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INDIANA STATE DEPARTMENT OF HEALTH
0
�C � �;, 'CERTIFICATE OF DEATH ,
002533 000000747373 state No 060719
gw.:� � ' Local No
EDR 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)
f(C DOROTHY IRENE KRAMER SMITH FEMALE 10:30 AM 12/08/2019
V"- 5. Social Security Number 6a.Age-Yrs 6b. Under 1 Year 6c. Under 1 Month-6d. Under 1 Day Be. Under 1 Hour 7. Date of Birth (Month/Day/Year) 8.Birthplace (City and State or Foreign Country)
84. Months Days Hours' Minutes FORT BRANCH, IN
tI r 9. Ever in U.S.Armed Forces? 10.If Death Occurred In A Hospital: 10a. If Death Occurred Somewhere Other Than A Hospital
®Hospice Facility ❑Decedent's Home ❑Nursing Home/Long-term Care Facility
❑Yes El No 0 Unknown 0 Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival ❑Other(Specify)
11.'Facility Name(If Not Institution,Give Street and Number) ,
kV LINDA E.WHITE HOSPICE HOUSE
12. City Or Town,State,And Zip Code 13.County Of Death 14. Marital Status At Time Of Death
c
y ❑Monied❑Married,But Separated ®Divorced
�.�`a, EVANSVILLE, IN,47710 VANDERBURGH 0 Wdowed ID Never Married 0 Unknown
r.j:,,' 15.Surviving Spouse's Name 15a.Last Name Before First Marriage 16 Decedent's Usual Occupation 17. Kind Of Business7ndustry
CSR HEALTHCARE
9jj/ 18. Residence-State 18a. County , 18b. City Or Town
.
)1g
Ir GI
INDIANA BSON. FORT BRANCH .
18e.Street And Number 18d.Apt.No. 18e. Zip Code 18f. Inside City Limits?
�,a
4 303 NORTH MAIN STREET • 47648 ®Yes 0 No
t- 19. Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedent's Race
1. HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
�, 22.Parent's Name(First,Middle,Last) 23.Parent's Name(First.Middle,Last) 23a..Parent's Last Name Before First Manage
•
b HENRY SMITH EMMALINE SMITH GIESELMAN
Q 24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address (Street And Number,City,State,Zip Code)
cn BRADLEY B KRAMER SON 702 EAST SINCLAIR STREET, FORT BRANCH, IN 47648
Q 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
W 0 Burial 0 Cremation ®Donation 0 Entombment
Cr 0 Removal From State
O 0 Other(Specify): MEDCURE . MARYLAND HEIGHTS, MO
ci 26,Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility 27a. Funeral Home License Number.
W
IX ❑Yes ®NoLLI B&G MORTUARY SERVICE,965'HIGH ST,CHARLESTOWN, IN 47111 FH1200041
27b.Signature Of Indiana Funeral Service Ucensee: 27c. License Number(Of Ucensee):
Q JASON BROWNFIELD, BY ELECTRONIC SIGNATURE I .0048 •
Cause Of Death (See Instructions d x pl ) Approximate
LL
.. 28.Part I.Enter The Chain Of Event 9 -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do of Ent T in nl Interval: Onset
O Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbr e.E r To Death
A Line. Add Additional Lines If Necessary.
0 Immediate Cause(Final Disease Or Condition Resulting In Death) A. ACUTE HYPDXIC RESPIRATORY FAILI�f N A R P2&ZO
� Sequentially List Conditions, If Any,Leading To The Cause Listed On B. ACUTE SYSTOLIC CONGESTIVE HEART FAILURE
w.mla A.Acan.e�anc.o
�V Line A. "ter The Underlying Cause(Disease Or Injury That Initiated
l�4qp. The Eve Resulting In Death)Last - C. SEVERE AORTIC STENOSIS �iT'.-.
�;,! GIBSON COUNT` r..;-. . ;jR
tionsequarroe OD
L D.
Part II.EntOther Sianiticant Conditions Confnbutina to Death But Not Resulting In The Underlying Cause Given In Part I 29 Was An Autopsy Performed?. ❑Yes ®No
`r( SEVERE PLMONARY HYPERTENSION,CHRONIC OBSTRUCTIVE PULMONARY DISEASE 30. Were Autopsy Finding Available To Complete The Cause Of Death?
0 Yes 0 No
it.
31. Did Tocco Use Contribute To Death? 32. If Female: 33.Manner Of Death:
❑HalPr.pnaavAn+nPaLYasr ❑ reo'.lAi re.oroem, ❑Not PrcpruN,Sot pr.punlesm,42wr.orwatn ®Natural 0 Homicide 0 Accident 0 PendmgInvestigation
0 Yes Probably❑No ❑Unknown ❑aw���em Prequm u Tn r Be e,.wnn ❑unamhnnPr. l v2a�n rtv P.c v.., ❑o.r. r.er c� ❑Suicide Could Not Be Determined
34. Dale Onjury(Month/Day/Year) 35. Time Of Injury 38, Place Of Injury(E.G.,Decedent's Home,Construction Site,Restaurant,Wooded Area) 37. Injury At Work?
r� ❑Yes ❑No
•\' 36.Location Of Injury-Slate 38a. City Or Town 38b. Street 8 Number 38c.Apt.No. 38d. Zip Code
It
�/ram- 39. Describe How Injury Occurred 40. If Transportation Injury, eci fy:
❑om.rron.,. ['Passenger j Pedestrian['Mar ISP.YI
fr!`r 41. Signature, Of Person Certifying Cause Of Death: ' 42. Certifier(Check Only One)
APRIL MICHELLE-SIMMONS TOELLE, BY ELECTRONIC SIGNATUREI ®Certifying Physician 0 Coroner ❑Health Officer
43. Name,Address And Zip Code Of Person Certifying Cause Of Death: 44. License Number 45. Date Certified
•
L APRIL MICHELLE-SIMMONS TOELLE ,600 MARY ST., EVANSVILLE, IN 47747 02003410A 12/10/2019
48.Additional Funeral Service Provider. 47. 'Alms:
-
MEDCURE MARYLAND HEIGHTS MO
I8` 48.Signature of Local Health Officer. 7 - 49. For Registrar Only -Date Filed(Month/Day/Year)'
,r(
STATE OF ON BACK THAT
APPEARS WHEN PHOTOCOPIED.