Death Certificate - Maier, Robert_12/15/2021 v
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INDIANA STATE DEPARTMENT OF 11" t1,11
ri,ilititti:4
CERTIFICATE OF DEATH
-............- )--/ Local No 000207 EDR No 000011209871 state No 2021-
Haubstadt,Indiana
9. Ever in U.S.Armed Forces? to.If Death Occurred In A Hooped, 10a. It Death OCCurred Somewhere Other Than A Hoepital ' ..
•
El Hoopla&Facility illIl Decedents Hours El Nursing Honneiteng-term Care Faddy
no Yes 0 No 0 Unknown 0 inpatient 0 Emergency DePoriffleni Ontiodled 0 Dead on Arrival ID otherr.(specify) ..;
it.Facility Name(lf Not IreaNdion,Give Street end Number) 1 •-'
304 S Hillcrest Street
12.City Or Town,Stale,And rap Code 13.County Of Death 14,Mantel Status At Time Of Dude,
Fort Branch,Indiana 47648 Gibson 0 Matried El Minded,Out Separated El Divorced
..M Wklowed 0 Neste Married 1:1 Unknown
15,Surviving Spouse's Name 15a.Last Name Before First Marriage 16.Decedent's Usual Occupation 17.Kind Of Dust waralndusby .
Truck Driver Transportation
is.Residence-Stale 18a.County 18b,Cary Or Town .
IN Gibson Fort Branch
iek..Seed And eturreer /Bd.Apt.No. lee.2:tp Code 16L triode City Limas?
304 S Hillcrest Street 47648 go Yee El No .
19.Decedent's Education 20,Decedent Of Hispanic Origin 21,Decedent's Race
High School graduate or GED completed Not Spanish/Hispanic/Latino iNhite i
22.Parents Name(First,Sitside,Last) 23.Parent's Name(Snot.Mackte,Lest) 234 Parents Lent Name Before First MisMege-
Robert Maier Sr. Elizabeth Maier dam
24.Informents Name 242.Relationship To Decedent 24b.Resting Address(Street And Number,City,Stele.To Code)
Sandy Maier Daughter 7400 Shadow Brook Drive,Newburgh,IN,47630
25.Place Of Disposition
25a.Method Of Disposition 25b.Place Of Disposition(Name Of Came.y,Crematory.Other Place) 25c.Location-City.Town,And Slate
Ila Sutter 0 Cremation El Donation El Entombment
0 Removal From State Holy Cross Cemetery Fort Branch,IN
Elotrivr(Spacity):
as.Was Coroner Contacted? 27.Name And Complete Address Of Funeral Facility 27a Furter**Home Licenes Number
Stodghill Funeral Home Inc -
0 Yee gia NO 500 E Park Street,Fort Branch,Indiana,47648 FH10900013
27b. Signature Of Indiana Funeral Service Gummi.: 27c. License Nornber(Of Licensee):Fo21400005
Andhra£Xrieg Electronically Signed
Cease Of Death(SatinistructIons And Examples) Approximate
28.Part I.Enter The gbainiaLgyerds -Diseases,Injuries,Or Complications-That Meaty Caused The Death.Do Not Enter TeManal 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
A Line,Add Additional Lines If Necessary.
imniediate Cause(Final Disease Or Condition Resealing In Death) A. left Upper lobe lung MOSS days
ow t.ex As A e.............04:
Sequentially Utst Conditions, If Any,Leading To The Cause Listed On B. Lew ix se Pa ACaneaweele•ca
Line A. Better The Underlying Cause(Disease Or Merry That Initialed
The Events Resulting In Death)Last C.
ove a ror 4.4 cwwwwerce 00:
D.
Pad IL Enter Other Sinoiltaint Conditions Contributino to DegthEtut Not Resulting In The Underlying Cause Given In Part I 29.Was An Autopsy Perfornerd7 0 Yes ill No
30.INere Autopsy Finding Available To Complete The Cause Of Death? 0 Yes 0 No
31.Did Tobacco Use Contribute To Death? 32-It Female: 93.&tomer Of Death:
ID....0.4.-........,...0,-. 0...op.*.-iii-ioi 0//iiii 13 ii.i.ivii..s.ii/iiiii*.viii.aii/w/...../. go Nrestral 0 Homicide El Accident El Pending Investigation
El Yes 11113 Probably El No Ell Unknown
El Piga Proognera.OW Proptseolpt3,O.%To$ytet 194tre Orktlft (3 u.,..,...p,....Will.Th41.Rol'Vow El Suidde ID Could Nat Be Determined
34.°ewer Merry(etoneVearYea) 35.Tine of Injury 96. Placer Of Injury(E.G..Decedents Home,Construction Site,Fetatiturant,Wooded Area) 37.Injury Al Work'
0 Yes 0 No
98.Location Of tniury-State 38a.City Or Town 38b. Street&Number 350.Apt.No. 33d.Zip Code
39.Describe Hoe Injury occurred 40.It Transportation Irdury.Spedtr
Elniverrteweiv 0 Plmsleftee 0P.6006116 One.'tepees
41.Si9nature,Of Person Certifying Cause Of Death: 43. Certifier(Check Only
, Apra'gificheire-Samtions 2" Electronically Signed ea Certifying Physician One)
Coroner 0 Hoeft Officer
' 43.Nana,Address And rip Code Of Person Caddying Cause Of bean, 44.License Number 46.Cede Certified
April Michelle-Simmons Melte 600 Mary St.,Evansville,IN 47747 02003410A 12/14/2021
I 40.Addams'Funeral Service Provider: 47. •Akaal
me. Far liergletrar Onty-Dale Filed(iriolierriYeer),
48.Signsture of Local HeadOfficer
1 (Bruce Ofinft„7r Electronically Signed 12/14/2021
/ AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR OIRIONIAL)
1 Dec lite)
ea( . 1'5'.e.01, •
' Ialte Form 83388 ATTENTION ESTATE:The Social Security it is being requested by this Mate agersar in order to pursue responsibility. Disclosure is voluntary and there welbe no penalty for refusat.
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