Death Certificate_French 40,"TMn; INDIANA STATE DEPARTMENT OF HEALTH ( )
CERTIFICATE OF DEATH
�.: 000011232708 State No 2022-005a96 i
` Local No
\,es,,% 000007 EDR No 2.Gender 3.Time Of Death
0 Hospice Fertility 0 Decedent's Florae 011 Nursing HomeA.ong term Care Facility
0 Yes X No 0 Unknown 0 Inpatient 0 Emergency Department Outpatient 0 Dead on Arrivel 0 Other(Specify)
11. Facility Horns 01 Not Inetuuaon.Give Street end Number) Premier Healthcare On New Harmony
12.City Or Town,Stale,And Zip Code ,
13.County Or Death 14.Marital Statue At Time Of Death
Posey ®Married❑Menied,But Sepotitod ❑Dworeed
New Harmony,Indiana 47631 ❑wldswad ❑Never Married ❑unw awn
15.Surviving Spouse's Name 15a,Leal Name Before First Marriage 18.Decedent'e Usual Occupation 17.Kind OI Business/Industry
Utley Tool and Die Maker Manufacturing
'Joan French
' is.Reeirisnos-sere 18n.county lab.City Or Town
IN Gibson Fort Branch
lea.Street And Number 18d.Apt.No. II 18e.Zip Code 18t. Inaide City Limits?
_147648 MI Yes 0 No
522E 600 S
19.Decedent's Education
20. Decedent Ot Hispanic Origin 21. Decedent's Race
White
Some college,but no degree Not Spanish/Hispanic/Latino
--- 23.Parent's Name(Firer,Mid ,Last) 23a.Parent's Last Nomo Bolero First Marriage
2Z Parent's Name(First,Middle,Last) Middle,
Doyle French Irene French Taylor
24.Informant's Nem., 24e.Relationship To Decedent 24b.Melling Address(Street And Number,City.State,Zee Code)
Joan French Wife 522 E 600 S,Fort Branch,IN,47648
25.Place Of Cris salon
25a.Method tit Disposition 25b.Place OI Disposition(Name 01 Cemetery,Crematory,Other Place) 25c.Location-City,Town.And State
®Burial 0 Cremation 0 Donation 0 Entombment
d' ❑Removal From State Walnut Hill Cemetery Fort Branch,IN
II „ ❑Other(Specify): 27a.Funeral Home License Number:
28.Wes Coroner Contacted? 27.Name And Complete Address Of Funeral Facility
Stodghlll Funeral Home Inc FH10900013
0 Yes ®No 500 E Park Street,Fort Branch,Indiana,47648
27b.Signature OI Indiana Funeral Service Licensee: 27c License Number(Of Licensee): FD21400005
Andrra L.Klieg Electronically Signed T T J�J T
iICause Of Death (SeelecInstructions And Examples) �1■■1- i■ ..■■V,■ Approximate
nterval:Onset
•"1:iP 1: ' 28.Part I.Enter The Ohaln Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal E nts To Death
Such As Cardiac Arrest,RoSpiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One use
ill, A Una. Add Additional Lines If Necessary. CardioreSpiratory failure 1/22/2022
Immediate Cruise(Final Disease Or Condition Resulting In Death) A. tkw w tat Nacamea "..A p R 0 2022 1/22/2022
B. severe COPD I` 2 L
Sequentially List Conditions, If Any,Loading To The Cnuse Listed On . twa to fa as a lbm.aenc.Ow
Line A. Enter The Underlying Cause(Disease Or injury That Initialed hypertension /' 1/22/2022
The Events Resulting In Death)Last C. mention ,' CC a y _,1�(. r
D type 2 diabetes GIBSON COUNTY Al infTO R 1/22/2022
Part It. ntar Other^sigh(learns rtdWQclt.0.2010bgl11191g-D6Btii But Not Resulting In The Underlying Cause Glean In Part I 29.Wee An Autopsy Pedormed? ❑yes ®No
30.Were Autopsy Findinrg Available To Complete The Crone Of Death? ❑Yee 0 No
1.d tia 33,Manner Of Death:
31.Did Tobacco Uso Contribute To Death? 32.If Female:
Cl aatP,.e,wwmPPmv.w ❑P,.an.nr4nikrratl..m ❑rww.trwr•swr+.sn.mtrraau.ao.r+ao.ra t�Natural❑Homicide 0 Accident 0 Pendingirwoatigenon
❑yes ❑Probably pp No ❑Unknown 0 Nan Propene..mu wooa.nr 43 feya 7a l year carer.ne-.ln I]u,menc v 1544,444,4 wean The P.«Vest 0 Suicide 0 Could Not Be Determined
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34.Date DI Injury(Month/Day/Year) 35.Time 01 Injury 36.Flare Of Injury(E.G..Decedent's Home,Construction Site,Restaurant,Wooded Area) 37.Injury At Work?
❑Yes ❑No
flIi•' 38.Location Ot Injury-State
30e.City Or Town 38b.Shoot&Number 38c.Apt.No. 38d.Zip Coda
let I'1'
40.If Tronsporletton Injury,Specify:
39.Describe How injury Occurred 0oneer43o.r.ree ❑e....rrer,❑ree«+"ar❑on...fsn«wt
` 41.Signature,Of Person Certifying Ceuso 01 Death: - 42.Certifier(Check Only One)
ZahidSagi6 Electronically Signed ®Certifying Physician 0 Coroner ❑Hersh Officer
44.License Number 45.Date Certified
43.Name.Address And Zip Code 01 Person Codifying Cause 01 Death:
1.
Zahid Saqlb 251 In 66,New Harmony,IN 47631
01086674A 01/28/2022
47.'Akers:
46.Additional Funeral So,vlce Provider: _
'48.Signature of Local Health Offices49. For Registrar Only -Date Flied(Month/Day/Year): 01/28/2022
�,'m xy�ROM' Electronically Signed
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
-v2.-3&E--3oO -rood -6o4 - 02 1- -
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to pursue responsibility. Disclosure Is voluntary end there will be no penalty for refusal.
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