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Death Certificate - Riedford, Regina_10/30/2019 'INDIANABTATE,DEPARTMENT OF HEALTH • • .. IS � •r`, CERTIFICATE OFDEATH �II 4,6n I r t.`; II • EDR No .000O II''i!734195 -estate No 047472"�I'�� �II''1. eb 3.-Time Of Death• I4I!Dela Of Death(Month/Day/Year) de Local M 00200-4 z.sex ( 1a. MeidenlNarne(Iffenale) • 1.Decedent's Leget Name'Tilt,Middle,Last). I Li!! IIII I! - - 09/27/2019 '' FARNY FEMA LE •02:15PM . REGINA GERTRUDE rs RD a.Blrthplece(City and State or Foreign Country) t 5. Social Security Number Ba.Aggee-Yrs 8b UnderlllYeary 6c Under 1 Month 8d. Under 1 Day Be Uhderl Hour. 7 Date if Blirlhu(MoOttilDa yKeaQ Months IIII ! .Days Hours •Minutes_ orces? 10.If Death Occurred In A Hospital: • • HI 'i l®:Hospice Facility ❑Decedent's Home ®Nursing Homellanp tellrm Ca lfegeciiity u1,, ❑. eOthr(Spec)fy). ❑.Yes.®1 No D�Unknown 0 Inpatient 0 Emergenypepenment Outpatient 0 Deed on Amval;i! II,�, _ � c ai 11.Facility Name:(If Not Institution,Give Street and Number). - UNIVERSITY NURSING AND REHABILITATION CENTER 13. County Of Death I !1.1• 14 Mental Status At Time Of Death ❑Married❑Married,But Separated ❑,Divorced f 12. City Or Town,State,And Zip Code .;i� "��'. . „°1!I;' 1 VJdowed 0 Never Mercied Unknown VANDERB,URGH 17. Kind Or Businessllndustry EVANSVILLE IN 47714 15a.Last NemeBefore First Mardage ' olI,li -18. Decedents Usual Occupation ul r 15.SurvivingSpouse'sName .i' DOMESTIC •I HOMEMAKER ill II!1 � ITV lll1i,01 q 11 1��� - •18b. City OrTown- 1 I�•.I 11 I 18a. County ,,•i 1e Resldencri-State • 1. EVANSVI LL"I. ` INDIANA VANDERBURGH' 1Bd. Apt No. 18e. Zip Code 16f Inside Cily,Limits? III I.I' ' I I,. ti18c.Street And Number 1.1,14 ❑�Yea ❑No-•- le.- 47714 1236 LINCOLN AVENUE 21. DecederiPs'Rece !Iliul!II„!' -•...- 20: Decedent Of Hlspani3OiOrigin . - ll I!0' tll Decedent's Education •-- °,r �' I II HIGH'SCHOOL GRADUATE OR GED .' NOT HISPANIC'1 - WhitelrStMlddle,Last) 11 II23a.Parents Last Name.BelOre First Marriage COMPLETED • 1 23.Parents Name(. 1 I;id' 22.Perenrs Name(First,Midtlle,Last) r I''' - � I'I!I il, • GERTRUDE FARNY JOST • • PAUL J'FARNY 'I'11' - 24a.Relationship To Decedent . 24b:Mailing Address!!(Street'And Number,City,State,Zip Code) •24.Informant's Name • ,I„ ,1 ql _ : ,-'1I i,I�III� 4' . • DAUGHTER 102'20 JOHN1;1MLL ROAD,WADESVILLE, IN 47638 MARY KOESTER . 25.Place Of Disposition 25a.Method Of Disposition • ,,; 25b.Place Of Disposition(Name OP,Cemelery,Crematory;OlherlPlace) 25c.Location-City,Town;And State III . • IS Burial ❑Cremation 0 Donadgn 0 Entombment • ';; ;I111 'll!_I�,, ! i.' `11 ❑.Removal'From State • PRINCETON, IN li 1 .1 j]'Otherl.(Specify): 1ST JOSEPHCEMETERY il,lrr;1 • 27a. Funeral Home Ucense Number. 26.:Wai:Coroner Contacted? 27.INeme And'Complete Address Of Funeral Facility 1 r•... y If111:, ' FH83005671 ❑Yes IS No COLVIN=FUNERAL HOMEINC 425 N MAIN ST -PRINCETON IN 47670;; ' - � ^� ��II t 1° -•� � 27c. License Number(Ot Licensee): � ' • IFD0L1012Num 1 r1 27b SignaturaOf DIndianaFunerallSer D.,,icensee..-'' • - - - (ILAlII IIII' RICHARD'DEAN HICKROD-;"BY ELECTRONIC SIGNATURE n11 Approximate • Cauiae Of Death (See Instruct10ns And Examples)' • o• Ilill'll I u'1I l Interval: Onset ,I To Death Such AsICa di c Arrest Chain Arrest Or Ventricular urie%Or Ca FibrillationWithout Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On ;I' A Line. Add Additional Lines If Necessary. YEARS A MYASTHENIA GRAVIS o locnengonsequence og Immediate Cause(Final Disease Or Condition Resulting In Death) • I:Y' YEARS' • 1 B. CHRONIC BRONCHITIS Sequentially List Conditions, If Any Ceeding!To The Cause Listed On rnem(Or an Consequence oq: • Line A. Enter The Underlying Cause,(Disease Or;Injury That initiated 11111i 1 YEARS R The Events Resulting In Death)Lasi,`"II ' C. HYPOTHYROIDISM ono i (Or As A Consequence Oq: • ull l p YEARS D IOSTEOARTHRITIS II li ,�• _ _ - q_ 129 Was An Autopsy Performed?,1 p ❑Yes ®No Part Il.Enter Other$ianificant Conditions Contributing to Death But Not Resulting In TheUnderlying Cause Given In Part I Autos Fmdln Available To Complete The Cause-0t Death?- _.__. ....�- - - -"":r It' 3P ,• .. P y,.:i 9 renee, ❑Yes,:❑No • DEPRESSION, ANXIETY ,i 33..MannerOfDeath: '. 31. Did Tobacco Use Contribute To Death? 32. If Female: • r ®Natural❑Homicide ❑Accident ❑Pending lnvesGgaGon ❑Not Pregnant Min Past Year ❑Pregnant Al The� •�am ❑Not Pregnam B IP eynan n420aye Ol N ❑Yes ❑Probably 0 No ®Unknown 0 Nat Pregnant,But Pregnant 4T Days To 1 year ore Deatn ❑urvnmm a Pr o ni W,wn Tlw P Year ❑Suicide 0 Could Not Be Determined 34. Date Of Injury(Monthioayfv'eer)• 35.Time Of Injury 36. Place Of Injury(E G',Decedent's H vie,Cons con Site,Restaurant Wooded Area), 37 :Injury At Work? ; I I ®'Yes ❑No h 1 rail 11 38e.Apt.No. 38d. Zip Code 36,Location Of injury-State 38a. City Or Town 1 38 S et 8 N I II 1 11 11 1 11., 11 • 40 If Transportation Injury,S ed fy:, ' I; 39. Describe How Injury Occurred ,lit;, 1�' j ❑onear/Operator ❑Paasenpar.UPemurlan❑Omer lspecty) • 0CT302019, • - 41.Signature, Of Person Certifying Cause,Of Death: c h(C ek Only One) DELLA ELLIS DILLARD;''BY,ELECTRONIC SIGN'TURE 42. C Nfier" ® erjlyi (Ch kOn ❑Coroner ❑Health•Officer 44. License Number 45. Date'Certjried 43. Name,Address And Zip Code Of Person Certifying C®use OF Uaatt{;��, � i.,.,p,l, ���' I�ri��� it r �M�(��1NTY AUDITO 0107,8907,A� • 09/30/2019 DELLPA'EL''LIS DILLARD.., 1750:OAK=HfL.PL�A�^.,.0 ANSI( q? Akas: 1 48.'AdditionatFuneral Service Provider.• •' i ,,• 49. For Registrar Only Date Filed(Month/DayNear): 48:Signature of Local Health Officer. - ,t OCT 01 2019 • ROBERT KENNETH SPEAR MA ELECTRONICSIGNATU_R • AMENDMENT TO CERTIFICA�E TYP DEATH(ENTRY OR ORIGINAL) _'6 -- 300-00 _ G;6 h.-26 °2�- II;1'. r 2� / - - 662 - 02R . State Form 53395 S'• 1.,I' ,l g. ATTENTION ESTATE:The Sorirl Secunty#is be ing requested by this state agency in order to pursue responsibility. Disclosure'is!;voluntary and there will be no penalty for refusal. %AIA 0 M I M I. ORIGINAL'DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHIT6SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT nnrr raeCnrT erne a.wsnnan'tiWiry r1N FRr1NT THAT APPFARA WHFN PHOTOCOPIED. :.