Death Certificate - Cousert, Dwight_4/18/2022 (3) 111. .,, -' INDIANASTATE�IERA, 710ENT OF-HEAL 'H
/. RTIFICATE OF DEA T 1
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�:-, -%� Local No 002025 EDR No 0000005 9235, ' State No 0' 9091
1:Decedent's Legal Name(First,Middle,Last)
a Maiden Nan a (If femal@) 2 Sex 3. Time Of Death 4. Date Of Death (MOhIIVDeylYoaf),
I MALE 04:59 AM
Months Days Flours Minutes . FRANCISCO, IN
82 10a. If Death Occurred Somewhere Other Than A Hospital
9. Ever in U.S.Armed Forces? 10.If Death Occurred In A 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 0 Dead on Arnvai ❑other(Specify)
11. Facility Name(If Not Institution.Give Street and Number)
DEACONESS HOSPITAL INC 13. County Of Death 14. Manta Status Al Time Of Death
12. City Or Town,State,And Zip Code ®Married 0 Married,But Separated 0 Divorced
VANDERBURGH ❑Wdowed 0 Never Married 0 Unknown
EVANSVILLE, IN,47747 15a Last Name Before First Marriage 16. Decedent's Usual Occupation 17. Kind Of Business/Industry
15. Surviving Spouse's Name
CONNIE CO WILLIAMS FARMER FARMING
18a. County 18b. City Or Town
18. Residence-Staatele
INDIANA GIBSON FRANCISCO
18c. Street And Number 18d. Apt.No. 18e. Zip Code 18f. Inside City Limits?
0 Yes No
68
19 D eE.d 550 SOUTH ]�47649
is. Decedent's Education
20. Decedent Of Hispanic Origin 21- Decedent's Race �1/
HIGH SCHOOL GRADUATE OR GED NOT HISPANIC (White /T/
COMPLETED 23.Parent's Name(First,Middle,Last) 23a. Lit ram=a irst Manage
22.Parent's Name(First.Middle,Last) �I
BLANCHE COUSERT A LIE ANN
I2IAn2V I N sName COUSERT 24a.Relationship To Decedent 24b.Mailing Address (Street And Number,City,Stat Zip Code) 4 2022
24.Informant's Name C
CONNIE COUSERT WIFE 6838 E. 550 SOUTH, FRANCISCelr4J649 ( r �� q
25.Place Of Disposition csiss.r'-'�1A �/CJ-
125b.Place Of Disposition(Name Of Cemetery.Crematory,Other Place) 25c.Location-City,Town,And Stafe� Co,
co Method Of Disposition NT y AVY'6`- J
®Bunel ❑Cremation ❑Donation 0 Entombment D/TOR
❑Removal From State FRANCISCO, IN
0 Other(Specify): PROVIDENCE CEMETERY 27a. Funeral Home License Number:
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility
®Yes ❑No LAMB BASHAM MEMORIAL CHAPEL, INC.,226 E.WASHINGTON STREET,OAKLAND CITY, FH83005312
IN 47660 27c License Number(Of L censee):
27b Signature Of Indiana Funeral Service Licensee: FD01016589
JERRY LEE BASHAM , BY ELECTRONIC SIGNATURE Cause Of Death (See Instructions And Examples) Approximate
Interval: Onset
28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events To Death
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On
A Line. Add Additional Lines If Necessary. HOURS
Immediate Cause(Final Disease Or Condition Resulting In Death) A. CLINICAL UPPER GASTROINTESTINAL HE MOR HAGEcv .w on
Sequentially List Conditions, If Any,Leading To The Cause Listed On
B. HEMORRHAGIC GASTRITIS oue toior n•ncon..w.niaan:
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last C. Dee to(Or As A c,n„a,.oc.na.
D.
Part II.Enter Other Significant Conditions Contributing to Death But Not Resulting In The Underlying Cause Given In Part I 129. Was An Autopsy Performed? ®Yes 0 No
130. Ware Autopsy:inding Available To Complete The Cause Of Death? ®Yes 0 No
320.
2 If Female: 33. Manner Of Death:
31. Did Tobacco Use Contribute To Death? ❑No1 7 w Natural 00
Homicide ❑Accident 0 Pending Investigation
gegn•n Ngnln raN Y.•r ❑Pre At time 0l Death ❑Not Pnqunl.But Pregnant MMNn a Y•Oi Doe.,
0 Yes 0 Probably 0 No 0 Unknown ❑Not Pr.gnere But Pregnant u Ow To 1 year e.tor.Death 0 unknown It Pregnant Within Th.Pee 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 Areal 37. Injury At Work?
38. Location Of Injury-State
38a. City Or Town 38b. Street&Number 0 Yes 0 No
38c. Apt.No. 38d. Zip Code
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4❑Ool,Transpo O:Nnju' 0"P-cesan.n❑o
39. Describe How Injury Occurred ..ro,»r.o r „gar [� tn«ISP•=wi
41. Signature, Of Person Certifying Cause Of Death: ', 42. Certifier(Check Only One)
`. 0 Certifying Physician 0 Coroner 0 Health Officer
STEVEN WYNnd LOCKYEAR, BY ELECTRONIC SIGNATURE \vl:\ 44_ License Number 45. Date Certified
43. Name,Address And Zip Code Of Person Certifying Cause Of Death:
STEVEN WYNN LOCKYEAR 201 S. MORTON
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