Press Alt + R to read the document text or Alt + P to download or print.
This document contains no pages.
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. :.