Death Certificate - Kiesel, Frank_5/21/2020 •�,r,. -- --- ---- ------ ',n..•'V _,I- --vn•.�V 7-------- -----_--Tm_�u=e Tn`w -"TAO' TWA(' eeT=__fl.1Mr_`9...-.�-1/T
4, �'r^4 INDIANA STATE DEPARTMENT OF HEALTH
1 aA CERTIFICATE OF DEATH
1.DecedenYsLegal Name
LOCeIstN 000067 EDR No 0000007e747231a: Maiden Name(If 2�x state No
D0211253.Timeate0iDeath (MonthlDay_4. ar'
i,';tq FRANK ALLEN KIESEL MALE 00:20 04/20/2020
�- 5. Social Security Number 6a.Age-Yrs 6b. Under 1 Year Sc, Under 1 Month-6d. Under 1 Day Se. Under 1 Hour 7. Date of Birth (Month/Day/Year) 8.Birthplace(City and State or Foreign Country)
jd%i 61 Months Days Flours Minutes FORT BRANCH, IN
ti 9. Ever in U.S.Armed Forces? 10.If Death Onniirred In A Hospital: - 10a. If Death Occurred Somewhere Other Than A Hospital
I�� ❑ Hospice Facility 0 Decedent's Home 0 Nursing Home/Long-tern Care Facility
i l'' 0 Yes ® No 0 Unknown 0 Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival ❑ Other(Specify)
�f\ 11. Facility Name (If Not Institution,Give Street and Number) i
g 10134 SOUTH 450 WEST -
4/,r 12. City Or Town,State,And Zip Code. . 13. County Of Death 14.Marital Status At Time Of Death
0 Married❑ Married,But Separated 0 Divorced
CYNTHIANA, IN,47612 GIBSON El Widowed 0 NeverMaried ❑ Unknown
i rer 15.Surviving Spouse's Name 15a.Last Name Before First Marriage 16. Decedent's Usual Occupation 17. Knd Of Business/Industry
4 SHERRY KIESEL STONE CARPENTER CARPENTRY
f�
-J,: 18. Residence-State 18a. County , 18b. City Or Tom
r INDIANA . GIBSON CYNTHIANA
18c.Street And Number
�� 18d.Apt No. 18e.Zip Code 18f. Inside City Um its?
4 10134 SOUTH 450 WEST 47612 ® Yes 0 No
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19. Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedent's Race
`i HIGH SCHOOL GRADUATE OR GED
f� COMPLETED NOT HISPANIC 'White
22.Parent's Name(First,Middle,Last) i 23.Parent's Name(First,Middle,Last) 23a.Parent's Last Name Before First Marriage
ffELMER KIESEL DOLORES KIESEL KNAPP
0 24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address (Street And Number,City,State,Zip Code)
W SHERRY KIESEL SPOUSE 10134 SOUTH 450 WEST, CYNTHIANA, IN 47612
U)
Q 25.Place Of Disposition
Cr 25a.Method Of Disposition 25b Place Of Disposition (Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State
W ® Burial 0 Cremation 0 Donation 0 Entombment
CC 0 Removal From State
O 0 Other(Specify): STS PETER AND PAUL CEMETERY HAUBSTADT, IN
0 26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility 27a. Funeral Home License Number.
In
cr ® Yes ❑ No
STODGHILL FUNERAL HOME INC, 500 E PARK ST HWY 1 o RANCH, IN 47648 FH10900013
LLI
i_ 27b.Signature Of Indana Funeral Service Licensee: 2 c. Lice Number(Of Licensee):
ANDREA LYNN STODGHILL, BY ELECTRONIC SIGNATURE F 21400 5
Q Cause Of Death (See Instructions An• ampler) ` Approximate
LL 28 Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do •t Enter T • I is Interval: Onset
�
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbre ate.En ly ne ause ; To Death
0 A Line. Add Additional Lines If Necessary.
O` Immediate Cause(Final Disease Or Condition Resulting In Death) A. SMALL CELL CARCINOMA --'� ONE MONTH
/ ON to(Or A.A Consequence Of
�[(�� Sequentially List Conditions, If Any,Leading To The Cause Listed On B. NEUROENDOCRINE CARC OMA u�yyM��y5 QL� ONE MONTH
l Line A. Enter The Underlying Cause(Disease Or Injury That Initialed wet°(OrTVI)'t9°°"'77°� 2020
44\ The Events Resulting In Death)Last C
Me In(Or N Acawquenu oq:
q D.
Part II.Enter Other SianificantComditions ConSribNino to Death But Not Resulting In The Underlying Cause Given In Part AUtyp;y,e'gAortned7
,,,���,,, 1' ��► l•V V N t 1' h..2 I i%1E71 Yes ® No
tie. Were Autopsy Finding Available To Comple The Cause Of Death? 0 Yes ❑ No
31. Did Tobacco Use Contribute To Death? 32. If Female. \ 33. Manner Of Dee .
(L 0 Not Pregnant What Post Yen 0 PnwenlAITlmPreps 0 NatPr. srd\..iPreaentwwn02 Days OfDeath ® Natural 0 Ho Icicle 0 Accident 0 Pending Investigation
0 Yes 0 Probably 0 No ❑ Unknown 1en.n,nut Prepn.m a o.»TBole.ol 0 N Pra
f y..r e•le Omit 0 Unknown If Pr. m new, i.T Past Yew ❑ Suicide 0 ould Not Be Determined
34. Date Of Injury(Month/Day/Year) • 35. Time Of Injury 36. Place 01 Injury(E.G.:Decedent's Home,Construction Site,Res rant Wooded Area) 37.Injury At Work?
ipL,pL \ 0 Yes 0 No
I. 38. Location Of Injury-State .38a. City Or Town 38b. Street 8 Number ' 38c.Apt No. . 38d.Zip Code
y
39. Describe How Injury Occurred If Trannpce1 tion Injury, citify.
t7 DmmroP..m O P....npm P.a.ewn❑oth.,lsP.ntrt
,IIII r' 41.Signature, Of Person Certifying Cause Of Death: ,. 1- 4L Certifier(Check Only One)
111C KATHERINE NAOMI LAZET, BY ELECTRONIC SIGNATURE ` I Certifying Physician ❑ coroner 0 Health Officer
43. Name,Address And Zip Code Of Person Certifying Cause Of Death. - 44. License Number 45. Date Certified
KATHERINE NAOMI LAZET ,3838 N. 1ST AVENUE SUITE C, EVANSVILLE, IN 47710 - 02005302A 04/22/2020
��{., 46.Additional Funeral Service Provider. 47. 'Akas:
`,1 48. Signature of Local Health Officer. 49;"For Registrar Only -Date Filed (Month/Day/Year):
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE APR 22 2020
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AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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t 4 -\R-- - . - 30z - 000 . 'A ate - 0 -,k .
((( State
Form 53395 ATTENTION ESTATE:The Social Security#is being requested by this state agency in order to pursue responsibility. Disclosure Is voluhtary and there will be no penalty for refusal.
0YYI\R N I N G. ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL
TURNS FROM ORANGE TO YELLOW WHEN RUBBED.ORIGINAL.DOCUMENT HAS SECURITYPHOTOCOPIED.OINDIANA
A HIDDEN VOID ON FRONT THAT APPEARS WHEN ON BACK THAT