Death Certificate - Houston, Marie_11/4/2020 f,,,, --..a''• vw.crvm -r -- "y,es.yr *41," i/,eMr,._: � -s7 I;i f - - oljAW.kr� i,6'iylif ar r.
I • INDIANA STATE DEPARTMENT OF HEALTH
�': _ -1 .1 CERTIFICATE.OF DEATH
C \ 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.
I Local No 000071 FOR No 000000195142- - - State No 018139'
R. 1.Decedent's Legal Name(First,Middle,Last) 1a. Maiden Name(If female) " 2.Sex '3.Time Of Death -4. Date Of Death(Month/Day/Year)
1' MARIE M HOUSTON WOLFE FEMALE 12:20 PM 04/18/2011'
'\ 5. Social Security Number 6a.Age-Yrs 6b. Under 1 Year 6c. Under 1 Month 6d. Under 1 Day 6e. Under 1 Hour 7. Date of Birth (Month/Day/Year) 8.Birthplace(City and State or Foreign Country)
c
(:/. 93 Months , Days Hours Minutes '
0 Hospice Facility 0 Decedent's Home ® Nursing HomerLong-tern Care Facility '
(r^ ❑ Yes ® No 0 Unknown D Inpatient 0 Emergency Department Outpatient•
.❑ Dead on Arrival ❑ Ottjer •(Specify)
QF'.' 11. Facility Name(If Nat Institution,Give Street and Number) ` - - ,
// RIVEROAKS HEALTH CAMPUS • • . '
i . 12. City Or Town,State,And Zip Code 13. County Of Death 14. Marital Status At Time Of Death
f`
(`J ® Widowed❑ Married,❑ Never ❑ed ❑Unknown(r PRINCETON, IN,47670 •
GIBSON
:•,!.,-( 15. Surviving Spouse's Name 15a. (If Wlfe)Give Maiden Last Name 16. Decedents Usual Occupation 17. Kind Of Business/Industry
\(
t'•.; - SALES RETAIL
ti'( 18. Residence-State ' 18a. Count
y ty i - i , 18b. City Or Town
r` INDIANA • GIBSON PRINCETON • • . •
\,, 18c. Street And Number _ . 18d.Apt.No. 18e.Zip Code 18f. Inside City Limits?
` 1244 VAIL STREET 47670 ❑ Yes ® No
i ,.. 19. Decedents Education '20. Decedent Of Hispanic Origin 21. Dec_edent's Race -
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
1a•1 HENRY WOLFE . , ROSE-WOLFE GREUBEL
a
24.Informant's Name 24a.Relationship To Decedent - ' 24b.Mailing Address'(Street And Number,City,State,Zip Code)
N LARRY WOLFE SON • 201 EAST GIBSON STREET, HAUBSTADT, IN 47639 ,
Q -- 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
El Burial ❑ Cremation 0 Donation❑ Entombment - -
e 0 Removal From State - .
O 0 Other(Specify): SAINTS.PETER AND PAUL CEMETERY . HAUBSTADT, IN
- 26,Was Coroner Contacted? . ' 27. Name And Complete Address.Of Funeral Facility - - - 27a. Funeral Home License Number, '
❑ Yes ® No " '
WADE.FUNERAL HOME INC;119 S.VINE STREET, HAUBSTADT, IN 47639 FH83002990
27b. Signature Of Indiana Funeral Service Licensee: '• ' 27c. License Number(Of Licensee):
-I ALAN J.WADE, BY ELECTRONIC SIGNATURE ' FD01017F11
Cause Of Death (See Instruction's And Examples) /LE
r28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.lid Nei Enter Terminal Events e Approximate
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate:Enter Only One Cause On Interval. Onset
a A Line. Add Additinal Lines If Necessary. . •. NOVTo Death
•
0 Immediate Cause(Final Disease Or Condition Resulting In Death) , A." RECORD ON FILE WITH THE GIBSON COUNTY HEALTH DEPARTMENT. NOV 04 2020
Due;to(Or AsA Cona.quenoe On'
Sequentially List Conditions, If Any,Leading To The Cause Listed On . B. a to As wn..arnv op. 4 ��
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated _-Lf
A> The Events Resulting In Death)Last C. V /BipAr_�',�'l- ,;i
f,{, Dueto(OfAsAConeewenoeOft /�relw""
• l GIBSON COUNTY FuDiTOR
i rl
y Part II.Enter Other Significant Conditions Contributing to Death But Not Resulting In The Underlying Cause Givin In Part I 29.Was An Autopsy Performed?
0 Yes ® No
30.Were Autopsy Finding Mailable To Complete The Cause Of Death? ❑ Yes 0 No ._
iy�1i 31. Did Tobacoo Use Contnbute To Death? 32. If Female: - • - 33. Manner Of Death:
;t, ® Nui PregnartveAn PeOl Year 0 Pregnant Al Tina or Deem 0 Not PregnaN,But Pregnant Man 42 Dey.Of D..g, Natural 0 Homicide 0 Accident 0 Pending Investigation
0 Yes ❑ Probably 0 No 0 Unknown -
4 0 Not Pregnant But Pregnant 43 Day.Tel year Belo,.Death ' ❑ Unn,vm'It Pregnant Wink,Tn.Pas Ye., ❑ Suicide 0 Could Not Be Determined
t)(ii 34. Date Of Injury(Month/Day/Year) 35. Time Of Injury 38. Place Of Injury(E.G.,Decedent Home,Construction Site,Restaurant,Wooded Area) 37.Injury At Work?
y _ ❑ Yes ❑ No
tf.t 38. Location Of Injury-State 38a. City Or Town - 38b. Street&Number 38c.Apt No. 38d Zip Code
Qy l 39. Describe How Injury Occurred If Trans Gon In
pr_ 1 rYQ. Por�LI jtx,.aQpecify.
L U DrinrrOperator U Paisenger U Pedestrian❑Other(Spray)
rP 41.Signature, Of Person Certifying Cause Of Death: 42. Certifier(Check Only One)
'�� QUENTIN BRENT EMERSON , BY ELECTRONIC SIGNATURE . , El Certifying Physician 0 Coroner ❑ Heath Officer
43. Name,Address And Zip Code Of Person Certifying Cause Of Death: 44. License Number 45. Date Certified
QUENTIN BRENT EMERSON ,7861 S. PROFESSIONAL DRIVE, FORT BRANCH, IN 47648 ' 01027038A 04/19/2011
k.-- 46..Additional Funeral Service Provider - 47. 'Akas:
48. Signature of Local Health Officer. 49. For Registrar Only-Date Filed (Month/Day/Year):
,• BRUCE BRINK JR,BY ELECTRONIC SIGNATURE . - r, APR 26 2011
,, AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
gt.r,. ,
:i. State Form 10110 (R6/3-07) .
WARNING. TURNIS FROM ORANGE TO YELLOW WHEEN RUBBEDGORIG NALL DOCUME T HAIS A HIDDE V10 D PAPER
ON FRONT THAT A PEARS W N THE
PHOTOCOP EDINDIANA ON,BACK THAT