Death Certificate - LeGrange, Elmer_11/17/2020 Qt,�:•...Al w�rr_�,fr,.:.4,�-evvrAmr r-vr .7rKWv_�•'• --,,rvAcc[r"-T ---- -- -- :%��7P,,CC,-ram -ir,i' e-s7 7-At.f $w'C lr�.Fi r4 .'31
Wt INDIANA STATE DEPARTMENT OF HEALTH
�' 64') CERTIFICATE OF DEATH .
)'t d.1 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.
Local No 000167 EDR No 000000805987 = state No 052342 -• . ' 0
1.�Decedent's Legal Name (First,Middle,Last) la.Maiden,Name (If female)' 2.Sex r 3.Time Of Death 4. Date Of Death (Month/Day/Year)
rr ELMER LEGRANGE •t",I MALE 11:30 PM 09/22/2020
6''- 5. Social Security Number 6a.Age-Yrs 6b. Under 1 Year Sc. Under 1 Month Sc. Under 1 Day 6e Under 1 Hour 7. Date of Birth (Month/Day/Year) 8.Birthplace (City and State or Foreign Country)
f .
Ppi/, IMMO 98 Months Days Hours Minutes FORT BRANCH, IN
p 9:,Ever in U.S.Armed Forces? 10.If Death Occurred In A Hospital. , 10a. If Death Occurred Somewhere Other Than A Hospital
t�� -. ❑ Hospice Facility ® Decedent's Home ❑ Nursing Home/Long-term Care Facility
(,f' ® Yes ❑ No 0 Unknown 0 Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival ❑ Other(Specify) '
Ill\' -
r,'- 11. Facility Name (If Not Institution,Give Street and Number) .
701 EAST JOHN STREET - , ,
%. 12. City Or Town,State,And Zip Code -13. County Of Death I; . ty 14. Marital Status At Time Of Death
0 Marred❑ Married,But Separated ❑ Divorced
Egrf. FORT BRANCH, IN,47648 • GIBSON ❑ Widowed ❑ Never Married 0 Unknown
1 r 15 Surviving Spouse's Name 15a. (If Wlfo)Give Maiden Last Name 18. Decedent's Usual Occupation 17. Kind Of Business/Industry
NORMA LEGRANGE HADFIELD TRUCK DRIVER MANUFACTURING
�r7( 18. Residence-State 16a. County lab: City Or Town
INDIANA GIBSON FORT BRANCH
r 18c.Street And Number
I''' - 18d. Apt_No. 18e.Zip Code 1St, Inside City Limits?
701 EAST JOHN STREET I 47648 ® Yes ❑ No
) : 19. Decedent's Education 20. Decedent Of Hispanic Ongin - 21. Decedent's Race
; HIGH SCHOOL GRADUATE OR GED
Q COMPLETED NOT HISPANIC WHITE',
\Y 22.Father's Name(First,Middle,Last) . , 23 Mother's Name(First,Middle,Last) 23a.Mother's Maiden Last Name
WILLIAM LEGRANGE LIZZIE LEGRANGE BLACKARD
.//
Q 24.Informant's Name 24a Relationship To Decedent 24b.Mailing Address(Street And Number,City,State,Zip Code)
W NORMA LAGRANGE WIFE - . - 701 EAST JOHN STREET, FORT BRANCH, IN 47648
Q 25 Place Of Disposition
cc 25a.Method Of Disposition 25b.Place Of Disposition (Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State
IIJ ® Burial i Cremation 0 Donation❑ Entombment '
cc
❑ Removal From State ,
0 • 0 Other(Specify): WALNUT HILL CEMETERY ' ' ,FORT BRANCH, IN •
0 26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility • . 27a. Funeral Home License Number.
C I 0 Yes ® No
CC STODGHILL FUNERAL HOME INC, 500 E"PARK ST HWY 168, FORT BRAN H, IN 47648 FH10900013
I.I. 27b. Signature Of Iniana Funeral Service Licensee: - 27c. U se ber(Of Licensee):
ANDREA LYNN STODGHILL, BY ELECTRONIC SIGNATURE. , ' ' FD2 0 ,
Q Cause Of Death (See Instructions And Examples) ��y
LL_ '28,Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Approximate
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibnllation Without Showing The Etiology.Do Not Abbreviate Enter Only One Cause On -4 Interval. Onset
CI A Line. Add Addibnal Lines If Necessary. .� To Death
/1/ Al LtAJ I
O Immediate Cause(Final Disease Or Condition Resulting In Death) A. COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE 0/ YEARS
, Due lo(Or As Acoiupueno on �t
72 AI LtArl 1U
B. NONRHEUMATIC AORTIC VALVULAR DISEASE
`0�o YEARS
Sequentially List Conditions, If Any,Leading To The Cause Listed On o,.to(O
kr Line A. Enter The Underlying Cause(Disease Or Injury That Initiated �j' '0'
�� The Events Resulting In Death)Last C. i C.
Due to(Or As A Carmpue ce 0
j/, D.
NTY .
Part II.Enter Other SionlficantConditions GorrtributinD to Death But Not Resulting In The Underlying Cause Ginn In Part I 29.Was An Autopsy Performed? t��l 23No
1 ` ESSENTIAL HYPERTENSION,CHRONIC KIDNEY DISEASE 30.Were Autopsy Finding Available To Complete TTheeauseOfDeath? ❑ Yes 0 No
p\\ 31. Did Tobacco Use Contribute To Death? 32. If Female: 33. Manner Of Death:
/gyp 0 nor Pr.. Vann Put Y..r 0 Pregnant Al Dale or Deem 0 not vf.on.rt so Pregnant wn.n as Days orb..rn El Natural 0 Homicide 0 Accident 0 Pending Investigation
0 Yes ❑ Probably 0 No 0 Unknown
klr`
El net Pregnant,IPA Pregnant A3 Days To 1 seer Babe Dean ❑ Lin ussern IfPf.prani venter The Past Year 0 Suicide 0 Could Not Be Determined
1
g;l' 34. Date Of Injury(Month/Day/Year) 35. Time Of Injury 38 Place Of Injury(EG.,Decedent Home.Construction Site,Restaurant,Wooded Area) 37. Injury At Work?
1 * - ❑ Yes ❑ No
+l1/'���`F 38. Location Of Injury-State 38a. City Or Town 38b. Street 8 Number 38c.Apt.No. 38d. Zip Code
ID;C 39. Describe How Injury Occurred N.If Transpor�gon Injury,�ar�fy:
,V ❑om.rrop«amr O P.re,q«❑'P.arnun❑oew fsoer+.'rl
r . 41. Signature.Of Person Certifying Cause Of Death 42. Certifier(Check Only One)
r.
1`• MICHELLE LEE SNYDER,BY ELECTRONIC SIGNATURE . ' , • El Certifying Physician 0 Coroner 0 Heath Officer
�/5 43. Name,Address And Zip Code Of Person Certifying Cause Of Death: ' 44 License Number 45. Date Certified
if MICHELLE LEE SNYDER , PO BOX 948 328 N 2 ND ST, SUITE 102,VINCENNES, IN 47591. . .02001984A 09/25/2020
1 , 48 Additional Funeral Service Provider. 47.•Akas:
��/r^
Its( 48.Signature of Local Health Officer. 49. For Registrar Only-Date Filed (Month/Day/Year).
%'• BRUCE BRINK JR,BY ELECTRONIC SIGNATURE SEP 25 2020
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
r
0._U, - q- i\6,--.. o .D. ..._ 0,0 . \--k-,R..... .0.D..k.„ .
State Form 10110 (R6r3-07)
� WARNING._ORIGINAL
TURNS FROMORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUMIENT HAL AIS ATE SHIDDEN VOID ON FRONT THATECURITY PAPER AND THE ApPEARS.WHEN INDIANAT SEAL OF THE STATE OF ON BACK THAT
P EARS WHEN PHOTOCOP ED