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- INDIANA STATE DEPARTMENT OF HEALTH
(7- ii'l CERTIFICATE OF DEATH
Local No 000038 EDR No 000000697581 State No 011300
1.Decedent's Legal Name(First,Middle,Last) 1a. Maiden Name(If female) 2.Sex 3. Time Of Death 4. Date Of
Hours Minutes 08/04/1933
8. Ever in U.S.Armed Forces? 10.If Death Occurred In A Hospital: 10a. If Death Occurred Somewhere Other Than A Hospital
0 Hospice Facility ®Decedent's Home 0 Nursing Home/Lang-terror Care Facility
0 Yes ®No 0 Unknown 0 Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival ❑other(Sp„r:fy)
11. Facility Name (If Not Institution,Give Street and Number)
7517 EAST 775 SOUTH 12. City Or Town,State,And Zip Code 13. County Of Death 14. Marital Status At Time Of Death
0 Married 0 Married,But Separated 0 Divorced
FORT BRANCH, IN,47648 GIBSON El widowed 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
HOUSEWIFE DOMESTIC
18. Residence-State 18a. County 18b. City Or Town
' INDIANA GIBSON FORT BRANCH
18d. Apt No. lee. Zip Code 18f. Inside City Limits?
18c. Street And Number
•
7517 EAST 775 SOUTH
47648 0 Yes ®No
19. Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedent's Race
, HIGH SCHOOL GRADUATE OR GED NOT HISPANIC White
COMPLETED 23.Parent's Name(First,Middle,Last) 23a.Parent's Last Name Before First Marriage22.Parent's Name(First,Middle,Last)
PAUL MASSEY HELEN MASSEY HIGHSMITH
24.Informant's Name 24.Relationship To Decedent 24b.Mailing Address(Street And Number,City,State,Zip Code)
BETH SCHMITT DAUGHTER 7285 SOUTH 650 EAST, FORT BRANCH, IN 47648
25-Place Of Disposition
25a.Method Of Disposition 25b.Place Of Disposition (Name Of Cemetery.Crematory,Other Place) 25c.Location-City,Town,And State
®Burial 0 Cremation 0 Donation 0 Entombment
❑Removal From State FRANCISCO,IN
❑Other(Specity). PROVIDENCE CEMETERY 27a. Funeral Home Ucense Number
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility
®Yes 0 No STODGHILL FUNERAL HOME INC, 500 E PARK ST HWY 168, FORT BRANCH, IN 47648 FH10900013
27c. se Number(Of Licensee):
27b. Signature Of Indiana Funeral Service Licensee: FD21 0 0� ED
ANDREA LYNN STODGHILL, BY ELECTRONIC SIGNATURE Approxiate
Cause Of Death (See Instructions And Examples)
Interval.m 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.
(T p ^ rrO��
Immediate Cause(Final Disease Or Condition Resulting In Death) A. CARDIAC DYSRHYTHMIA DAYS
Due to(Or as A CoNeeSP.nse oh A 1-fl V L
DAYS
•
Sequentially List Conditions, If Any,Leading To The Cause Listed On
B. CHEST PAIN ow is tour As A cow.
•
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated .l YEARS
The Events Resulting In Death)Last C. HYPERTENSION owm(Or c.ccer..w(.y{®SON C 11--- „�
• COUNT AUDITOR YEARS
D. IRON DEFICIENCY ANEMIA
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
30.Were Autopsy Finding Available To Complete The Cause Of Death? ❑Yes 0 No
CARDIAC DYSRHYTHMIA 33. Manner Of Death:
31. Did Tobacco Use Contribute To Death? 32❑. IfINoFemaant El At Timm Or Death 0 Not
r Pregnant varvn Past YearPr.gn.b.eve Pregnant wkn.n+s Days or o..h 33 Natural 0 Homicide 0 Accident 0 Pending Investigation
0 Yes ❑Probably®No ❑Unknown ❑Not Pregnant.Bit Pregnant u Days To t r..r Beer.oath 0 unknown If Pregnant Within The P.O 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 ElNo
38a. City Or Town 38b. Street&Number 38c. Apt No. 38d- Zip Code
38. Location Of Injury-State �peu
39. Describe How Injury Occurred 46.
oreIf
ToP. ❑P.Inn/�UP.°cNy.rn❑wwr<sr.cih)
41. Signature,Of Person Certifying Cause Of Death: 0 Certifying Physician 0 Coroner 0 Health Officer
BRUCE CARLTON BRINK JR,BY ELECTRONIC SIGNATURE 44. License Number as. Date Certified
03/08/2019
43. Name,Address And Zip Code Of Person Certifying Cause Of Death: 42. Certifier(Check Only One)
0200061 OA
BRUCE CARLTON BRINK JR ,410 NORTH MAIN STREET, PRINCETON, IN 47670 47 •Aka,:
c 46.Addit onal Func®I Service Provider
49. For Registrar Only -Date Filed(Month/Day/Year):
48- Signature of Local Health Officer MAR 11 2019
j BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE
MENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
g 0 '26-1,o--7-o-`1.‘=,0-000 .21.5-001
L
a CD 26- '2o-
53395 ATTENTION ESTATE,The Social Security at'is being requested by this state agency in ord.r to pursue responsibility. Dsclosure is voluntary and there will be no penalty for refusal.
if WARNING: TTURNISN FROM ORANGE TO YELLOW WHEN RUBBED.ORIGINALL DOCUMEN HAS ASHIDDEN VOID ON FRONT THATEAP EARS WHEN PHOTOCOPIED AN ON BACK THAT