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f=l s,�'n'�, INDIANA STATE DEPARTMENT OF HEALTH _
. sa ) CERTIFICATE OF DEATH -RESUBMIT'
� ° ATTENTION ESTATE'The Social Security#is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary and thetew,be no penalty for refusal.
t�;il Local No 000128 EDR No 000000792641 State o e 940 ��
fti 1.Decedent's Legal Name (First,Middle,Last) la Maiden Name(It female) 2.Sex 3$0 :
Tim-)•r-^ea '` 4. Date Of Death (Month/Day/Year)
9 -
t� ❑ Hospice Facility 'a Decedent's Home 0 rsing Home/L le re acit 'Qt.
I)`f'- ' ID Yes 0 No 0 Unknown 0 Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival ❑ Other(Specify) n,�'�\
`'. 11,'Facility Name(If Not Institution,Give Street and Number) - .' -
107 EAST MULBERRY STREET ,.�.LL��vN�
!g%( 12. City Or Town,State,And Zip Code ., 13. County Of Death: 1�JRlfantal Status At Time Of Death
r` �eS ❑ Married❑ M,aried,But Separated ® Divorced
I- FORT BRANCH, IN,47648 GIBSON G ❑ Widowed ❑ Never Manied 0 Unknown
I;.,.\: 15. Surviving Spouse's Name 15a. (If Wife)Give Maiden Last Name 16. Decedent's Usual Occupation 17. tOnd Of Business/Industry
t�:/ ASSEMBLY MANUFACTURING
)•,r 18. Residence-State 18a. County -18b. City Or Town •
ir INDIANA GIBSON - FORT BRANCH
:, 18c. Street And Number lad. Apt.No. 18e.Zip Code 18f. Inside City Limits?
` El Yes ❑ No
t.
107 EAST MULBERRY STREET 47648
19. Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedent's Race
v HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC ' WHITE
I 22.Father's Name(First,Middle,Last) 23.Mother's Name(First,Middle.Last) 23a.Mother's Maiden Last Name
C��
C JACK HALL THELMA HALL . MEYER
CI24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address(Street And Number,City,State,Zip Code)
W N STACY HAGAN DAUGHTER 901 HOING ROAD, EVANSVILLE, IN 47725
Q 25.Place Of Disposition
CC 25a.Method Of Disposition 25b.Place Of Disposition (Name Of Cemetery,Crematory,Other Placa) 25c.Location-City,Town,And State '
W ® Burial 0 Cremation ❑ Donation 0 Entombment
CC 0 Removal From State '
0 0 Other(Specify) BLYTHE CHAPEL CEMETERY . OWENSVILLE, IN
CI 26 Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility , 27a. Funeral Home License Number
CCM Yes 0 No
W STODGHILL FUNERAL HOME INC, 500 E PARK ST HWY 168, FORT BRANCH, IN 47648 FH10900013
27b. Signature Of Indiana Funeral Service Licensee: 27c. License Number(Of Licensee):
-I ANDREA LYNN STODGHILL, BY ELECTRONIC SIGNATURE FD21400005
Q Cause Of Death (See Instructions And Examples)
LL 28.Part I.Enter The Chain Of Events -Diseases,Injunes,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Approximate
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate Enter Only One Cause On Interval: Onset
0 A Line. Add Additinal Lines If Necessary. To Death
O Immediate Cause(Final Disease Or Condition Resulting In Death) A. RESPIRATORY FAILURE MINUTES
> Dv.to(a A.A cona.ameeoe oq-.
.0.d
Sequentially List Conditions, If Any,Leading To The Cause Listed On B. PULMONARY HEMORRHAGE ASSOCIATED WITH LUNG CANCER MINUTES
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated oe.to(Or AsACo,.ma...op
0 The Events Resulting In Death)Last C.
Due to(a A.A Consequence on
D.
Part It Enter Other Significant Conditions Contributing to Death But Not Resulting In The Underlying Cause Givin In Part I 29. Was An Autopsy Performed? ❑ Yes ® No
r HYPERTENSIVE CARDIOVASCULAR DISEASE, CHRONIC OBSTRUCTIVE 30.Were Autopsy FindigAvailableToCompleteTheCauseOfDeath?
./1 31.PULMONARY
e DISEASE El Yes 0 No
Death? 32. If Female: 33. Manner Of Death:
W.
0 Not Pr.,,are veten Peal Year 0 Preprint Al Tne or own 0 Not PreQirt,Bel P,.Q,.nrWInn 42 Deye a Death ® Natural 0 Homicide 0 Accident 0 Penang Investigation
J ® Yes 0 Probably 0 No ❑ Unknown
i1 ❑ Not Pregnant,But',levant a3 Days To 1 year Were Death 0 Unluva,n If Nagnant Wesel The Pal Year ❑ Suicide 0 Could Not Be Determined
r'1 34. Date Of InjuryMonthrD /Yea 35. Time Of Injury 36. Place Of Injury E.G.,Deceden't Home,Construction Site,Restaurant,Wooded Area) 37. Injury At Work?
Lr ( aY r) try 1rY( C try
k_x - ❑ Yes ❑ No
0 38. Location Of Injury-State 38a. City Or Town - 38b.Street 8 Number ' 38c.ApL No. 38d.Zip Code
f',r// 39 Describe How Injury Occurred 4 . If Transpor(�pon Injury,$pedfy:
,&/ I�Dm.nopenmr O Paa.rger❑Peafrnn 0 Ortrr(sp.ceyl
41. Signature, Of Person Certifying Cause Of Death: , • ' 42. Certifier(Check Only One)
r ❑ Certifying Physician ® Coroner 0 Heath Officer
•\ MISTY G. HOKE, BY ELECTRONIC SIGNATURE _
:tri 43. Name,Address And Zip Code Of Person Certifying Cause Of Death: 44. License Number 45. Date Certified
v
F/' . MISTY G. HOKE ,203 S. PRINCE ST., PRINCETON, IN 47670 07/22/2020
; 46.Additional Funeral Service Provider, . , - 47.*Aires:
•1 48. Signature of Local Health Officer 49. For Registrar Only-Date Filed(Month/Day/Year):
BRUCE BRINK JR,BY ELECTRONIC SIGNATURE I .
'
9:07/21/2 (..)
1 ' 4:2020/07/1645:7/17/20620 12 OO OO AM _ Z02 r oy,. 45:07n1n20000 ,
Qa6r 4:2020/07/16 /(v1
45:7/17/2020 12:00:00 AM
ti/ State Form 10110 (R6/3-07)
WARNING: TURNS FROMCORANGE TO YE LOW WHEN RUBBED.ORIG NAODOCUMELNT HATS A HIDDEN VOID ON FRONT THAT AP E RSOWH NE PHOTO CO PIFDD
IANA ON BACK THAT
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