka-. - �- 48 Sigature:glo !Heapt9t8tet r `), , L > , , , e' ,: ? . -49..F ReglstnroNY gated(M gYDayyyear)c^� : ROBERT KENNETH:SPEAR,AVIA ELECTRONICISIGNATURE z 1. 'JUN 16 201I5% j . : i - : [AMENDTAENT TO CERTIRCATE OF DEATH(ENTRY,OR ORIGINAL) 7t A(° 41` a.1� aoD OD 2e 311- oa4 c . £ , yl ! i .i 1 F • Stir eF 533e5 ATTENTLON EST TE*The SoWI a isbe ested Ws state a e yyrm- A sgar)y mgtequ W e ma,order m prove reaponsmibty-.DlsSbwre H vgluntarJt etid it,ere wsYl be ti4pe4alry for refusal �y =.,:WARNING•�,ORIGINAL•OOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER'AND THE GREAT SEAL Of TL4E STATEQF'NDIANA ON BACK THAT>"' `Q . TURNSFROM„ORANGE.TOYELLOW!'YMENHUBBEDL0RIGINAL DOCUMENT.HAS HIDDEN VOID ONFRONyTHAT.APPEARS WHF"N.PHOTOr'.hPIFnv' f Ns