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`,,,;xrri,, • INDIANA STATE DEPARTMENT OF HEALTH r
1
= ) CERTIFICATE OF DEATH \\ 1'
' )4s.,/ ATTENTION ESTATE:The Social Security 8 is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary and there will he no penalty for refusal.
Local No 000028 EDR No 000000763199 State No
1.Decedent's Legal Name(First.Middle.Last) la. Maiden Name (If female) 2.Sex 3. lime Of Death 4. Date Of Death (Month/Day/Year)
ARRY FLOYD GEORGES MALE 12:10 AM 02/27/2020
5. Social Security Number 6a.Age-Yrs. 6b. Under 1 Year 6c. Under 1 Month 6d. Under 1 Day Be. Under 1 Hour 7. Date of Birth (Month/Day/Year) B.Birthplace (City and State of Foreign Country)
Hospital
❑ Hospice Facility ® Decedent's Home 0 Nursing Home/Long-term Care Facility
0 Yes El No 0 Unknown 0 Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival ❑ Other(Specify)
11. Facility Name Of Not Institution,Give Street and Number) ,
506 SOUTH CUMBERLAND STREET
12. City Or Town,State,And Zip Code 13. County Of Death 14. Marital Status At Time Of Death
® Married❑ Married.But Separated 0 Divorced
=ORT BRANCH, IN,47648 GIBSON 0 Widowed 0 Never Married 0 Unknown
15.Surviving Spouse's Name 15a. (If Wife)Give Maiden Last Name 16. Decedent's Usual Occupation 17. Kind Of BusinessAndustry
JANET GEORGES ,CURL RAILROAD ENGINEER TRANSPORTATION
i8. Residence-State 18a. County 18b. City Or Town.
NDIANA GIBSON FORT BRANCH
18c. Street And Number 18d. Apt.No. 18e. Zip Code 1Bf. Inside City Limits?
El
506 SOUTH CUMBERLAND STREET 47648 Yes ❑ No
19 Decedents Education V 0. [Decedent OI Hispanic Origin 1 21. Decedent's Race
iIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC WHITE
22.Father's Name(First Middle,Last) 23.Mother's Name(First,Middle,Last) 23a.Mother's Maiden Last Name
=LOYD GEORGES MILDRED GEORGES GREUBEL
24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address (Street And Number,City,State,Zip Code)
JANET GEORGES _ SPOUSE 506 SOUTH CUMBERLAND STREET, FORT BRANCH•IN 47648
25.Place Of Disposition
25a.Method Of Disposition 25b.Place Of Disposition(Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State
$ Burial 0 Cremation 0 Donation 0 Entombment
❑ Removal From State
D Other(Specify): ST BERNARD CATHOLIC CEMETERY FORT BRANCH, IN
26.Was Coroner Contacted? 127. Name And Complete Address Of Funeral Facility 27a. Funeral Home License Number.
❑ Yes El No ISTODGHILL FUNERAL HOME INC,500 E PARK ST HWY 168, FORT BRAN FH10900013
27b. Signature Of Indiana Funeral Service Licensee: 2 cense Number(Of Licensee):
4NDREA LYNN STODGHII_L, BY ELECTRONIC SIGNATURE D21400005
Cause Of Death (See Instructions And Examples)
28.Part I.Enter The Chain Of Everts -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Te final Events roximate
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Wthout Showing The Etiology.Do Not Abbreviate.Enter my One C nix_ Int I: Onset
A Line. Add Additinal Lines If Necessary. To Dee
Immediate Cause(Final Disease Or Condition Resulting In Death) A. METASTATIC ADENOCARCINOMA GAL LADDER ( 2 MONTHS
b(a A.A CornepuaEry.Oe: -.HN.ac
Sequentially List Conditions, If Any,Leading To The Cause Listed On B.
line A. Enter The Underlying Cause(Disease Or Injury That Initiated w.to(Or A.A Can.eq>noe on: g
The Events Resulting In Death)Last C MAY 2 6 2020
Ou.to(Or A.A Consequence On:
D.
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Part II.Enter Other Significant Conditions Cont butinq to Death But Not Resulting In The Underlying Cause Givin In Part I 29. Was An Autopsy PeA es No
VIETASTATIC ADENOCARCINOMA GALLBLADDER - - 1 30.wereAut9* it ve3ie4J t I140'4 14 r;rtDeath? ❑ Yes ❑ No
31. Did Tobacco Use Contribute To Death? 32.1 If Female: T 33. Manner Of De: . ---
❑ Not Pregnant WaNn Pail v.., ❑ Prep".nt At Tana Of Death 0 Nat Pr.(gura.out Pr.gn.ra WOO ..ys or own ® . -omicide 0 Accident 0 Pending Investigation
0 Yes 0 Probably® No 0 Unknown ❑ Not Preprint,But Pta t a o To .Propane, ay. year Demre Death 0 linkman°Pnvant WthI,tM Past Year 0 Suicide 0 Could Not Be Determined
34. Date Of Injury(Mont fDay/Year) ' 35.Time Of Injury 38. Place Of Injury(EG.,Deceden't Home,Construction Site,Restaurant,Wooded Area) 37. Injury At Work?
❑ Yes ❑ No
38. Location Of Injury-State - 38a. City Or Town 38b. Street 8 Number 38c.Apt.ND. 38d. Zip Code
39. Describe How Injury Occurred g(I. If Transportation Injury,Specify.
❑Drnarropentm ❑Pa>•anpar PaaCNn 0
ornu(tp.dtfI
41. Signature,Of Person Certifying Cause Cf Death: 42. Certifier(Check Only One)
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A RRY WILLIAM LUT7_, BY ELECTRONIC SIGNATURE ® Certifying Physician ❑ Coroner 0 Heath Officer
43. Name,Address And Zia Code Of Person Certifying Caus.o Of Death: 44. License Number 45. Date Certified
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ARRY WILLIAM LUTZ , 802 E. OAK ST.,.FORT BRANCH, IN 47648 01027538A 02/27/2020
48.Additional Funeral Service Provider 47. •Akas:
48.Signature of Local Health Ot6cer. 49. For Registrar Only -Date Filed(Month/Day/Year):
3_R_UCE BRINK JR,BY ELECTRONIC SIGNATURE FEB 28 2020
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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irate Form 10110 (R6/3-07)
WA P I i�.l ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT