Death Certificate - Kruse, Eliza_3/3/2020 •rn,,rr:-." - rrr.•a,r.` asz In. X•...'s, '- ,rfratr...".ris,.'�-,NEVIS.r�: - ;:%,17f0i� •..• 1,1.1U'r�; .''�..{lllr'ICi re �",�71 -+
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.. t' - INDIANA STATE DEPARTMENT OF HEALTH . - ----' , .
0
:, CERTIFICATE OF DEATH. -
`,, �L" ATTEN•TION ESTATE:The Social Security#is being requested by this state agency in order to pursue responsibility: Disclosure is voluntary and there will be no penalty for refusal.
f '"' • " Local No'000025 EDR No 000000762312 . state No-009300 ' 1
X6. 1.Decedent's Legal Name(First,Middle,Last) le. Maiden,Name (If female)'. . ' 2.'Sex 3.Time Of Death - ' 4, Date Of Death (Month/Day/Year)
( ELIZA ROSE KRUSE : PUMPHREY . FEMALE • 04:20 PM , -02/22/2020
4 5.Social Security Number 6a.Age-Yrs.. 6b. Under 1 Year, Sc. Under 1 Month`6d..,Under 1 Day 6e..Under 1.Flour. 7. Date of Birth(Month/Day/Year) ' .Birthplace (City and State'or Foreign Country)
It
Hospital - - -
- ' 0 Hospice Facility ❑ Decedent's Home ® Nursing Home/Lang-term Care Facility
g[ 0 Yes ® No ❑ Unknown' 0 Inp.atient 0 Emergency Department Outpatient 0 Dead on Artival ❑ Other(Specify) - ' - ".
(, , 11.E Facility Name(If Not Institution,Give Street and_Number) -' • - ,
// _ RIVEROAKS HEALTH CAMPUS - = _
C 12.City Or Town,State-And Zip Code ' - ' • 13.'County Of Death ' '- i .14. Marital Status At Time Of Death
- ❑ Married❑ Married,But Separated 0 Divorced
G PRINCETON, IN,47670- GIBSON ' • ® Wdowed .0 Never Manied ❑,Unknown '
f'\V ' 15.SurvivingSpouse's Name - 15a. (If Wfe)Give Malden Last Name 16. Decedent's Usual Occupation ' 17. Kind Of Business/Industry
6 ,
HOUSEWIFE . - DOMESTIC .
18,Residence-State -. ),' - 18a. County 18b. City Or Town . , _- i i - - ,
•r. INDIANA GIBSON PRINCETON -
18a"Street And Number - , - - '18d. ApL No. - 18e. Zip Code 18f. Inside City Limits?
ElYes ❑'No
'�1�/`;. 1244 VAIL STREET ' 47670
19. Decedent's Education . i - 20. Decedent Of Hispanic Origin - - 21. Decedent's Race' -
., H/ IGH SCHOOL GRADUATE OR GED
r
COMPLETED , . , , - , NOT HISPANIC , „ • .- , ' WHITE ; ,
:� 22.Father's Name(First,Middle,Last) a 23.Mother's Name(First,Middle,Last) - - ' - '23a.Mothers Maiden Last Name
I r ZENAS PUMPHREY FLORENCE•PUMPHREY - • ' BAYER
24.Informant's Name - 24a.Relationship To Decedent - 24b.Mailing Address'(Street And Number,City,State,Zip Code) - - -
KAREN.ETCOVITCH ' DAUGHTER .- 2402,WEST 625 SOUTH_;FORT BRANCH,-TN 47648
- ' - • 25.Place Of Disposition - I ' , ,- , , , - - - -
W 25a.Method Of Disposition 25b.Place Of Disposition (Name Of Cemetery,Crematory,Other Place) 25c.Location?City,Town,And State . ' ,
" ® Burial'0 LL Cremation 0 Donation 0 Entombment - - . •'
O ❑ Removal From State' - - - . . - _ -
0 Omer(Specify): : • • WALNUT HILL CEMETERY 'FORT BRANCH, IN . -
W 1-4 26.Was Coroner Contacted? -" 27. •
,Name And Complete Address Of Funeral Facility ' - - . 27a. Funeral Home License Number.
❑ Yes ® No " '
W STODGHILL FUNERAL HOME INC, 500 E PARK ST HWY 168,-FORT BRANCH, IN 47648 FH10900013
J27b. Signature Of Indiana Funeral Service Licensee: - •. - - 27c. License Number,(Of Licensee): - - ,
Q ANDREA LYNN STODGHILL, BY ELECTRONIC SIGNATURE. -'. . • -. `FD21400005 I . , .
Cause Of Death (See Instructions And Examples) . ' , . ,'I,; "
- 28.Part I.EnterThe'Chain Of Events -Diseases,Injuries,Or Complications,-That Directly"Caused The Death.Do Not Enter Terminal Events' Approximate
CI . Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On ', Interval: Onset
O -A Line. Add Additinal Lines If Necessary. To Death
> "Immediate Cause(Final Disease Or Condition Resulting In Death) A RENAL FAILURE ' . ' . 2 WEEKS
_ - Due to As Aeemeque�oq: _
'�" Sequentially List Conditions:If Any,Leading To The Cause Listed On B.1y"�\' Line A. Enter The Underlying Cause(Disease Or Injury That Initiated ouele(Or AsA caroewenFe Oh.
The Events Resulting In Death)Last O
• Ye
C D to As Consequence OQ
1 , Part It.Enter Other Significant Conditions Contributing to Death But Not Resulting In The Underlying Cause Givin In Part I- 29.Was An Aiutopsy Performed? - ElYes . ® No '
DEAF;BLIND - -.. 30. Were Autopsy Finding Available To Complete The Cause Of Death?
_ 0 Yes r 0 No
31. Did Tobacco Use Contribute To Death? 32. If Female: 33. Manner Of Death:
0 Not Pregnant Wlsn Pa egnant Al lime 01 Death. ❑ Not P ggant,amp,egn.nl wnm .2 Days or Death ® Natural 0 Homicide ❑ Accident 0 PendingInvestigation
ht% ❑ Yes 0 Probably® No ❑ Unknown 9
,❑ Not Pr-. -.Pregnant a3 m r yea, a Death, , ,0 U Arran If Pregnant wan.The Pall year ❑. Suicide❑ Could Not Be Determined ,
le 34.,Date Of Injury(Month/Day/Year);' 35 ime Of Injury 36. Place Of Injury(E.G.,Deceden't,Home,Construction Site,Restaurant,,Wooded Area) 37. Injury At Work?
- ❑ Yes ❑-No
0\- 38. Location Of Injury-State , 38a.City Or Tam 38b. treet 8.Number 38c.ApL No. 38d:Zip Code
1E
l4. 39. Describe How Injury Occurred I E
. - _ - 4 . If Transp non Injury,..+C�{pecify.'
t1 -" DrNerlOpenlor Paaeenger LJ PeOetlrun❑ONer(SlxrEy)
r 41. Signature, Of Person Certifying C. se Of Death:,: ' 42.'Certifier(Check Only One) , --'' '
1 4 TERRY GEHLHAUSEN;IcY ELECTRON'gION'A e , Cr.' - •1 • ' ® CeNfying Physioan ' 0 Coroner 0 Heath Officer ,
43. Name,Address And Zip Code Of••rson Certifying'Caus I� the �/I 44.•License Number 45. Date Certified
LLL, TERRY GEHLHAUSEN•, '020 W.,MORT N, OA , IN 47 60 02000730A 02/24/2020
46.Additional Funeral Service Provider. ' 47. 'Akan: .
�, _ - ._ -
rj�( 48.Signature of Local Health Officer: G 113 S O N-Ci O U NTY-AU D:__ 49.-For Registrar Only -Date Filed (Month/Day/Year):
�fi BRUCE BRINK'JR,BY ELECT' IC SIGNATURE I ' - , ' .FEB 25 2020 . ..
MENT'TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)'• ' , ' -
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State Form 10110 (R6/3 07)
04 -ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL'OF THE STATE OF INDIANA ON BACK THAT
WARNING:-
TURNS'FROM ORANGE TO YELLOW WHEN RUBBED.ORIGINAL'DOCUMENT HAS A HIDDEN'VOID ON FRONT THAT APPEARS WHEN PHOTOCOPIED. • .