Death Certificate_Beste - - 11/ .71A.. Tunrs. .1.1 -
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INDIANA STATE DEPARTMENT OF HEALTH
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; .. CERTIFICATE OF DEATH . . .
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.,,,, ''':,• ::.:v ATTENTION ESTATE:The Social Security#is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary and thee will be no penalty for refusal.
4,...;., Local No 000022. EDR No 000000761686'. - State No 008533 . .
L.: 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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r\\ JOSHUA M.BESTE .
ro'• MALE 04:20 PM
irt 5. Social Security Number 6a.Age-Yrs 6b. Under 1 Year 6c. Under 1 Month Ed. Under 1 Day 6e. Under 1 Hour 7. Date of Birth (Month/Day/Year) 8.Birthplace (City and State or Foreign Country)
‘-: • . 34 Months Days Hours Minutes .03/27/1985 EVANSVILLE, IN •
9. Ever in U.S.Armed Forces? 10.If Death Occurred In A Hospital: 10a. If Death Occurred Somewhere Other Than A Hospital
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i-i I El Hospice Facility' ID Decedent's Home D Nursing Home/Long-term Care Facility
vA. 1.--. Yes 0 No a Unknown D.Inpatient El Emergency Department Outpatient 0 Dead on Arrival, i-i .-•:.,_ -.
,--. '0/tier(Specify) ' ' : ,
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0 . 11.Facility Name(If Not Institution,Give Street and Number) .
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`/) 6657 WEST 400 ROAD SOUTH • , .- . , . • .. .
12 City Or Town,State,And Zip Code , - 13. County Of Death 14. Marital Status At Time Of Death
PA- • 1 2 i Married 0 Manied,But Separated 1:1 Divorced
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OWENSVILLE, IN,47665 GIBSON , o Wdowed 0 Never Married 0 Unknown
2;0 15.Surviving Spouses Name 15a. (If Wtia)Give Maiden Last Name 16. Decedent's Usual Occupation 17. Kind Of Business/industry
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MANUFACTORING
,L. JESSICA RENEA BESTE TEEL LABOR ,
TOYOTA
18.'Residence-State -- . : 18a. County . ' . t 186. City Or Town. • .
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ri INDIANA ' .-_ .. GIBSON . OWENSVILLE .
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!P „ 18c.Street And Number . 18d. Apt.No. 18e. Zip Code 18f. Inside City Limits?
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`)., ' • . a Yes rE No .it 6657 WEST 400 ROAD SOUTH . •. . . 47665
19.Decedent's Education 20. Decedent Of Hispanic Origin ' - 21. Decedent's Race
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t.g, SOME COLLEGE CREDIT, BUT NOT A
IF
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- DEGREE
22.Father's Name(First,Middle,Last) NOT HISPANIC . WHITE
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23.Mother's Name(First,Middle,Last) . .
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23a.Mother's Maiden Last Name
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,'• NEIL FREDERICK BESTE • . SUSAN BESTE, ' , GATES •
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24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address(Street And Number,City,State,Zip Code) • .
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CI) JESSICA BESTE WIFE 6657 WEST 400 ROAD SOUTH, OWENSVILLE, IN 47665
CC 25.Place Of Disposition. . '
ui 25a.Method Of Disposition ' , 25b.Place Of Disposition (Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State
D Burial IN Cremation 0 Donation 0 Entombment
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O El Removal From State • - .
0 Other(Specify): ' . HALEY MCGINNIS CREMATORY, ,• OWENSBORO, KY
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26.Was Coroner Contacted? ' 27. Name And Complete Address Of Funeral Facility . • - ' 27a. Funeral Home License Number
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LLI 0'Yes 1=1 No '
HOLDERS FUNERAL HOME,319 SOUTH MAIN STREET, OWENSVILLE, IN 47665 FH11700008' •
...11- 27b. Signature Of Indiana Funeral Service Licensee: '27c. License Number(Of Licensee):
rt BRANDI MACER i BY ELECTRONIC SIGNATURE . - FD21400065
il. . . Cause Of Death (See Instructions And . - - -
- 28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.D• •ot Enter Terminal.vents • • Approximate .
CI Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not•••reviate.Er-25_911y One Cause On Interval: Onset ,
• A Line; Add Additinal Lines If Necessary. -
✓ , . . To Death
> , Immediate Cause(Final Disease Or Condition Resulting In Death) A. PULMONARY THR•':•' t,' . 7 .'
of) MINUTES
Sequentially List Conditions, If Any,Leading To The Cause Listed On B. d ....4 L oh. •
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated .ou
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a to As
The Events Resulting lit Death)Last C . - . enca 7 4
2 5'21)20c°''
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Part II.Enter Other Significant Conditions Contributing to Death But Not Resulting In The Underlying Ca se Givin In Part EH I 29.Was An Autopsy Perfomr?
0 Yes a No
HYPERTENSIVE CARDIOVASCULAR DISEASE '
Acli
..4-.. utopsy Finding ailable To Complete The Cause Of Death?
0 Yes a No '
4 31. Did Tobacoo Use Contribute To Death? 32. If Female: . 33. Manner Of Death:
0 Yes ID Probably 1:9 No a'Unknown
O Not Pregnant Wallin Past Year El Pregnant At Tone 01 Dee I q1SPINX 0 UNIKALID,- 121 Natural 0 Homicide 0 Accident 0 Pending Investigation
10 El Not Pregnant.But Pregnant 43 Days To 1 year Before Death,- , know;II Pregnant Wenn The Past El Suicide 0 Could Not Be Determined
6. 34. Date Of Injury(Month/Day/Year) 35.Time Of Injury . 36. Place Of lnju . ., ome,Construction Site,Restaurant,Wooded Area) 37.Injury At Work?
0 Yes a No
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k... . 38. Location Of Injury-State -' 38a. City Or Town . 38b. Street 8 Number . • ' ' , . ' 38c.ApLNo. 38d.Zip Code. , .
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39. Describe How Injury.Occyrjed 't‹,t. A .- ' ' ' O.Dri,,If.Tiranr.snliop.n InjnQueryr,aptfy:.n 0 c(s,.....,)_
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41. Signature,t Of PersonCertitA i rCattse Of.011.54-)- l • • 42.Certifier(Check Only One)
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MISTY G. HOE.,43Y;ELECTRCNICZ4v0ATURE p Certifying Physician ' [3 Coroner . 0 Heath Officer
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43. Name,Address',761dCip:Code Of Person CertifYIng CausiOf Death; • . 44. License Number 45. Date Certified
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MISTY GoHbKE AZ253,,..:T.PFANC .S.t' PfkltsICETON, IN 47670' ' • .. ' . ., .
' 02/20/2020
" 46 Additionaf Fun I Se 'cA PrOickar • k '- . ' - - . 47. 'Aims:
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r*-;‘`..-•: HALEY MGGPraINNA FUN-E.RA. L HOME: :.,., 'f, -: . •
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48,Signature of Loca,Health,Officer. ' '' ' ..^ ...,..4 .-1-.
,.. C , 49. For Registrar Only -Date Filed(Month/Day/Year):
. 1 BRUCE BRINK JWBY.ELECTRONIC i-1G NATURE , ,
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. • - • •- FEB 21 2020 '
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- ' . '''--- -,:). .''-...„ ' _. AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)- , . -
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(SO's3(0.".1 1-'001' a%,„2.,
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5 T (,3 Li 0 0 o NA\1e-Y) - -6C - -' . . • -.. .. -
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16 State Form 10110 (R613-07) , ' , ' ' . .
m 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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