HomeMy WebLinkAboutDeath Certificate - Georges, Larry_3/4/2021 II
•"A INDIANA STATE DEPARTMENT OF HEALTH
a ..
�j CERTIFICATE OF DEATH 1
0
' j: "� Local No 002663 EDR No 000000820409 State No 066303
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)
• LARRY G GEORGES MALE. 23:57 11/24/2020 -
GIBSON COUNTY, IN i
9. Ever in U.S.Armed Forces? 10.If Death Occurred In A Hospital: 10a. If Death Occurred Somewhere Other Than A Hospital
❑Hospice Facility ❑Decedent's Home ❑Nursing Home/Long-term Care Facility
0 Yes ®No ❑Unknown 0 Inpatient❑Emergency Department Outpatient 0 Dead on Arrival Other(Specify)
11. Facility Name(If Not Institution,Give Street and Number)
ST.VINCENT-EVANSVILLE 3.
12.City Or Town,State,And Zip Code 13. County Of Death 14. Marital Status At Time Of Death
_
0 Married❑Married,But Separated 0 Divorced
EVANSVILLE, IN,47750 VANDERBURGH ®Widowed 0 NeverManied 0 Unknown
15.Surviving Spouse's Name 15a.Last Name Before First Marriage 1 18. Decedents Usual Occupation 17. Kind Of Business/Industry
TRUCKING AND
• BUSINESS OWNER ; EXCAVATING
18.,Residence-State 18a. County - 18b. City Or Town
INDIANA GIBSON _FORT BRANCH
18c. Street And Number 18d. Apt.No. 18e. Zip Code 18f. Inside City Limits?
' 900 BLACKFOOT DRIVE 47648 ®Yes ❑No
19.Decedents Education 20. Decedent Of Hispanic Origin 21. Decedents Race -
HIGH SCHOOL GRADUATE OR GED '
;c COMPLETED NOT HISPANIC • White
'222.Parents Name(First,Middle,Last) ' - 23.Parents Name(First,Middle,Last) 23a.Parent's Last Name Before First Marriage
DENSIL GEORGES MARGARET GEORGES MCCLARY
24.Informant's Name 24a.Relationship To'Decedent 24b.Mailing Address (Street And Number,City,State,Zip Code)
JAQUELINE FULTON FRIEND • ' • 900 BLACKFOOT DRIVE, FORT BRANCH, IN 47648
25.Place Of Disposition
25a.Method Of Disposition 25b.Place Of Disposition (Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State
• ®Burial 0 Cremation ❑Donation 0 Entombment
❑Removal From State
0 Other(Specify): WALNUT HILL CEMETERY FORT BRANCH, IN ,
28.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility 27a. Funeral Home License Number.
❑Yes Ik]No 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):
ANDREA LYNN STODGHILL, BY ELECTRONIC SIGNATURE FD21400005
Cause Of Death (See Instructions And Examples) Approximate
11, •;28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events 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
II, . A Line. Add Additional Lines If Necessary. 141e>
Immediate Cause(Final Disease Or Condition Resulting In Death) A. COVID 19 PNEUMONIA DAYS
Due to(Or As A Consequence Ofy r(Iyij 0,(/L�
Sequentially List Conditions, If Any,Leading To The Cause Listed On B. ACUTE HYPDXIC RESPIRATORY FAILURE �l I!. _ {,`7 DAYS
• Line A. Enter The Underlying Cause(Disease Or Injury That Initiated , Doe is(or As Consequence op: 1,r��
The Events Resulting In Death)Last C. ACUTE ON CHRONIC RENAL FAILURE �i DAYS
Dee to(or A.A Consequenn oq:
• ' D. SEPSIS DAYS
, Part II.Enter Other Significant Conditions Contributing to Death But Not Resulting In The Underlying Cause Given In Part I 29.Was An Autopsy Performed? - ❑Yes ®No
I, 30. Were Autopsy Finding Available To Complete The Cause Of Death? 0 Yes 0 No
31. Did Tobacco Use Contribute To Death? 32. If Female: 33. Manner Of Death:
0 Not Pre punt Mtn Past Year ❑Pregnant A(Time Of Death ❑Not Pregnant.But PragnrnrNNNn42 Days OfDeath ®Natural 0 Homicide ❑Accident 0 Pending Investigation
❑Yes ❑Probably 0 No ®Unknown Not Pregnant.But Pregnant 43 Day.To 1 Before Death una,oen,If Pregnant Wain ma Pee yam
_ ❑ gn gyear ❑ g ❑Suicide 0 Could Not Be Determined
' 34.Date Of Injury(Month/Day/Year) 35. Time Of Injury 38. Place Of Injury(E.G.,Decedent's Home,Construction Site,Restaurant,Wooded Area) 37. Injury At Work?
❑yes ❑No
I''I.,38.Location Of Injury-State 3Sa. City Or Town 38b. Street&Number ' 38c.Apt.No. 38d. Zip Code
39. Describe How Injury Occurred - . 40. If Transportation❑D Injury,S ecify: • '
rverfOperator ❑Pae.enger LIPedestren❑Ober(Specify)
41.Signature, Of Person Certifying Cause Of Deatr ' ' 42. Certifier(Check Only One)
MUHAMMAD ISHAQ,'BY'ELECTRONIC SIGNATURE Isi Certifying Physician 0 Coroner 0 Health Officer
43. Name,Address And lip Code Of Person Codifying Cause Of Death: 44. License Number • 45. Date Certified
MUHAMMAb'ISHAQ , 3700 WASHINGTON AVE., EVANSVILLE, IN 47750 01084286A 11/27/2020
4.8.jAdditional Funeral Service Provider. 47. 'Akas:
48.Signature of Local Health Officer. 49. For Registrar Only-Date Filed (MonthVDay/Year):
ROBERT KENNETH SPEAR,VIA ELECTRONIC SIGNATURE . , , NOV 30 2020
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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State Form 53395 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.
WARNING. TURNIS FROM ORANGE TOS YELLOW WHE
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