Death Certificate - Church, Robert Jr_3/4/2021 k:INI • .. ..,-
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INDIANA STATE DEPARTMENT OF HEALTH ''
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CERTIFICATE.OF DEATH ,.,,i,,...1,2..11;
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1,1,11:Local No 000476 ,..,,illi I/I, EDR No 00061,iip1.7782 - .,IN II State No 2020-064344Jhi
1.Dacadents Legal Name(First.Middle,Last) 11:!;:IIIIIIIr."1IIII la.Maiden Hama ill female) 2.,Frqlrder.0111, I, 3.Time 01 Death 4.Date 01 Death graonavDayNear)- .•„6 0.11:1;:i ::'
ROBERT LEO CHURCH JR
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9.Ever If:1,1.1,1'S.,Artned Forces? 10.It Death Occurred In A f4ospital: I'll,: :::::r'10a. II Death Occurred Sorra:whore Other Than A fiesphal • :I.
, I. ID Hoc:lige Facrity ri Decedents Hama E:i Nursing Hornalonce,form Caro. ihy
DillYeill1PrINO 0 Unkrietrm Iria&Wert El Emetpeary Department Outpet6snt 0 Dedrie:41.14Myel 0 ...i'41!.........'1.11,4
0, Other(Si?ecity)
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1 I.Fatsily Name(11 Not Institution.Give Stroel OrpiNii,111-lbon Good
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P' 12,City Or Tdrm,State,And Zip Coda
II 11.11.i:':.11:'11'''' 13.County:Of:D.190k' 14.Marital StatUG At Time Of Death i:•:',-:::'!,:'1::'111:,'
;1 Vincennes,Indiana,47591.1j;,'I.,.r.,Ill ..,.,I, 1,1 ini
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...1, marriodlp marriod.But Separated Ill:I:Divorced
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.SuryitiMg. sas Name 15e.Last 4000:Before Rest Marriage '' 18.Decadants Usual OompatiolUn.,V449"d,,, 11:liji:•::1. 11:37.Kind 01"ABusinesaaff1"111111;31ndirstry Yn'ulawn
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..11k1 ,00,EARY RETIRED MILITARYISERVICE UNITED STATES NAVY
IIllESTA CHURCH ...loll
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e .III 18''Rubian°-Sta 18a. County 'Ir,' "I I,' 18b.City Or Town
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Gibson -"' Princeton ":.,::',I.I!,[.., .,.......;....
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I8d.Apt.No. 180.Zep Code
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-let Decedente Education''r",'' 20.Door:dent Of144 poripprigin "'":6' 21.Decedents Race 41;"hi
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White
ill:''High School graduate or GED completed Not SPectiabifliapartickatino
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22.Parents Name(First.k4kkais.Last)
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ROBERT LEO CHURCH SR ....o.".4.:.irg. 1 ' LAURA CHURCII i:',1,, .',.1.,!,1. LEWIS ,?
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i . 24.Informants Name '''"IIII'l'Ir'Ili I 24a.Relationship To Decedsmt 24b.IV:aging',41,41,1re.,_I(Street And Number.City,State.ZiO Code)
. ROBERTA WISE ,,,,,,.1111(111.iii, I
Daughter 2419 N:rEiFNCHMARK DR,Princeton,I,N:iii.1,,,..i..,,141:rii....,...71;.1.,6,....138,711:10
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iiilli41„ '''I'i";01,IIII• i',.:1,,.. 25.Pleas 01 Disposition 1:116.
251'IllP:51.,....0,Defecation 25b.Place Cl Ditixeleaf 1 felarricr,01:Cometery,Cremelory,Other Place) 25c.Locaden•City,Teem.And State,II.'III.,
,f,t8unaliqj Cremation 0 Donalion El Entombment '11:11: 10.' I:III.'Ill III :1
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Clifierndrial From State . MONTGOMER.ncEMETERY •
• Oakland City,IN .,,o:Ji:,..1.1111'..„;
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26.Was Comm Contacted? :I127.„Name And Complete Addreis'01 Funeral Facility ' rI if,i. ',LirlI, 27e.punerel Hoar Licenee Ilurrber.
6 {limb Basham Memorial Chapel,' .,11.1y ,111.'1.''
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27b.84/1911N0 Cl Indiana punceal:Soeride Licensee: 21°' User's°NUnthat Pt uccms'"°):FD0101656911'.:;!1,:'
„JEX,ICI'LEE diff,S7f,ff:%f.,!ii,.' - . _ III.. Electronically Signed II
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,.,..,.I,.. ,,,,,"Ilic0 Of Death(See Instructions And Examislas) l'I'll"Ii' "11' ".' Approximate
IIIII!..,II.11'';28.Pan I.Enter The Chain or Events -Diseases,Injuries.Or Compticalitiha, ,', Iiiiat Directly Caused The Death.Do Not Enter Terminal Events 111/!',..111"",,!. Interval:Onset
Such As Cantiac Arrest.Respiratory Arrest,Or Ventrbular FthrillatIonyirritiotrt Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On ';';';;IT111.!fi,I'.1..!!!. To Death
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Immediate Cause(Final Disease Or Condition Resulting In Dealt/I)i,:I'h rs- 'I.....:;,1',, ,...
pr..vi'ibreits A Crwwwww*be •L',1,I l';' 11'11' I,' ..1. !j,.1 .,..I..,i 1.'1
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Sequenttelly List Conditions, If Ariy,::Lea:lring To The Cause Listed Onilk„..„,..1
Line A.Enter The Underlying C•atiselOtiease Or Injtry That Initiated ',I';I, 1.( , 91'..... I,-.'
The Events Resulting in Delaitileg ;;Ii",' C. ..,.kik!1111,:',III.i„ '1[4111r1.1111.1 " '11,!1'1 ,,., ',ii,..1.,,i I, Dos to cat A.A Conon.wroOtt III!l ,1!:11,...
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I Fen Jai 9*Ir Other Starnicant Condqims Contributext IA Death Bie Noi Resulting 111,•1"evallrfclerlyirg Cause Own In Part I I ,r::i
29.Was An Autopsy Perfoim.O..'V'...:1.1:II: ID yes 181 No
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• I 1 II:cciv. ID 19 , di!.1,1,11 iIII,il'Il 30.Were AutorcyFInceng ATebryliTcr Complete The Cause 01 Death? r3 Yea in No
ill''31.Did Tobetco Use Contritsno TO Deilef...',Ir,, 32.a Female:- ''':' • ,,,III.I::,,,, 33.Mithetv Of Death:
,r ,1111,111.:Y•I!'l''' El"r.11.4=4"-','IPrm we 13 Provo m rwe vow. Ei w..,,...„,,Ffp,4 ,4A:....,ban OrPse, Da Neural 0 lionidoe Ei Accident Ei peodooloOsoo, an,13.
I .yes, 13 Probably El No OUremtsvn __,_' .:.
I I i.':::!:.,11:'::: Ei Nol Ptecrariew I'vp.wrd 41Days To I par Sciar•C4.16 El titY-CrIrfra+kriinThlrPtalYereg El Sultide 0 Could Not Be Doarmirrod .0::,.11111,,
34.Dame Cl Injury(MonthiDayr•Y,earl'',"''. 35.Time Of Injury 36.Place 01 Irritny' (E.G.,:i•DOcedont's 1-isme.Construction Site,Restaurant.Wooded Area) 37.Injury':1141Work?
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i 1111111,,11,,03.Location Of Iniury•State 38a.City Or Town ,;thliiI;;;.111,,II.,• 38b.Shoot&Numter
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r--: 39.Describe How fny..n.7y 06-pined / ,. -; . ".I'....i,T.:.., 40:..tf Transportation Injury.Specify:
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41.Skraturi:,01 Pefe041Ceadyng Clige#02111:--- 111..1..:'''.5'.'''' 42.Conifer(Chea OniY Ona)zi .
Aqsge4.VI V:s2Mli.1.7fi,tliii,•';:!"..! ..r."':-- I.-. Electronically Signed Da Cortrtylrg Physician Coroner Ei Health Offr4dyC'.,,'-':::''
1 43.Mann:ILess And tp Co:dif'01 Person Certifying tlau.se Cl Death: ..:I ;',HI,1:' ' 44.Ucense Number 45.Date:Ferellod,.:'
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AYSHMQAUSHER KHAN 520 SC!UT11:7TH STREET,VincerineS,AN 4750111/19/2026
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6 IS.Ackfiti.?5iTi Funeral Senile°Pruv.kior: , • .. 47. 'Afiee:rill,'""
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• Il, .:4&Signalt!o cs,Local Health Officer: . .• . ':II:".'II:: Ir:'' 49. For Ritglertrar Only,' Date Feed(R4onth/Day:Yonr):
= III:.r Il'''AL.;41(a 7FEWIXT ' . Ilf.'Ill::11' Electronically Signed 1.:;;10,.11,1.. 11/20/2020,
AtierzonitT TICERTIFICATE OF DEATfiti( NTRY OR ORIGINAL) '111,!1...,,",,.',;':
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,r,i Stale Form 53395 ATTENTION ESTATE"The Social Security Iiii.!!?piniilititheated by this stale agency in order to pursue responsibility. Div.clocti71!ay,eyttary and there wit be no penalty Ifor refusal
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r WARNING ORIGINALDOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE;SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA,ON'IOK THAT
[. - TURNS!,FROM ORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUMENT t-IAS:Ali-IIDDEN VOID ON FRONT THAT APPEARS WHEN PHOTOCOPIED. •!,,'
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