Death_Certificate Marsch THIS IS ANiOFFICIALCOPY OFRECORD OF DEATH:ORIGINAL-COPY:ON FILE•ATIINDIANAISTATEiDEPARTMENTJOFHEALTH -
.s nt INDIANA STATE DEPARTMENT OF HEALTH 1088256
-4:_.:.
:_ .f. CERTIFICATE OF DEATH
3' Local No 000247 EDR No 000000679368 State No 059057-
I.Decedent's Legal Name(Fin,Middle.Last) la. Maiden Name (It female) 2.Sex 3. Tune Of Death 4. Des Of Death(Mardi/Day/Year)
EUGENE HEAVRIN MARSCH MALE 08:37 AM 12/02/2018
Hospital
0 Hospice Faoity ®Decedents Horne 0 Numbs;Hanaltng-temh Care Facility "
®Yes 0 No 0 Unknown 0 Inpatent 0 Emergency Department Ouyatem 0 Dead on Arrival 0 Other(specify)
11. Fact/Name(If Not lnsttnon.Give Street and Number)
401 CRESTVIEW DRIVE
12. Ccy Or Twit Stab,And bp Code 13.Canty Of Death 14.Mantel Status At T.Of Dealt
G Married0 Mamed.But Sepadted 0 Dirorred
OWENSVILLE, IN,47665 GIBSON • ' owed 0 Never Manned 0 Unnnan
15. Surviving Spouse's Name 15a.Last Name Before First Marriage 18. Decedents Usual.• 17. Kind Of Bhuvtssardhaty
LAURA MARSCH COX QUALITY C • h I MANUFACTURING
18. Residence-State 18a. County 180. City Or Town
INDIANA GIBSON OWENSVILLE ,70
18c Street And Number lad. Apt 18e. Zip •• 181.Inside City this?
401 CRESTVIEW DRIVE ,P �s,6`c 0' rigYes 0 No
19. Decedents Ecuraon 20. Decedent Of Hispanic Ongn 21. Decedents Race . 4$ Pv
9TH- 12TH GRADE; NO DIPLOMA NOT HISPANIC White ,• Ov3
22.Parents Name(Fist Middle,Last) 23_Parents Name(Flit,Middle.laser O_\Ci 23a.Parents Last Name BeforeF t Manage
CHARLES BURKE MARSCH - MYRTLE ABB MARSCH 6' \_ CHAPPELL
24.Imomants Name 24a.Rdeao atip To Decedent ' 240.Maeng Address(Street And Number.City.State.Zip Code)
LAURA MARSCH WIFE 401 CRESTVIEW DRIVE,OWENSVILLE,IN 47665
25.Place Of Disp ositon
25a.Metiat Of Dispostton 250.Race Of Dispcaibn(Name Of Cemetery.Crematory.Other Race) 25c.Location-Cry,Town,And State
0 Burial 0 Cranston 0 Drawn 0 Ereamcmem
❑Removal Fran State
❑Other(Specify): HOLY CROSS CEMETERY FORT BRANCH, IN
26.Was Coroner Gemmed? 27.Name And Complete Address Of Funeral Facility 27a Funeral Horne License Marten
❑Yes ®No HOLDERS FUNERAL HOME,319 SOUTH MAIN STREET,OWENSVILLE, IN 47665 FH11700008
27b. Signature Of In6ua Funeal Service Licensee: 27c. License Number(Of Licensee):
BRANDI MACER, BY ELECTRONIC SIGNATURE FD21400065
Cause Of Death (See Instructions And Examples) Approxmate
28.Part I.Enter The Chain Of Events -Diseases,Ire.tries.es,Or Canphcatiors-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset
Such As Cardiac Arrest,Respiratory Arrest,Or Ventrnyar Fibrillation WWt ceit Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Add:eonal Lines If Necessary.
-
Immediate Cause(Final Disease Or Condition Rear/Ling In Death) A MULTIPLE LUNG MASSES ON IMAGING CONSISTENT WITH METASTATIC LUNG CANCER
we a la w.rwn vCA
Sequereially List Cendaions, If Any,Leading To The Cause Listed On B- ----
Line A Enter The U.fal7:y Cause(Disease Or'nary That Initiated
aw mla...4aoar
The Events Resulting In berth)Last• C.
Lb aid w.cfle.m at'
I D.
' Pal IL Enter Otter Sewfa;atradrxns Cmmnburno to Death But Not Resultrg Li The Urtlalyvng Cause Given In Pan I 29.Was An Auopsy Performed? 0 Yes 0 No
30.axe Attopsy Faxing Available To Complete The Cause Of Dean? 0 Yes 0 No
31. Did Tobacco Use Cambia&To Death? 32. If Female. 33. Manner Of Dean
0 N ;mein° in Ate Psv... 0 n.>.r w m..a o..a a 0 e Pw err.a pes eu w.g�e woe re o.a 0 Neural 0 Homicide 0 Accident 0 Pasting hwestigatut o
0 Yes ❑ Probably El No 0 Unkmmh
0 ea Pnrae e4 PtP.e a Car ra l ton eta..air 0 UnictmntrPinuillvan he en, ❑Sddde 0 Cold Not Be Determined
34. Dab Of Injury(Mai/Coy/Year) 35.Time Of Injury 36. Place Of lnjuy(E.G.,Decedents Home.Consauton Site,Restaurant,Wooded Area) 37.Irjhay Al Work?
❑Yes ❑No
38. Locabon Of lriuy-Sato 38a. City Or Town 38b. Sweet 8 Number 39c. Apt_No. 3ed. Zip Cade
39. Describe Hoe lt*ay Oared a. It TraispatY.an lryay, lY.
l 1 ") 0ow.ai}..v D'.n auyn Oar R:+W1
41.Signature.Of Penal Cettfyvig Cause Of Dealt '.l ' 42. Getter(Check Only One)
JULIE K. GERHARDT•, BY ELECTRONIC SIGNATURE 0 Cerfying Physician ❑Coroner 0 Hen)Cesar
43. Name.Address And Zip Code Of Person Cen yvq Came Of Death: 44. License Number 45.Da*Certified
l
\ JULIE K. GERHARDT 600 MARY.ST.;EVANSVILLE, IN 47713 01057271A 12/03/2018
46. Addtonal Funeral Swat'Provider t �I 47. 'Alm:„' i) Lr r \
4.3 S entalre of Local Hap OISwr. 49. For Registrar Only -Dab Fled (Monntayflea):
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE DEC 04 2018
• •<I AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
•
(.' O
$rote Fan 53395\ATTENTION ESTATE:The Social Security#is being requested by this state agency in order to pursue respmsibl5ty Disclosure is voluntary and there will be no penalty fa reftaaL
h- , IVRA-20
t[. _-.:j (1105)� . - "- ,- �-'-. . _' -..-.V., .ES�