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TIIEMMING1-..:,.'-'....'•• '... ..•-•-•-...z.,... •,...,• ....„ •::,..,..RMALE',.••••-•:3 ‘.47.:Pirli:•--=::... ,..F.c..=•...;,,b /g012016?-,/,':••••'...;;;,•.,,:--;•-: • •5'Social Security Number•••eia.Age,i Yrs % 613: Under 1 Year •6c.-;Under 1 Monthird. Under 1 Day.•; ',5e==j-LIndeel Hour 7:,.'Date of Birth,;(Month(Day/Year) •'E.Birthplace(City east Slate or Foreign-CoUnhy) ••• - '-% Hospital- ',•''', rii• ?, •„,„/,' i•: ,:•,- ,,• . :, • "::.•-, , '''-• ,,, • ;,...•••,,,,, ''";!:;,, .";•i%••;:i.,-,": '''',,•-•...„:41; 0 Hospice.FaOility a Decedents`Horne' '0,Nursing Home/Long-tenn Care Facility 1), 0;yes ISI No 0 Unknown 0,rinpatient 0 Emergency Departnlenttiutpatient Ej Dead anAray 10 oiheiSpeCify) , ••••• , -. • ' . "•';•• =,•'' ,` \=:•,:i W 11. Facility Name,;(If Not Institution,Give Str,eet and Number) .: -•,„: ;.- •;••.• =-':; -. ' , i %, % ",, '% ', i, ', ', • " ` '', ''• •; • ' 6760 WEST-.450-SOUTH", .' , ,, , , . „ , •-• • K ; "-,', '7, I- :. .. r. . • .. -; -,• ,s. • -' '- ,k 12 City Or Town State And Zip Code ; • :, , • , .. 13. County Of Death • : ",i ' ' 14.'Marital Status At Time Of Death Yl' • • , . „ , , Manied 0 Married,But Separated 0 Divorced , . 4-... OWENSVILLE,IN,47665, , • s " '‘. -'s ' GIBSON .---,,,, '., •-• - 0 Wdowed ' 0 Never Manied 0 Unknown -,.., 15 Surviving Spouse's Name • ,• .15a. (If lAfife)GiVe Maiden Last Name • •,•• ., 16. Decedents Usual Occupation ; '17, Kind Of Business/Industry "•' JEFFREY DUNN ROUDEBUSH .,• - . -'. -'. ; i i , = • TEACHER . • : EDUCATION. (... .16. Residence-State.•• '.," z•.. ,,,• • 18a. County . 18b. City Or Tciwn ' „:: .,=• , , . V . / -, . . . ,v INDIANA -•' ''.• • ' GIBSON . -..• .. ••-:,.• ,••••.•-•., OWENSVILLE •,:•;.., '...;;1;,.. •,,..,• . • -• • '',c z' ' ,1;--:•,, 18c. Street And Number ', ;; •• ,, ; 18d.Apt.No. 18e. Zip Cede 18f. Inside city Limits?• cri, ' : • _L • • ' . , • , ,/ : : % " • % . \` ;,..:, ...•`•"•', „ • 0 Yes Ei No 6760 WEST 450 SOUTH ' • - , : - •• .., - - ..•, , ' ', Z -: ,- : . -- ' -- - • 47665 , . ,. . ip. Decedent's Education , ; %..., "„ ,. ,- 20. Decedent Of Hjspanicrigin• % , .," -•,. 'I,"21.Decedepti s Race/. .,., , . .. i'. MASTER'S DEGREE(MA MS MENG, • • . , • , . . . W. MED/NtSW, MBA) •1 - ‘, - NOT HISPANIC - ---,,, . •' '', ,'S\,.. White ,,,,•.,. ,•., ,.0 22.Father's Name(First,Middle.Last) :- • ' : -•, ,. ',. •-„. == ,./ ,; 23.Mother's Name(First Middle,Last) • - 23a.Mother's Maiden Last Name /'' • -' ,• \';'>,s'. ' ' , s "` , , • i• ":; •, :,. %.. • ."sii ,i• .=.' ',. ••i ., ,-: , ,•.,- .;• • ', ", , : , -', , DONALD ROY STREMMING , . .., . ,. ' RATRINA'STREMMING- ', .. - ,: MCKEE- . . . : it 24.Infon-nanteName-, ,• ,- = , "• 24a.Relationship To Decedent i.,„ ,•24b.Mailing Address (Stre,et Apd NLimher,City-State,Zip Code) ,, '-,;" . ' . ,••••• ; . \ ,' •. .,. CI JEFFREY DUNN ROUDEBUSH HUSBAND .:""..••:, , '''''‘, 6760 WEST,,450SOUtH,OVVENSVILLE, IN 47665, , • -,. ,:.' '... -,•...:. 25:Place OfDisposltion %,• ;'•/ ; % •: "• • : ,• , , . • . , „cc 25a.Method Of Disposition ,' •.• % ' ,2 25b.Place Of Disposition'(Name Of Cemetery,Creepatory.Other Place) • 25c.Location:-City,Town,And State ' ;.. : • . • , = ..•,- •„,-, .,; •„,, CC .El-Burial 0 Cremation 0-Donation b Entombment , , ; ' • . , . I-1.1 11 Removal From State ' / , , ,,,... ' ," "„'. ' . ...• ; . ,.., . CC , 0 Other(Speciiy):,„/' ,...„ • • ,,,, •.; " OWENSVILLE CEMETERY , , ,;'.. OVVENSVILLE, IN' ,, • 0 • 26.Was Coroner Contacted? ' "; , 27. Name And Complete Address Of Funeral Facility, ‘,/'",., .:•:, • ,,,,, .••";. ; -'''.." ';: • • ' , 27a. FurTral Home;License Number O 'Yes No HOLDERS FUNERAL HOME OBSON•COUNTY, INC,,319-SOUTH MAIN STREET IA , , --„. • 0 El OWEN8VILLEAN'47665 , , - -., , :, •••.:.-. : N : •. • . FH89000021 ; •, .. ' LLI 27b. Signatum Of Indiana Funeral Service Licensee: ' , ; • • ii. • , ) •,=, , ,z. , ", ,, 27c.License Number(Of Licensee): • I.- RANDALL K'DIKE , BY ELECTRONIC SIGNATURE , / i'- . %,„ ,- ; -..- • ; :' , FD01010177 , .. , . , _.1 . . • •,.. , . - Cause Of,Death (See Instructions And Examples) „, ,. . s••• . • . .,- „ , < " Approximate , 28.Part LcEnter The Chain Of Events -Diseases,Inj6ries,Or ComplicatiOnS-,,Thatbirectly.Ciused The Death.Do Not gnter,Terminal Eyenia , • ,.., ,•, interval Onset ,,. LI- Such As Cardiac Arrest Respiratory Arrest Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate:Enter Only One Cause On , To Death • • - ' A Line. Add Additinal Lines If Necessary. , ' ' , . • • .'• / •, ;-, ': . ;•. O , • : - " Imrriediate"Cause(Fin"al DiseaseOr Condition Resulting In Death) A `DEHYDRATION "= • ; ,.. . , , ' -. -:- •• „ „•,, , : 1 WEEK• 0 •,,, , ,,,,;, ;cv.1 o(Or As 4 Conrquence 01):. • . • . • > . „ , „ , ,B. DYSPHAGIA- '-' - , : -• ' ", Sequentially List Conditioni, If Any,Leading/To The Cause Listed On ' 1 WEEK . •-. Line A. Enter The.Underlying Cause(Disease Or Injury That Initiated • • ', ....:/ -. ", ; ; - ' • , ,, . The Events Resultirig.tri•Death)Last '' C. •UROStrSIS " ' : - : .-- == ' ,: , 1 WEEK - . , , ' . , ', ., ,-, • ' :,'DY,"°101 A.4,C44:4egtfertee pn:s. t , - :,- tit.'n. : ,, , ,,- , • . ' ,.., ?, ;, .,, ...; '•. • , - , ' •APPROX,10 , 'YEARS .....‹-: , . . D. •OLIGOPONTOCEREBECLARATROPHY'-',. ' z . . , . D. , , .,, ,, - , , „ r .Part IL Enter Other Significant Conditions COntributino to Death But Not Resulting In The Underlying Cause Gain In Part I " "•29:-Was An Autopsy Performed? ..•5-•`, r, • , . , ,, ,..„. ,0 Yes 1:81 No , , '• „•--,,. „ •'..„„, ;.,•„„;. „,,,,.. 30,Were Autopsy Finding Available To Complete The Cause Of Death? 1:-. U Yes 1:1"No NONE TO REPORT , . /I".., 31. Did Tobacco Use Coptrihute To Death? 32. It Female: • • r s = •' - ‘•„„. -.-•,,,, -,,, ; /.' -, ', • , , 33.•Manner Of Death •" •=.‘•••:- '";' ....., ' , 0 ; .: . , '0 Nol Pregna re 1,441.101 Past Year Ei.p,;‘,..n,41"Yene Of Death ti Ni Pregant.but Pr4fnent rellen 42 Dar Of 13e;s1h ...` • .. . . . t. ISI Natural 0 Homicide;1:1 AcCident 0'Pending Investigabon • "•-•:- 0 Yes 0 Probably El No 0 Unknown , 1:1 Not erpg.m.aii'l Negnent 43 Dip 1"4 1 year eirorio.iji, ,0Unknovrill Pre•A4411411.4 Peal Year , "' b Suicide 0 Could Not Be Determined , •, • ,- 34. Date Of Injury(Month/Day/Year) % 35.Time Of Injury , • Place f In - -dents,Horne Construction Site;Restaurant,Wooded Area)•• 37. Injury•At Work? `...• ' , .. . ,., . No , . `'s• - g•n 38. Location Of InjurY-Blate . ' 38a. City Or Town ••.• ., treet 8 Number„ : . . 38c.Apt No. / ,38d.,ZipCode, .•• ;. _ -, • ; • .• '• , . \ „ . . , . , . . . p. .:-39-Describe How.lnjury.Occurred , _._ ,'" 40. If Transportation litjuly,.§_pecify. ,, . ' - ••• - ••• - •••., • '.• ,'' • ' „, ElDrlyarOperator ElPassenger Li Padearion DOther(Speeity) . , „ , 41.Signstdre(Of Person,Certifying Cause Of Death: , _, = '= : -,, • ,,: i • .• , ,,. 42. Certifier(Check Only One) , . , . , b MICHELLE LEE SNYDER,'BY ELECTRONIC-SIGNATURE , , . , . -, •••, -•,--- .. Ei Certifying Physician -, 0 Coroner 0 Heath Officer 43. Name,Address And Zip Coda Of Person Certifying Cause Of Death: 41,Thl ai3-reOUt:,,ITy iliMprryi!: -;; %,- . •• 44. License Nuinber - 452,Date Certifiecl ;I - i\,,ii, ; . , , ' • ; ,, .,, , r ( _,' ; ; •,. ; , MICHELLE LEE SNYDER , PO BOX 948-328 N 2 ND ST,;SUITE 102,•VINCENNES;IN 47591 :. • 02001984A. , , , . 02/24/2016 . , .„, ,A . ,46,,AdgitipnalFunpralServiceyrovider.•,„„, ••-' ' , ., 48 Signature of LocarHealthOfficeP.- ' ',„ •:,..; ?; . 3 , „;,"/',.., ";1, -; ;.••••••••,,,,;•"„•".•,„• .,"•i •••• .,..,'- .•,.,=, 40 or Registrar Only‘-Date Filed (Month/Day/Year) ',;. • ,;„,/ - • • ".• ':. s,,, BRUCEBRINK•jR VIA ELECTRONIC SIGNATURE. •,-.:-., •t. -.;- •i..: •..-, •,.....f......:: ;:.:. ..•,.:..- :: -. -,. :-.,.. 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