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1.4:. - INDIANA STATE DEPARTMENT OF HEALTH
1 is i CERTIFICATE OF DEATH
j Local No 000038 EDR No 000000697581 State No 011300 0
1.Decedent's Legal Name(First,Middle,Last) la. Maiden Name (If female) 2-Sex 3. Time Of Death 4. Date Of
Death Occurred In A Hospital: 10a. If Death Occurred Somewhere Other Than A Hospital
❑Hospice Facility 10 Decedent's Home 0 Nursing Home/Long-term Care Facility
0 Yes ®No 0 Unknown ❑Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival ❑other(Sp<v-%fy)
VI. 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 ❑Divorced
FORT BRANCH, IN,47648 GIBSON 0 1,Mclowed 0 Never Maniac' 0 Unknown
15. Surviving Spouse's Name 15a.Last Name Before First Marriage 18. Decedent's Usual Occupation 17. Kind Of Business/Industry
HOUSEWIFE _DOMESTIC
18. Residence-State 18a. County 18b. City Or Town
INDIANA GIBSON FORT BRANCH
18c. Street And Number lad. Apt No. 18e. Zip Code 18f. Inside City Limits?
7517 EAST 775 SOUTH 47648 ❑Yes ®No
19. Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedent's 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.Parent's Last Name Before First Marriage
PAUL MASSEY HELEN MASSEY HIGHSMITH
24.Informant's Name • 24a.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,Arid State
El Burial 0 Cremation 0 Donation 0 Entombment
❑Removal From State
❑Other(Specify): PROVIDENCE CEMETERY _FRANCISCO, IN
28.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility 27a. Funeral Home License Number.
®Yes 0 No STODGHILL FUNERAL HOME INC, 500 E PARK ST HWY 168, FORT BRANCH, IN 47648 FH10900013
27b. Signature Of Indiana Funeral Service Licensee: 27c. LLIlB�Number(Of Licensee):
ANDREA LYNN STODGHILL, BY ELECTRONIC SIGNATURE Or E D
Cause Of Death (See Instructions And Examples) FD21 1■ 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. CARDIAC DYSRHYTHMIA APR 2 p 2022 DAYS
Du.to(Of Asa Comm.Oil
Sequent• ially List Conditions, If Any,Leading To The Cause Listed On B. CHEST PAIN Dv.w(of can cen..w� DAYS
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated Qj� �� � �
The Events Resulting In Death)Last C. HYPERTENSION r"r-�/LtLLI r Z f�Yr�.b' 1 YEARS
D.ete(OrA.Acen..e,�ny{®SON COUNTY AUDITOR
D. IRON DEFICIENCY ANEMIA YEARS
Part II.Enter Other Sionificant Conditions Contributino to Death But Not Resulting In The Underlying Cause Given In Part I 29. Was An Autopsy Performed? 0 Yes ®No
30. Were Autopsy Finding Available To Complete The Cause Of Death? 0 Yes 0 No
CARDIAC DYSRHYTHMIA
31. Did Tobacco Use Contribute To Death? 32. If Female: 33. Manner Of Death:
0 Not Pregnant within P.O Yea, 0 Pregnant At Ilene Of Dssth 0 Nol Pregnant.But Pregnant Valle 42 Days Of D.es ®Natural❑Homicide 0 Accident 0 Pending Investigation
❑Yes ❑Probably®No 0 Unknown ❑Not Pregnant,But Pregnant 43 Day.To I year Before Drag. 0 Unknown a Pregnant We,.,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. If Transportation Injury, y:
❑om.noen.a ❑Pa ,.Oar..(ss.crrl
41. Signature.Of Person Certifying Cause Of Death' 42. Certifier(Check Only One)
BRUCE CARLTON BRINK JR, BY ELECTRONIC SIGNATURE ®Certifying Physician 0 Coroner ❑Health Officer
43. Name,Address And Zip Code Of Person Certifying Cause Of Death: 44. License Number 45. Date Certified
BRUCE CARLTON BRINK JR ,410 NORTH MAIN STREET, PRINCETON, IN 47670 02000610A 03/08/2019
48.Add,ttonal Fune'el Service Provider
48. Signature of Local Health Officer 49. For Registrar Only -Data Filed(Month/Day/Year):
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE MAR 11 2019
AMENDMENT TO
-21-300 -oCO. 2 -oo(
State Form 53395 ATTENTION ESTATE:The Social Security#is being requested by this state agency in ord:r to pursue responsibility. D.sUosure is voluntary and there will be no penalty for refusal.
WARNING. TURNS FROMCOANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUMENT AS ASHIDDEN PON FRONT THAT EAPPEARS WHEN PHOTOCOPIED.
ON BACK THAT