Death Certificate - Beard Jr, Ray_10/16/2019 eit `"' , INDIANA STATE DEPARTMENT OF HEALTH
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sa, CERTIFICATE OF DEATH
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► i . Local No 000085 EDR No 026107
``' -� 000000712213 state No
1.Decedent's Legal Name(First,Middle,Last) la. Maiden Name(If female) 2.Sex 3. Time Of Death 4. Date Of Death (Month/Day/Year)
i_��i RAY BEARD JR MALE 07:41 AM 05/27/2019
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e : 5. Social Security Number 6a. Age-Yrs 6b. Under 1 Year 6c. Under 1 Month 6d. Under 1 Day 6e. Under 1 Hour 7. Date of Birth (Month/Day/Year) 8.Birthplace (City and State or Foreign Country)
4i j 81 Months Days Hours Minutes
Hospital
❑ Hospice Facility ®Decedents Home ❑Nursing Home/Long-term Care Facility
El Yes El No ❑Unknown 0 Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival ❑other(Specify)
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#` 11. Facility Name(If Not Institution,Give Street and Number)
Lqt`' 301 EAST VINE STREET
if 12. City Or Town,State,And Zip Code 13. County Of Death 14. Marital Status At Time Of Death
ir.•F ❑Married 0 Married,But Separated 0 Divorced
, FORT BRANCH, IN,47648 GIBSON N Wdowed 0 Never Marred 0 Unknown
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15. Surviving Spouse's Name 15a.Last Name Before First Marriage 16. Decedents Usual Occupation 17. Kind Of Business/Industr•
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C ALUMINUM
�,;: I FABRICATOR FABRICATION
' 18. Residence-State 18a. County 18b. City Or Town
INDIANA GIBSON FORT BRANCH
. 18c. Street And Number 18d. Apt No. 18e. Zip Code 18f. Inside City Limits? '
301 EAST VINE STREET 47648 ®Yes ❑No
19. Decedents Education 20. Decedent Of Hispanic Origin 21. Decedents Race
VHIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
i 22.Parents Name(First,Middle,Last) 23.Parents Name(First,Middle,Last) 23a.Parent's Last Name Before First Marriage
RAY BEARD SR GENEVIEVE BEARD JARMULA
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Q 24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address(Street And Number,City,State,Zip Code)
W TRACEY BEARD SON 1225 PARMELY DRIVE, EVANSVILLE, IN 47725
4 25.Place Of Disposition
CC 25a.Method Of Disposition 25b.Place Of Disposition (Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State
LLI ❑Burial ®Cremation 0 Donation 0 Entombment
CC 0 Removal From State
0 0 Other(Specify): WALNUT HILL CEMETERY FORT BRANCH, IN
0 26.Was Coroner Contacted? • 27. Name And Complete Address Of Funeral Facility 27a. Funeral Home License Number
LU
cc ❑Yes ®No STODGHILL FUNERAL HOME INC, 500 E PARK ST HWY 168, FORT BRANCH, IN 47648 FH10900013
W 27b. Signature Of Indiana Funeral Service Licensee. 27c. License Nu
ANDREA LYNN STODGHILL, BY ELECTRONIC SIGNATURE FD2140000 Eileri Q Cause Of Death (See Instructions And Examples) proximate
LL 28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events tterval: Onset
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
CI A Line. Add Additional Lines If Necessary.C Immediate Cause(Final Disease Or Condition Resulting In Death) A. RECTAL CANCER OCT
16 2019 8 MONTHS
Due to(0r A.A Consequence Op-.
Sequentially List Conditions, If Any,Leading To The Cause Listed On B. a»to(or A.A Consequence Of A , . .,.1
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated . ,q
The Events Resulting In Death)Last C. o•to(ormACAn..w.nr.Of GIBSON COU TY
AUDITOR
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Part II.Enter Other Significant Conditions Contributing to Death But Not Resulting In The Underlying Cause Given In Part I
1I 29. Was An Autopsy Performed? ❑Yes ®No
1 1\ 30. Were Autopsy Finding Available To Complete The Cause Of Death? ❑Yes 0 No
31. Did Tobacco Use Contribute To Death?0 Yes ❑Probably®No ❑Unknown 32. If Female: 33. Manner Of Death:
El NotPregnant earn Past Year ❑Prepn•PregnantAtr.or Death Nor Pregnant,an Pr.yn.nt Within 42 Drys of Death El Natural El Homicide 0 Accident 0 Pending Investigation
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Ti❑Nat Pregnant.ButPregnant 43 ay+ra t y..r Before a•Nate ElunMwA„a Pregnant.nt WithinWithinrn.Pastv..r ❑Suicide❑Could Not Be Determined
34. Date Of Injury(Month/Day/Year) 35. me Of Injury 36. Place Of Injury(E.G.,Decedents Home,Construction Site,Restaurant,Wooded Area) 37. Iryury At Work?
❑Yes ❑No
38. Location Of Injury-State1.
38a. City Or Town 38b. Street 8 Number 38c. Apt No. 38d. Zip Code
39. Describe How Injury Occurred 40. If Transportation Injury, ecify:
❑0m.riOp.r.m ❑P•«npw UPWerrl.n ❑o1Mr(sp.cryr
irk 41. Signature, Of Person Certifying Cause Of Death: 42. Certifier (Check Only One)
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EDWARD PATRiCK FOX,BY ELECTRONIC SIGNATURE N Certifying Physician ❑coroner 0 Health Officer
43. Name,Address And Zip Code Of Person Certifying Cause Of Death. 44. License Number 45. Date Certified
EDWARD PATRICK FOX ,3699 EPWORTH ROAD, NEWBURGH, IN 47630 01038620A 05/29/2019
_. 46.Additional Funeral Service Provider 47. 'Akas:
17jy1 48. Signature of Local Health 015cec 49. For Registrar Only -Date Filed (Month/Day/Year):
��r@1 BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE MAY 29 2019
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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State Form 53395 ATTENTION ESTATE:The Social Security#is beingrequested bythis state agency in order to pursue responsibility. Disclosure is voluntary and there will be no penalty for refusal.
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�., WARNING. ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT
• TURNS FROM ORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUMENT HAS A HIDDEN VOID ON FRONT THAT APPEARS WHEN PHOTOCOPIED.
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