Death Certificate - Miller, Charles_1/14/2020 2a-Tt (�"r•.:eszwg r• a xo �' -�y it',+`C rri? +A# • • !fir 1 + rr :%�? + CX �,�_-_'-a�tl��AWV.S.
IrAl. INDIANA STATE DEPARTMENT OF'HEALTH • _
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i�. ', '. 1'100 / CERTIFICATE;OF,DEATH
�(f• ' � � ATTENTION ESTATE:The Social Security#.is being requested by this state agency in order to pursue responsibility.ibility. Disclosure is voluntary and there will be no penalty for refusal.
I _ Local No 000191 EDR No 000000748290 _ 'state No..062231
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)
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�����,,,,;,,��`� CHARLES MILLER ' . - - ' 'MALE 04:54'PM 12/15/2019
5. Sotial Security Number 6a. Age-Yrs 6b. Under 1 Year 8c. Under 1 Month 1 6d. Under 1 Day 6e. Under 1 Hour' 7. Date of Birth (Montt✓Day/Year) •8.Birthplace (City and State or Foreign Country)
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Hospital ,
1 ..t - •
•• 0 Hospice Facility 0 Decedent's Home ®.Nursing Home/Long-term Care Facility _
111 . - El Yes ❑ No ❑ Unknown 0 Inpatient 0 Emergency Department Outpatient ❑-Dead on Arival ❑ Other(Specify) - . •
/,� it Facility Name(If Not Institution,Give Street and Number) . -. ' , -
- GOOD;SAMARITAN HOME AND REHABILITATION CENTER .
� , 12. City Or Town,State,And Zip Code'- - 13..County Of Death ' 14. Marital Status At Time Of Death
6 - ❑.Married❑ Married,But Separated 0 Divorced
1 OAKLAND CITY, IN,47660 GIBSON . ® Widowed ❑ Never Marmed ❑ Unknown
i ' 15. Surviving Spouse's Name 15a. (If Wde)Give Maiden Last Name 16. Decedent's Usual Occupation 17. Kind Of Business/Industry
14
- RETIRED COAL MINER COAL MININGy - , . . :
��;`- 181Residence-State 18a. County 18b.'City Or Town' t , f- - ,
•
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INDIANA GIBSON ' OAKLAND CITY . .
.; -( 18c.Street And Number , . 18d.Apt.No. 18e. Zip Code - 18L Inside City Limits? I
- ❑ Yes ® No
4,- 8719 E.360 SOUTH I , . . 47660 .
;_ 19. Decedent's Education . 20. Decedent Of Hispanic Origin , 21. Decedent's Race . . '
HIGH SCHOOL GRADUATE OR GED
• COMPLETED .
NOT HISPANIC',' - '.,WHITE
a, : ,2..?.Father's Name(First,Middle,Last) 23.Mother's Name(First,Middle,Last) 23a.lMother's Maiden Last Name_
C - BERTIN C. MILLER • - . MABLE A..MILLER . • . ' ,YAGER ' , •
Q 24.Informant's Name - 24a.Relationship To Decedent . 24b.Mailing Address. •
(Street And Number,City,State,Zip.Code) ,
• I
N :I STEVEN MILLER . SON 8710 E.360 SOUTH, OAKLAND CITY, IN 47660 . .
Q •
, • - . •' 25.Place Of Disposition ` - . . . . . .. -
IIr 25a.Method Of Disposition' • 25b.Place Of Disposition (Name Of Cemetery,Crematory,Other Place)- 25c:Location-City,Town,And State, ,
IL ' 0'Burial ® Cremation 0 Donation❑ Entombment - - - . -
•.❑-•'Removal From Stale - _ -
0. ❑ Omer(Specify):. ' EVANSVILLE CREMATORY EVANSVILLE, IN , ' . . .
t7 , ,26.Was Coroner Contacted? • 27, Name And Complete Address Of Funeral Facility , ' ' ' l . - ' , - 27a. Funeral Home License Number.
LIJ LAMB BASHAM MEMORIAL CHAPEL', INC.,226 E.WASH,INGTON STREET, OAKLAND CITY,
cc p.Yes No . --• • . IN 47660 - , . -, --. ,
. FH83005312
1._. . 27b. Signature Of Indiana Funeral Service licensee: - • 27c. License Number(Of Licensee):
JERRY-LEE BASHAM , BY,ELECTRONIC.SIGNATU_RE ", . FD01016589
, ., ' Cause Of Death (See Instructions And Examples) - -
I' - I" - I - Approximate
LI-- '' 28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-7{tat Directly Caused The Death.Do Not Enter Terminal Events , Interval: Onset
Such As Cardiac Arrest Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On . - To Death
- - ALine. Add Additinal Lines If Necessary. _ • • "
0
> Immediate Cause(Final Disease Or Condition Resulting t A. el(IT•. . BROVASCULAR ACCIDENT MINUTES
oue mror A.A comew•�00:
Se uentiall List Conditions, If Any,Lead• ing To The Cau Liste n T A CATION 5 YEARS
q Y_ Y 9 - . Due to(Or Ike A Cem.que�OT:
,Line A._Enter The Underlying Cause(Disease Or Injury a India ed
1\1 The Events Resulting In Death)Last C, . , .
JAN 1D:4 2020 . �el.,o A.AC.n.�e�OD:,
•
Part II.Enter Other Significant Conditions Contributing to Death But Not Resulting In The Underlying Cause Givin In Part I 29.Was An Autopsy Performed?�\ El.Yes El No •
PRIOR CEREBROVASCULARACCIDENT, DE NTIA • 30.Were Autopsy Finding AvailableTo Complete The Cause OfDeath?
El Yes 0 No
A - 31. Did Taloacoo Use Contribute To Death? 32. If Female: _ $I ; - 33.Manner Of Death:
o PLC GU NT ad e I�JdT.Q I$ Not Pregnant,But Pregnant Welin 42 Dap Or eath ® Natural❑ Homicide 0 Accident 0 Pending Investigation .
❑'Yes ❑ Probably 0 No 0 Unknown O. Net Re puma ''anonIuwo Thi Pad r.er - 0 Suicide,❑ Could Not Be Determined 1
## Rapture.But Re Day.To 1 year Berne Death ❑ Unknown RPrs
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34. Date Of Injury(Month/Day/Year)' 35. Time Of Injury 36. Place Of Injury'(E.G.;Decedent Home,Construction Site,Restaurant,Wooded Area) .37. Injury Al Work?
''' ' ❑ Yes ❑ ND
�'y, ii '38;Location Of Injury-State 38a. City Or Town I 38b. Street 8 Number . , , 38c.Apt.No.. 38d. Zip Code
( 39. Describe How Injury Occurred .- .. • 40. If Transpor�ytion lnjury., pedfy:.
❑omerropor.tor ❑P� rger❑P.arme 0 onr.r(sp.ay)
�8Y _ 41 Signature, Of,Person Certifying Cause O/Death:' - 42. Certifier(Check Only One) •
A[ TERRY GEHLHAUSEN BY ELECTRONIC SIGNATURE ® certifyngPhysican 0 Coroner 0 Heath Officer
(qC 43. Name,Addres And Zip Code Of Person Certifying Cause Of Death: 44.-License Number 45. Date Certified
', TERRY GEHLHAUSEN , 1020 W. MORTON, OAKLAND CITY, IN 47660 • 02000730A 12/16/2019
48.Additional Funeral Service Provider. - 47, 'Akas: -
viln1'-
•
48.Signature ofLocal Health Officer. - - - 49..For Registrar Only -Date Filed(MonthiDay/Year):"
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BRUCE BRINK JR,BY ELECTRONIC SIGNATURE DEC 19,2019 •
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) '
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> State Form 10110 (R6/3-07) ' • . . ..
WL►R N1NC'a ORIGINAL DODUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER AND.THE GREAT SEAL OF THE STATE OF INDIANA ON,BACK THAT
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