Death Certificate - French, Michael_4/20/2022 (2) _-_
4"Tsn INDIANA STATE DEPARTMENT OF HEALTH
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_ CERTIFICATE OF DEATH _
Local No000011232708 State No 2022-005496
ecaden�- 000007 EDR No
1.Decedent's Legal Name(First,Middle,Lest) le.Malden Name(11 female) 2.Gender 3.Time Of Death 4,Dale OI Death(Month/Day/Year)
Male 04:00 AM
Michael J French
76 Months Days Hours Minutes
Hospital'
0 Hospice Facility 0 Decedent's H m
ome IBI Nursing Hoe/Long-term Care Facility
El Yes IIII'No ElUnknown 0 Inpatient 0 Emergency Department Outpatient 0 Dead on Arrive) ❑Other(Specify)
•
11. Facility Name(If Not inenlution,Give Street and Number) Premier Healthcare On New Harmony
12.City Or Town,State,And Zip Code . 13.County 01 Death 14.Marital Status At Time Of Death
New Harmony,Indiana 47631 Posey ®Married❑Married,But Separated ❑Divorced
❑Widowed ❑Never Married ❑Unknown
15.Surviving Spouse's Name 15a.Last Name Before First Marriage 10.Decedent's Usual Occupation 17.Kind Of Business/Industry
F , Utley Tool and Die Maker Manufacturing
'Joan French
;4' ta.Residence,-State 18a.County 18b.City Or Town
IN Gibson Fort Branch
18c.Street And Number t8d.Apt.No. lee.Zip Code 181. Inside City Limits?
522 E 600 S 47648 II((Yes 0 No
' 19.Decedent's Education 20. Decedent Of Hispanic Origin 21.Decedent's Race
, Some college,but no degree Not Spenlshe-aspaNc/Latino White .
it23a.Parent's Last Name Bolore First Marriage
'I�)� 22.Parent's Name(First.Middle.Last) 23.Parent's Name(Rrel.Mkklin,Last)
Doyle French
Irene French Taylor
24.Informant's Neme 24e.Relationship To Decedent 24b.Mailing Address(Street And Number.City.State,Zip Code)
Joan French Wife 522 E 600 S..Fort Branch,IN,47648
25.Place Of Disposition
25a.Method 01 Disposition 25b.Place Of Deposition(Name 01 Cemetery,Crematory.Other Place) 25c.Location-City,Town,And Stale
®Burial ❑Cremation❑Donation 0 Entombment
d' ❑Removal From State Walnut Hill Cemetery Fort Branch,IN
li 0 Other(Spccuy):
,` 28.Was Coroner Contacted? 27.Name And Complete Address Of Funeral Facility 27a.Funeral Home License Number:
Stodghill Funeral Home Inc
❑vow DPNo 500 E Park Street,Fort Branch,Indiana,47648 FH10900013
27b.Signature Of Indiana Funeral Service Licensee: 27c License ica Number(Of Licensee):FEDD21400005
...if L Krieg Electronlly Signed L
i, Cause Or Death(See leInstructIon•ica And Examples) Approximate
'll':iy.;i: '' 28-Part I.Enter The 4ttain Of Ev@N5 -Diseases.Injuries.Or Complications-That Directly Caused The Death.Do Not Eider Terminal E nis Interval:Onset
Such As Cardiac Arrest.Respiratory Arrest.Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only On se To Death
F A Uno. Add Additional Lines II Necessary.
cardiorespiratory failure 1/22/2022
Immediate Cause(Final Disease Or Condition Resulting In Death) A. ....rw A.A ce,,.«w.nc.AP U -
severe COPD 1` Z 0 2022 1/22/2022
• Sequentially List Conditions. It Any,Leading To The Cnuse Listed On B. Ifw b ION A*A Gm.wenc.,O,):
• Line A. Enter The Underlying Cause(Disease Or Injury That Initialed hypertension ._'•1/22/2022
The Events Resulting in Death)Last C. -
D type 2 diabetes GIBSON COUNTY AUnlTOR 1/22/2022
Part It.Enter Other SignitiCgNSA9ditiOrl5 CoMdDutlOgt99�atil But Not Resu111ng In The Underlying Cause Given In Pert Id tia 29.Wee An Autopsy padeased? ❑Yaw ®NO
30. ere Autopsy Finding Ava9nb a To Complete he 01 Death? ❑Yea 0 No
*.Did Tobacco Did Tobacco Use COnlrbNe To Death? 32. It Female: 33.Manner OI Death:
❑feePrernW Main Postwar 0 v»m.i.,-.n.as..m ❑Net Warne*t ir repays yawner Depot ones ®Natural 0 Homicide 0 Accident 0 Pendingimroatgatlen
❑Vas ❑Probably®No ❑Unknown 0 tar Parse.nut P,eon+nr 43 oa.To i most e.Nr.o.-n, ❑Lleb,o.n v n,.a..,n WA,The PeO v..r 0 Suicide❑Could Not Be Determined
34.Date Of Injury(Month/Day/Year) 35.Time Of Injury 36.Piece Of Injury(E.O.,Decedent's Home,Construction Site,Restaurant,Wooded Area) 37.Inkrry At Work?
❑Yes ❑No
n
�• � jj,1 3a.LOnaifan Of Injury-State 38a.City Or Town 3Bb.Street 8.Number • 38c.Apt.No. 38d. Zip Code
'i
i
39.Describe How Injury Occurred 40. if Transportation Injury,Specily:
❑on..,ron.r.•n ❑e-°'e.,❑earim.Done roo.rwt
41.Signature.Of Person Codifying Canso 01 t30ath: 42.Certifier(Check Only One)
ZaiidSali6 Electronically Signed ®Certifying Physician 0 Coroner 0 Health Officer
43.Name,Address And Zip Code 01 Person Certifying Cause Ot Death: 44.License Number 45.Data Certified
Zehid Sagib 251 In-66,New Harmony,IN 47631 01086674A 01/28/2022
46.Additional Funeral 5orvlce 7mv2r: _ 47.'Alias:
i •48.Signature of Local Health Oilicern. 49. For Registrar Only-Dote Filed(Month/Day/Year): 01/28/2022
Il: ,xy&r�2RpP Electronically Signed
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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ze-kq -0g-100-ID oo - Zrz- o2s'c s)
agency In order to pursue responsibility. Disclosure Is voluntary and there will be no penalty for refusal.
TE SECURITY PAPER AND THE GREAT SEAL OF
STATE OF
'N t►ARNING a TORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL URNS FROM ORANGE TO YELLOW WHEN RUBBED.OFl 0 NAL,LH)CUMENT �S�H1LD gN VOID ON Er10NT THAT_.�1PPEAns WHENTHE INDIANA ON BACK THAT
PHOTOCOPIED.