Death Certificate - Cousert, Dwight_4/18/2022 ar4'4i;, INDIANA STATE DEPA TMENT OF HEALTH
f CERTIFICATE.OF,DEATTH '0
`'. ,,�' Local No 002025 EDR No 000000529235 State No.049091
Il.t:Decedent's Legal Nerve(First,Middle,Last) 1a, Maiden Ntinte'(If female) 2.Sex '3. Time Of Death 4. Date Of Death(MOnth/Day/Year)
DWIGHT M COUSERT MALE 04:59 AM
5. Social Security Number 8a. Age-Yrs Bb- Under 1 Year 6c. Under 1 Month 6d, Under 1 Day 6e,'Under 1 Hour 7, Date of Birth (Month/Day/Year) 8.Birthplace (City and State or Foreign Country)
82 Months Days hors Minutes
Hospital
❑HOspice Facility 0 Decedent's Home 0 Nursing Horne/Long-term Care Facility
®Yes 0 No ❑Unknown ®Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival 0 other(Specify)
11. Facility Name(If Not Institution,Give Street and Number) .
DEACONESS HOSPITAL INC
12. City Or Town,State,And Zip Code 13. County Of Death 14. Mental Status At Time Of Death
®Married❑Married,But Separated 0 Divorced
EVANSVILLE, IN,47747 VANDERBURGH ❑Wdowed 0 Never Married 0 Unknown
15. Surviving Spouse's Name 15a.Last Name Before First Marriage 16. Decedent's Usual Occupation 17. Kind Of Business/Industry
CONNIE COUSERT WILLIAMS FARMER FARMING
18, Residence-State 18a. County 18b. City Or Town
INDIANA GIBSON FRANCISCO
18c. Street And Number 18d. Apt.No. 18e. Zip Code 18f, Inside City Limits?
6838 E.550 SOUTH 47649 0 Yes ®No
le. Decedents Education 20- Decedent Of Hispanic Origin 21. Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Parent's Name(First,Middle,Last) 23.Parent's Name(First,Middle,Last) 23a.LAGr7ri=a irst Marriage
MARVIN COUSERT BLANCHE COUSERT A fIVANN
24,Informant's Name 24a.Relationship To Decedent 24b.Mailing Address(Street And Number,City,Stat ,Zip Code) 1 2022
• CONNIE COUSERT WIFE 6838 E.550 SOUTH, FRANCISCC4�649 4
25.Place Of Disposition GjeS mow. e - _/ �i`,�t�`
I 25a.Method Of Disposition 125b.Place Of Disposition(Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And St3Ce. CO „vY_.'
®Burial ❑Cremation ❑Donation 0 Entombment NT s,,
j 0 Removal From State D/rOR
1 0 Other(Specify): PROVIDENCE CEMETERY FRANCISCO, IN
1 26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility 27a. Funeral Home License Number:
El Yes ❑No LAMB BASHAM MEMORIAL CHAPEL, INC.,226 E.WASHINGTON STREET,OAKLAND CITY,
; IN 47660 FH83005312
' 27b. Signature Of Indiana Funeral Service Licensee- 27c. License Number(Of Licensee):
JERRY LEE BASHAM , BY ELECTRONIC SIGNATURE FD01016589
Cause Of Death (See Instructions And Examples) Approximate
I 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
1 A Line. Add Additional Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. CLINICAL UPPER GASTROINTESTINAL HEMORRHAGE HOURS
Consequence
o.to/Or As A Con.. .nce g.
Sequentially List Conditions, If Any.LeadingTo The Cause Listed On B. HEMORRHAGIC GASTRITIS ow
q y e to for As A consequence gr.
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last C.
50.to(Or As A Consequence OR.
D.
Part II.Enter Other Significant Conditions Contnbutino to Death But Not Resulting In The Underlying Cause Given In Part I 29. Was An Autopsy Performed? ®Yes ❑No
1 30. Were Autopsy:inking Available To Complete The Cause Cf Death? ®Yes ❑No
31. Did Tobacco Use Contnbute To Death? 32. If Female: 33. Manner Of Death:
❑Not Pregnant Warn Past Year 0 Pregnant At Time Of Death 0 Not Pregnant,But Preg,.ct wxron 42 o.r.Or oaath ®Natural 0 Homicide 0 Accident 0 Pending Investigation
0 Yes El Probably®No ❑Unknown ❑Not Pregnant.eoi Pregame!.
De,
r to r Before o..tn 0 unknown it m P,egnt Within The Past Year 0 Suicide 0 Could Not Be Determined
34. Date Of Injury(Month/Day/Year) 35. Time Of Injury 36. Place Of Injury(E.G.,Decedent's Home,Construction Site,Restaurant,Wooded Area) 37. Injury At Work?
❑Yes ❑No
38. Location Of Injury-State 38a. City Or Town 38b. Street 8 Number 38c. Apt.No. 38d. Zip Code
39. Describe How Injury Occurred ^� 40. Ifl Transportation Injury.ape iffy n❑other,..oM)V ❑or anon., o. ❑Paa.rpar L� ro
41. Signature, Of Person Certifying Cause Of Death: 42 Certifier(Check Only One)
W STEVEN YNN LOCKYEAR BY ELECTRONIC SIGNATURE s .. p Certifying Physic ®coroner 0 Health Officer
\
43, Name,Address And Zip Code Of Person Certifying Cause Of Death: t/\ 44. License Number 45. Date Certified
STEVEN WYNN LOCKYEAR ,201 S. MORTON AVENU E ANSVILLE, IN 47713 10/19/2016
46. Additional Funeral Service Provider r-----3°O_ 47 A
48. Signature of Local Health Officer. 49. For Registrar Only -Da a Filed(Month/Day/Year):
ROBERT KENNETH SPEAR,VIA ELECTRONIC SIGNATURE OCT 20 2016
AMENDMENT
- .. -y_, • _! i. .- to._.:eR'-. ..• MENT A HI..6. •_ R-s.T .a W'..FHeT• . .