Death Certificate - Cousert, Dwight_4/18/2022 (2) ---- INDIANA'STATES pEPA. ,TNIENT OP,HEALTH
CERTIFICATE.OF;DHEAT
c`* ;� Local No 002025 FOR No 000000529235. " state No 049091
1:Decedent's Legal Name (First,Middle,Last) =fa,Hlaiderti Name (If femal@) 2 Sex 3. Time Of Death -4_ Date Of Death(MontNDay1Y9a.
DWIGHT M COUSERT MALE 04:59 AM -
5. Social Security Number 6a.Age-Yrs 6b. Under 1 Year 6c. Under 1 Month 6d,, Under 1 Day Be.',Under1 Hour 7 Date of Birth (Month/Day/Year) 8.Birthplace (City and State or Foreign Country)
82 Months Days Hours Minutes
Hospital
0 Hospice Facility 0 Decedent's Home 0 Nursing Home/Long-term Care Facility
®Yes 0 No 0 Unknown ®Inpatient 0 Emergency Department Outpatient ❑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. Marital Status At Time Of Death
®Marred 0 Married,But Separated ❑Divorced
EVANSVILLE, IN,47747 VANDERBURGH 0 Wdowed 0 Never Married 0 Unknown
15. Surviving Spouse's Name 15a.Last Name Before First Marriage 16. Decedents Usual Occupation 17. Kind Of Business/Industry
CONNIE COUSERT WILLIAMS FARMER FARMING
18. Residence-State 18a. County 18b. City Or Town
INDIANA GIBSON FRANCISCO 18d. Apt.No 18e. Zip Code 18f. Inside City Limits?
18c. Street And Number
❑Yes ®No
19 O 550 SOUTH 47649
lb. Decedents Education 20. Decedent Of Hispanic Ongin 21- Decedents Race
HIGH SCHOOL GRADUATE OR GED NOT HISPANIC
COMPLETED White
22.Parents Name(First,Middle,Last) 23.Parent's Name(First,Middle,Last) 23a. t m=a irst Manage
MARVIN COUSERT BLANCHE COUSERT 4/9)VrOANN
24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address (Street And Number,City,Stet Zip Code) 2022
CONNIE COUSERT WIFE 6838 E.550 SOUTH, FRANCISCC) 44: CL4�p
25.Place Of Disposition G1e S((''')�♦�
25a-Method Of Disposition 125b.Place Of Disposition (Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And StATAe COUNTY 'u�`;�J
ID Burial 0 Cremation ❑Donation 0 Entombment �-p�/TOR
o Removal FrontState
❑Other(Specify): PROVIDENCE CEMETERY FRANCISCO, IN
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, FH83005312
IN 47660see27c. License Number(Of Licensee):
E RY Of Indiana Funeral, BY Licensee: FD01016589
JERRY LEE BASHAM , BY ELECTRONIC SIGNATURE
Cause Of Death (See Instructions And Examples) Approximate
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
A Line. Add Additional Lines If Necessary.
, Immediate Cause(Final Disease Or Condition Resulting In Death) A. CLINICAL UPPER GASTROINTESTINAL HEMORRHAGE HOURS
Due to for As A Consequer,c.on.
Sequentially List Conditions, If Any,Leading To The Cause Listed On B. HEMORRHAGIC GASTRITIS Due a(Or As a Consequence on.
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last C.
we to for As A Consequence 00
D.
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 0 No
1 30. Ware Autopsy Finding Available To Complete The Cause Ct Death? ®Yes ❑No
31. Did Tobacco Use Contribute To Death'? 32- If Female: 33. Manner Of Death:
❑Not Pregnant Nevin Past Year 0 Pregnant At ran.of Death 0 Not Pregnant.But Pregnant yMNn 42 Day.01 Death ®Natural 0 Homicide 0 Accident 0 Pending Investigation
0 Yes 0 Probably 0 No 0 Unknown ❑not Pr.a,,..eat Pr.4n.nt u Days To t year Before Death 0 Unknown If Pregnant wino m.P.r Y.., El 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 38. City Or Town 38b. Street 8 Number Ni 38c. Apt.No. 38d. Zip Code
39. Describe How Injury Occurred ^v 4❑O.o If Transportation Injury,Oetdeerry
` v .rrransp ❑P.wjprr,Spe n pother lsputYl
41 Signature, Of Person Certifying Cause Of Death: 42. Certifier(Check Only One)
STEVEN WYNN LOCKYEAR BY ELECTRONIC SIGNATURE \ 0 Certifying Physician 0 Coroner 0 Health Officer
43. Name,Address And Zip Code Of Person Certifying Cause Of Death: 44. License Number 45- Date Certified
STEVEN WYNN LOCKYEAR ,201 S. MORTON
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