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Death Certificate - Helmbrecht, Romona_4/5/2022 IIIII?IIII IL..,n _ „ l III DEATH HEI�Ii� _ a " as,:II' INDIANA STATE DEPARTM lliiiir aliil CERTIFICATE FI, Iilioriiiil, II16 IIIII II IIII IlUlld I.111l1111, Igili„IIII IIII'lu IIII ill 7T• I�'�� III LOO14,i.No 000049 EDR NO 00001,01V,V. State No 2021-01891ii3',i!;Ilh 1.Decederes Lepel) (mile(Finn,Made,Lae0 le.Meideri,INW 1..,(I$fanbb) 2.Gatler 3.Tuns Ot Death 'III il1J14_il Dehm Ot Deed.(4bMh/DayKaa) :'':I;II'''Tillae Fetnalle 03:50 AM 03/21/2021 Ramona Helmbrecht nu:C,'.''Ir,iJ:,i I ,ID&I„'uWg,..IIII. Ti III, 1 11IIIi 9.Eve n u S I it Ili ° dill IIIIIIIIII,I, Magnin.Facility Ea Decedent's Home ❑Nursing FbmNlarp-bum�Yrel.. ollin Yee ❑ ®6�I Emergency Department Outpatient ❑opts p�l I'inu' ❑asror(Sp.city) �I Vli�'ll•l ,III 11.Fedldy (t Not Institution,Give Street end Number) IIII ("II'ill'iv- 1 .1 lilt" - I'I111 ::nnnm,. 7751 S 950 W IIIU,i tllr , .it •IWIIII u,, n'" ,,,RIIIll ti 12.ply Or Town,Slab,And Zip Code Illli"!lull :IIII 13.Courtly 01 W'Yilt. Ills: 14. Mensal St a Al Time Of Death •IIIII II I II�III,'y' 'lli'p•.•ryi III 'IIII;'�.,,III IIII Owensville,Indiana 47665 'I'Iglil iiii!;i,,••` GibsortII!11;41111!;,lil ®wined❑r O.ButsePe•atep❑p• It,II lull,...11il iilL�lu..II1.I1 ❑wan..dd Nevi`Married II I: 15.So riving IS us.a Name ''Ii!il!l f jj1 15a.tat Mneme Beton First Mrrl°pe ul'll IIII I i "II 16 Daoed°nrs throat Occ.e.bon ,.LLI„ 17. kind Or BuiMW• w+lnduary James11'j1 �! HQIP11o1brec 't Hume Maker I Ii1 Own Home o1�'IRIi II;'111 can Stalls lea.Canny 111111�11i 11/11111 l!III' tab City Or Town I i I!IIII I 1. "IIII,I'll' Gibson ill hull 1 Owensville -!11111'ao,,. slut,. 'tan:. :!!Al: 18c Street And Number II Il I I ''11u !IIIIIII+', ( 17'''' tea.AVL flop lee-aP Code l81 /nsde'CMy'Li.be? IIII'.I IIIII IIIII ,! IHI lilt .01%IIII 7751 s 950 w oaII a011111 w':;;Iiili Iio IIII;;�II�I 47665 1IIIU© tS 0 No • a111'Ip 41111 ngtl.IIIII hII9,,l,Iuoeceeenh Educatia, Iiii;IIIIII!I',. 20. D.wdeu4 Ot ,�r4n IIIINI!BIIIt I' 21. Decedent's Race lllaii,° illllll!„IIu!'r,. l- h s1,1,u.,AcompletedII" 11mull Ip" talc I mI I graduate or GED Not Sllan7chA .7.M,Ill li" n,10lN IlIl,I I. IUI,n l,. rrnn 'II'lll;Il' ,.:,in1L I I'I1 II ,'l'22.Parson Name(First.Middle,Last) !II 'ltlII 'la!!- ,I i glib IIP 9.Parent's Name(First.Md,lla,Uaat) III In,i ' 23s.Paa4'a Last Warne Before Fi,el Menage IIII. James Eugene Schaefer ""!l'III IIII dp• Gladys Virginia Schaefer *II,', 1 'ill Chumley I. ' In II nh, ! ,l°Illilwiiiu. 24.edormers's Name ! 1 24a.Relationship To Decedent 24b.Mailing I(S�neell And Number,City,Store,Zip Code) hil11 ltjlj Ilm' James Helmbrecht III'lliil,II,, II. Husband 7751 S 9 ;Ilowensville,IN,47665 'ili'11111j�lllllll. rin' 25.Puce Of De ikrekk.'III"..'. 'II'll1110,q, 'n1a':.. Illliiin111116'" - 25.Method O(i.*poaibon '''s' 25b.Place Of Deposition(lease 3 wmetery,Ccemalon,OlterrlPlxa) 25e Location-C°y Town,And Sub nil Iigiiigl'. 'II;,',II' ❑ButleI®t>arra(lon ❑Donnie°❑Ent,mbmem II1111I.IIIl1,"I I; 1111IWIll II'IIII ❑ I,t Ff a $d1e Cremation Cen oft vansville Evansville,IN l;: III, h II,1 '0!Rmla(SpecH): _ ,fiiI''IIIII,, lii i, '.lilt Igal1,, zmli, mond Avenue,Horn die.Indiana, nm llli I IIII,,' 27c License lnr_ 27a Fineryra,eLce.ww, :I28, es Coroner Contacted? 27 N Fad' ( yes ❑No 'I'"'Did II 111,L'' FH10t3000112u1111I11I111111' Bf1DNT fIg Ste ene COC4 Indiana Funeral S�rvic r Llcen see: I Inn: dill Illle, I1 ..e,t '8ruce Q),1,,1 ;III IIIIIIIII llllllii, Number(Of Licensee):FD21�, ,y' nu• Efec�tedt7caliy Signed Mali ro l III• IVI, 'III '.u::ilillppl' n w Ot Death(See klabwieflbne And Examples) Ty I III'!,IIII 'III!;iiii111I'' 111• BB Pan 1.Erne,The Chain of Fverm -Diseases,Y*resa Or Com ' Directly Caused The Death.Do Not Enter Terminal Event i,i'� Y1Mrvtl:Onset 11 !!St'xi,As Ca,,b c Arrest,Respiratory Arrest,Or Ventricular Fibrillation" glt,ll5howirp The Etiology.Do Not Abbreviate.Eager Only One CaAS6 On ! ���..!!! To Death II'I A Line. Add AdWtlonal Lines t Necessary. 'III' !IIII' "i tll'r ',ill, 1Ical,qI Illlly,,. p1'I!la;I:' � �77 1 sudden cardiac event Pia �� ,�R O$ 2UZ2 0 1 ILM1111 Inerledlete Cause(Fetal ni9Pase Or IIIReatlBnp In DeaIIt)'llhll Ili A. IIII ill IJII till,,„,1, Mil•li IIIIIII JLII �^ ,..0.ll0l'.IIII Sequecilaly List Conditions H Any Leading To The Caine head On B' III I nla» la n.• Dry. III !11 i1x^;11�1' Line The Events R The esuftlrro In ca�!,dl�ease a irl)ury That Initialed 1 Ill'. �'t� ,, D°ah) '( c nIIIIIIIIIIIIIIII' /�lschwf t�wn� 111IIIIIIIII'011„,„ IW1 hl 'IIIIII1,,1 II I�a "'IIIIl1 ov-'o'"“`""g?BSON GUUNTI I,RUDITOR !'IIr11111' IIIIi,.:!!!1,. D III''11.•.III iiiII,,,. m',! I,II-I:II',n... IIIII,,IIIIIII all: �. q'IP Il ,N, Conditions Connecters)to Death But Not Reef a lI IIb. o Cede Given to Part 1 29. Was An Autopsy Perbmwd'1 1 1l,;IIII' A nl!'lle lI II El yes ®No IINI IIIIIII III llll I I 30.Were Autopsy Arcing Al can IIII III To Complete The caua.Of Death? ❑ape ❑No . 31.Did Tube®Use Corstibuta To Death?I,t!,11IU., 32. 8 Farmer All lipl hl 33. Manner Of Dees': 'lulu!II'61,I ❑Yes ❑ta,obaely❑No ®tn4mwn nil: ®es w.w•sew Pet r.. 0 P.e...r T,.,..Maw ❑...v.,v. .".'hngliil .5ne.v o..n' ®Noe.❑Nominate ❑Access ❑Psndhtl kr 1tigetion nil II.iol)..n11 ❑•at P•,..Sot P-.n..4 Dept To 1,e.se.opts. 0 uson I t fees..,..Pre Yew ❑Stake❑Could Nor Be Debm9n.d IIII 11111,1 Il,ll I: 34.Data Of Whey teeor,tVDayK,,,)VI. 35. Time Of eery 36. Piece Ot Inii,ylEig..Da des Home,ConetmctIon She,Restaurant.Wooded Ares) Y:(illtnJ,ey At Work? 'tllllll(IIIII II 'ihl i111i 1j' ,IIII II III:I;ll l '!Iliif.IIa1j""" „Ming IIIII IPI IilliilA'Yes ❑No �u.11, III III!per"LI0!cata.Of injlsy-State 38a. City Or Town I I I11111I1'71m1 I!!l 38b. Street a Number l dill'!!II IIIII!„i1i 38- API.No- 384.Z.Code II i IIII .i ,nta!,•'a Il, IIIII i,„1;!Il:l 411 39.Desc.be How Injury Ocanned ,Iiill''JAIL., "''II !I!,(,!Ui, 40.'8 Tramtporutior.Injury.Specify: II I'!!ih, IIII ii i,lihl pII, El1,1...ac.o ❑P.-.v.❑P-r..'...❑v'-cao.,rr, ,!Ault :',.I.IIIr111' "wlti I Iii,111I 'dll'lk!!hill ul�pi 41.Signature,Of Penton Certifying C Of Death, !IIII..'1I'1j1a!i!' 42. Centers (Check Only ones II'gpullll IIII;L.. ,gdr1e.ferStmo nsau;• III 1,1 !'I'' E)ectroniCa fly,,,buigned ®Certifying Pt•yaua. O Coroner ❑Hea it�figic 43.Nana Address And Zip Code 01 Person Certifying Cause 01 Death, ill, !IIIII , 44.t.m.e Nrneer 45."iltl>gCeNr.d -IIIII,g111'1,. "' '1�•�l f� Illlll• IIII I' I 11' I'i II1'I'xl Jenr>Iifer Simoneaux 4015 Gateway Blvd 3000,Newburgh rl, lll�l.ip 0105100 {+i•` 04/02/2021 S4nasae Funeral Swear P.ovider II '1;hnlfl'' 47 1aI1tr�, 149 Siealunt ow.. lijlllll IIINIII Eletironita+lX ,,, 49. For eft44. •!:Date U Filed(MantvoeyKear): r of Low Hemel Officer, to w1 m,.. Registrar:petty'- enact Orirskjr .,nl.mr, IIIIIIId1Il1^ 04/07/2ti2;A,i,,,. m'il ik'n!i' AMENDtlSENT TO CERTIFICATE OF DT}1(E14TIRY OR ORIGINAL) )III n ,11$111 IIIIIII;:",' 'I IIII IIIIII'IIIIl1i: III iI1.111.. II all Ile I Ili! 'III!. III Nlu ia, I �Q 1 I:!' u� i a III I ' ilMl ,IIII IIII I 'lip,,. < '�o �` II III,, V V I I VYI; 8 yr-'�� I I.. ^ III Il:llln- vv l II I '�ilill,n �),Q II,11I ,.Iiu,.„„„„:.:IIII life,„„„,...,llll' 1, il'• Stew Form 93395 ATTENTION FSTATEfThe Social Security I I.(ielr+g requested by this state agency in order lb W,:npue.Fespon trinity. Discbii.iitIs vdumary and there will be no penalty for rehrd,,; ll „ i:: 1 p,.•ill'! ORIGINAL'DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL W IT S>=GUItITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON' A'OK F!fHAT WARNING.