Death Certificate - Fishback, Dustin_10/21/2020 p�� •0.`='°4 INDIANA STATE DEP i MENT OF HEALTH .
if �� �\
'�'`� ;"` � CERTIFICATE OF DEATH '
li
��° � Local No 00.0109 • EDR No 000000577436' State No 02522$'-
��% 1.Decedent's Legal Name(First,Middle,Last) la. Maiden Name'(If female) 2.Sex 3.Time Of Death , 4. Date Of Death(Month/Day/Year)
it DUSTIN MATTHEW FISHBACK • MALE' 06:00 AM 05/11/2017
5.Social Security Number 6a.Age-Yrs 6b. Under 1 Year 6c. Under 1 Month 6d. Under 1 Day 16e. Under 1 Hour 7. Date of Birth(Month/DaylYear) 8.Birthplace(City and State or Foreign Country)
;'!
10.If Death Occurred In A Hospital: 10a. If Death Occurred Somewhere Other Than A Hospital
$� , ❑Hospice Facility 0 Decedent's Home ❑Nursing Home/Long-term Care Facility
(t' 0 Yes El No ❑Unknown 0 Inpatient ID Emergency Department Outpatient 0 Dead on Arrival, (0 Other(Specify) - COUNTY ROAD
' 11. Facility Name(If Not Institution,Give Street and Number)
700 WEST 400 SOUTH
1?/ 12. City Or Town,State,And Zip Code _ 13.County Of Death 14. Marital Status At Time Of Death
®Married 0 Married,But Separated ❑Divorced
OWENSVILLE, IN,47665 GIBSON . ❑Widowed 0 Never Married 0 Unknown
l 15. Surviving Spouse's Name 15a.Last Name Before First Marriage 18. Decedent's Usual Occupation 17. Kind Of Businessllndustry
la
(alREBECCA ANN FISHBACK BROWN COAL MINER COAL
18. Residence-State 18a. County 18b. City Or Town -
LL" INDIANA . GIBSON • OWENSVILLE .
,r - -
I) 18c. Street And Number 18d.Apt No. 18e. Zip Code 18f. Inside City Limits?
7874 SOUTH WILLOWBROOK COURT 47665 ®Yes 0 No
V' 19. Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedent's Race
' a ASSOCIATE DEGREE(AA,AS) NOT HISPANIC White
{(.ram
11 22.Parent's Name(First,Middle,Last) 23.Parents Name(First,Middle,Last) 23a.Parent's Last Name Before First Marriage
UNKNOWN CARLA YVONNE JACOBS FISHBACK
s 24.Informant's Name 24a.Relationship To Decedent 24b.MailIng Address(Street And Number,City,State,Zip Code)
REBECCA ANN FISHBACK WIFE 7874 SOUTH WILLOWBROOK COURT,OWENSVILLE, IN 47665
-I 25.Place Of Disposition
a■ 25a.Method Of Disposition 25b.Place Of Disposition (Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State❑Burial ®Cremation 0 Donation 0 Entombment . ,
a 0 Removal From State
• ❑other(Specify): SOUTHERN ILLINOIS CREMATORY BENTON, IL
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility 27a Funeral Home License Number.
la
�■ ®Yes ❑No BOONE FUNERAL_HOMES, INC_ ,5330 WAS'rIINC;TOIV AVE EVANS\'IEEE, IN 47715 _ FH88900004 ___
27b.Signature Of Indiana Funeral Service Licensee: i 7c. License Number(Of Iucensee):
JEREMY E.JORDAN , BY ELECTRONIC SIGNATURE I FD20400003
• ' Cause 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 •
t's Interval: Onset
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 Additional Lines If Necessary.
• Immediate Cause(Final Disease Or Condition Resulting In Death) A. BLUNT FORCE TRAUMA OF THE CHEST. . • IMMEDIATE
Doe ro(Or As A Consequence Op' .
i
Sequentially List Conditions, If Any,LeadingTo The Cause Listed On
� q Y Y B' weto(aA,Aco..gre�OD:
j l Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last C. ''I • '
.I : Ow to(Or As A Conwgnnoe Or):
.1 • D. ''
t.
Pr
Part II.Enter Other Significant Contributing to Death But Not Resulting in The Underlying Cause Given In Part I 29.Was An Autopsy Performed? • ®Yes 0 No
MOTOR VEHICLE ACCIDENT 30.Were Autopsy Finding Available To Complete The Cause Of Death?' ®Yes 0 No
0 31. Did Tobacco Use Contribute To Death? 32. It Female: 33. Manner Of Death:
0 Not Pregn.lveen Pare Year ❑Pregnant Al Tina OfDeals ❑NotPrapuN,B,ePrep,uMxtlhinQDeyeOfOeen 0 Natural 0 Homicide ®Accident 0 Pen inglrnestigation
0 Yes 0 Probably 0 No ®Unknown •
�(/►� El Nat Preptur�ea Pregnant 43 Days To I year Before p.m 0 uoe.,,'d Pre�untvX.tln TM Pert veer 0 Suicide 0 Could Not Be Determined .
((,r. 34. Date Of Injury(Month/Day/Year) 35. Time Of Injury 36. Place Of Injrr•r(E.G.,Decedent's Home,Construction Site,Restaurant,Wooded Area) 37..Injury At Nark?
TTIlPP 05/11/2017 Unknown 700W 400 S '' ❑Yes ®No
It-! 38. Location Of Injury-State 38a. City Or Town 38b. Street 8 Number 38c.ApL No. 38d. Zip Code
��yJ
14-
q INDIANA OWENSVILLE 0000 Q W 4 WEST 0 47665-0
39. Describe Haw Injury Occurred '. 40. If Transportation Injury, eclty:
® v 2 Ortc. pereror ❑Pa mercer �PseetN en❑O (Swift)er(Swift) f
'cf.' SINGLE MOTOR VEHICLE COLLISION WITH TREE RESULTING IN VEHICLE COMBUSTION ,r A A .
v{ 41. Signature, Of Person Certifying Cause Of Death: 42.Certifier(Check Only One)
MISTY G. HOKE, BY ELECTRONIC SIGNATURE • ❑certifying Physician ®coroner ❑Health Officer
0, 43. Name,Address And Zip Code Of Person Certifying Cause Of Death O C T 212020 44.License Number 45. Date Certified
NMISTY G. HOKE ,203 S. PRINCE ST., PRINCETON, IN 47670 05/19/2017
46.Additional Funeral Service Provider. ., 47.'Akas:
CAMPBELL FUNERAL HOME 609 W MAIN CARMI IL
kl48. Signature of Local Health Officer. 9. For Registrar Only -Date Filed(Month/Day/Year):
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE GIBSON COUNTY AUDITOR MAY 22 2017
) I ' AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
I
•
;C. 6- 1l- - \-2o0 -0 05 co \\ -�21
R4 State Form 33955 ATTENTION ESTATE:The Social Security#is being requested by this state agency in order to pursue responsibility. Disclosure'is voluntary and there will be no penalty for refusal.
l� WARNING. TURNS FROMOORANG TO YELLOW WHEN RDUBBED.ORIGINAL DOCUM NT HAS ASHIDDEN O DPON FRONT THAT APPEARS WHEN PHOTOCOPIED.RA ON BACK THAT