Death Certificate - Barton, Rita_5/18/2020 �; `J� INDIANA STATE DEPA MENT OF HEALTH �'� --- -__
011:`:a, CERTIFICATE OF DEATH
..1111
‘' •, Local No 000445 FOR No 00000076'3409 State No 010551
1.Decedent's Legal Name(First,Middle,Last) 1e. Maiden Name(If female) 2.Sex 3. lime Of Death 4. Date Of Death (Month/Day/Year)
RITA J BARTON I' STURGEON FEMALE'' 10:35 PM 02/25/2020
5.Social Security Number 8a.Age-Yrs 8h. Under 1 Year 6c. Under 1 Month 8d. Under 1 Day 8e. Under 1 Hour 7. Date of Birth (Month/Day/Year) 8.Birthplace (City and State or Foreign Country)
78 Months Days Hours Minutes PATOKA, IN
9.Ever In U.S.Armed Forces? 10.If Death Occurred in A Hospital: 10a, If Death Occurred Somewhere Other Then A Hospital
Ii Hospice Facility 0 Decedent's Home
Cl Yes No Unknown 0 Inpatient 0Emergency Department Outpatient ❑Nursing Home/Long-term Care Facility
pp tp ❑Dead on Arrival ❑Other(Specify) '
11. Facility Name(If Not Institution,Give Street end Number)
LINDA E.WHITE HOSPICE HOUSE ' .. ,
12.City Or Town,State,And Zip Code 13. County Of Death 14. Marital Status At Time Of Death •
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0 Married 0 Married,But Separated ❑Divorced
EVANSVILLE, IN,47710 VANDERBURGH ®VNdowed ❑Never Married 0 Unlmawn
15.Surviving Spouse's Name 15a.Last Name Before First Marriage 16. Decedent's Usual Occupation 17. Kind Of Business/industry
• REGISTERED NURSE. MEDICAL •
18. Residence-State 18a. County �I„ 18b. City Or Town
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1' - I
, II
INDIANA GIBSON FORT BRANCH
18c.Street And Number 18d. Apt.No. 18e. Zip Code 18f. Inside City Limits?-
5868 SOUTH 175 EAST 47648 i❑-des ❑No
18,Decedent's Education '20. Decedent Of Hispanic Origin 21. Decedent's Race
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BACHELOR'S DEGREE(BA,AB, BS) NOT HISPANIC White ii. 'I
'22.Parent's Name(First,Middle,Last) 23.Parent's Name(First,Middle,Last) i, 23a.Parent's Last Name Before First Marriage
' I
SHIRLEY STURGEON AUGUSTA STURGEON HOOVER '
24.Informant's Name ' 24a.Relationship To Decedent 24b.Mailing Address(Street And Number,City,State,Zip Code) I I
•STEPHEN BARTON SON 5758 SOUTH 175 EAST, FORT BRANCH, IN 47648 - ''
•
25.Place Of Disposition I '
25a.Method Of Disposition 25b.Place Of Disposition (Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State I -
®Burial 0 Cremation 0 Donation 0 Entombment II , , - •
❑Removal From State I'
❑other(Specify): MAPLE HILL CEMETERY PRINCETON, IN
28.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility " ,I i 27a. Funeral Home License Number. I
❑Yes ❑No
COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671 ' .
27b.Signature Of,Indiana Funeral Service Licensee: 27c. License Number(Of Licensee): j
MARK R.WALTER, BY ELECTRONIC SIGNATURE FD01013010
Ceude Of Death (See InstructIons And Examples) - '
'Approximate
28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Even Interval: Onset
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Wiithout:Showing The Etiology.Do Not Abbreviate.Enter Only One Ca e n ' 1 To Death
A Line. Add Additional Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. PERITONITIS STATUS POST COLON PERFORATION I' I(
I ...,- A.Acon.w.,Df„ MAY Q q ,III ,
Sequentially List Conditions, If Any,Leading To The Cause Listed On B. V L�2�
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated ow to(Dr Ae A Co,.oqunn o
The Events Resulting In Death)Last C. ///(� r
w Db(Dt A.A Corr. .no equ 0/jI:,
D.
G1RS (o p
Part II.Ester OtherSionificent Conditions Conttibutina to Death But Not Resulting Iq The Underlying Cause Given In Part I 29.Was An Autopsy Perform mdY tN T f-+14 I TC�tNo
I,' ,„i I .30. u I•
HYPDXIC RESPIRATORY FAILURE,PULMONARY FIBROSIS,CHRONIC OBSTRUCTIVE PULMONARY DISEASE Were Autopsy Finding Available To Complete The Cause Of Death?•• ❑Yes ❑No
31. Did Tobacco Use Contribute To Death? 32. If Female: - - . - ,' 33.Manner Of Death: '
0 No P.pent Yth,Put Y..r ❑Pr onA Th.Of NO' ❑rat Prprura,aulpr.eary Min 42 Days Death ®Natural 0Homicide 0 Accident 0 Pending InvestigationI ❑Yes 0Probably®No ❑Unknown
❑Not Pregnut.Sot Pregnant 43 Day.To t year Before Death 0 Unknown if Pnpn.nl W enn The Pad Year 0 Suicide❑Could Not Be Determined LI , .
34. Date Of Injuno(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?
. El yes El No -
38. Location Of Injury-State 38a. City Or Town 38b. Street&Number 38c.Apt.No. 38d.Zip Code
1" 11 Il li(�
lit';II ,
39. Describe How Injury Occurred 40. IfTransportatlon Injury, eciy:
I
❑DMarxlp.nlor ❑Para.nue( P.O.a .o❑on, lswrrYl
41.Signature,Of Person Certifying Cause Of Death: 42. Certifier(Check Only One) '
APRIL MICHELLE-SIMMONS TOELLE, BY ELECTRONIC SIGNATURE 12]Certifying Physician 0 Coroner El Health Officer
43. Name,Address And Zip Code Of Person Certifying Cause Of Death: • . .2 _ 44. License Number 45. Date Certified '
APRIL MICHELLE-SIMMONS TOELLE ,600 MARY ST., EVANSVILLE, IN 47747�-�--_• 'I '
02003410A' 02/28/2020
48,Additional Funeral Service Provider. ' I 47."Akas:
48. Signature of Local Health Officer. - _ "- _ _ ^`'' (-49. For Registrar Only-Date Filed (Month/Day/Year): - '
ROBERT KENNETH SPEAR;VIA ELECTRONIC SIGNATURE : = MAR 03 2020 ,I II -
I AMENDMENT TO CERTIFICATE OF DEATH"(ENTRY OR ORIGINAL) II
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(,, tc,i - 0q . •'100 . 4-0.0• • 04 I - 0.), ', '
State Form 53395 ATTENTION ESTATE:The Social Security#is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary end there will be no penalty for refusal.
WA R N I N G• 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.ORIG NAL DOCUMENT HAS A HIDDEN VOID 0 FRONT THAT APPEARS WHEN PHOTOCOPIED...�a.a ..u..es.a's .,s..rr.• it RN?, ..ROM VSE2:..0 v-c.,n.�EN �: ,.,... . ._. . ,®_..HAT Alys.�....�..�� H9TO ..m- __ -�_-__