Death Certificate - French, Michael_4/20/2022 un
s?;"' a. INDIANA STATE DEPARTMENT OF HEALTH
FICATE OF DEATH
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" -p I' 2022-005496
,-_t. i Local No 000007 EDR No 000011232708 • State No
1a.Malden Wane(It female) 2.Qender 3.Time Of Death 4.Date 01 Death(Mon hiDay/Year)
1.Decedent's Legal Name(Final.Middle.Leal) Male 04:00 AM
Michael J French
10.11 Death Occurred In A Hospital: 10a. 11 Death Occurred Somewhere Uaier han A Hospital
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❑Hospice Facility 0 Decedent's Home Da Nursing Home/Long-term Care Facility
0 Yes 1&No 0 Unknown ❑Inpatient 0 Emergency Department Outpatient 0 Dead on Arrive' ❑Other(Specify)
11.Facility Name(II Not Inentueon,Give Street end Number) Premier Healthcare On New Harmony
1-27-bBy Or Town,State,And Zip Code , 13.Courtly OI Death 14.Marital Status At Time Of Death
Pose ®Married❑Married,But Separated 0 Divorced
New Harmony,Indiana 47631 Y ❑Widowed ❑Never Married ❑Unknown
15. Surviving Spouse's Name 16a.Last Name Selma First Marriage tr,.Decedent's Usual Occupation I 17.Kind OI Business/Industry
Joan French Utley Tool and Die Maker . Manufacturing
le.Residence-Stele lea.County 18b.City Or Town .
IN Gibson Fort Branch
18c.Street And Number 18d.Apt.No. II 18e.Zip Code let. Inside City Limns?
522 E 600 S 47648 MI Yes 0 No
' 19.Decedent's Education 20. Decedent Of Hispania Origin 21.Decedent's Race
Some college,but no degree Not Spenlah/HIspanicJLatino White •
22.Parent's Name(First.Middle,Last) 23.Parent's Name(Firm.Mid,iin,Last) 23a.Parent's Last Nomo Before First Marriage
Doyle French
Irene French Taylor
24.Interment's Name 24e.Relationship To Decedent 24b.Melling 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 Dlepoafbon 25b.Place 01 Disposition(Name 01 Cemetery,Crematory.Other Place) 25c.Location-City,Town.And State
.pg Blnkii 0 Cremation 0 Donation 0 Entombment
fr ❑Removal Front State Walnut Hill Cemetery Fort Branch,IN
li ,, 0 Other(Specify):
,• 26.Was Coroner Contacted? 27.Name And Complete Address Of Funeral Facility 27a. Funeral Home License Number:
Stodghlll Funeral Home Inc i
p Yes DoNo 500 E Park Street,Fort Branch,Indiana.47648 FH10900013•
270.Signature Ol Indiana Funeral Service Licensee: 27c. License Number(Of Licensee):FD21400005
'Anima L Krieg Electronically Signed Cause Of Death(See Instructions And Examples) LED
Approoimnto-.i'fig , ' 28.Part I.Enter The Shah Of Event4 -Diseases.Injuries,Or Coutplicallons-That Directly Caused The Death.Do Not Enter Terminal E ets Interval:Onset
Such As Cardiac Arrest.Respiratory Arrest.Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One use To Death
A Line. Add Additional Lines If Necessary. 1/22/2022
Immediate Cruise(Final Disease Or Condition Resulting In Death) A. cardiorespiratory failure
1,f-rainTT As 0cowovencr Ap J 0 2022 1/22/2022 i
B. severe COPD 1 r 1` L/
Sequentially List Conditions, If Any,Loading To The Cause Listed On IM.e w ial Ar n uom.yenr.rip:
Line A. Enter The Underlying Cause(Disease Or Injury That initialed / 1/22/2022
The Events Resulting In Death)Last C. hypertension
ow re tor 0, -` F /7 '`p
D type 2 diabetes GIBSON COUNTY AI1nITOR 1/22/2022
S
-Part It,Erie.'Other Slant/OaniSA0d812II£0i00lghYWJg_t046ath But Not Resulting In The underlying Cause Given In Per 1 29.Was An Autopsy Performed? 0 Yes II No
dementia 30.Were Autopsy Finding AvaIl tble To Complete The Cause Of Death? ❑Yes 0 No
31.Did Tobacco Use Contribute To Death? 32.If Female: 33. Manner Of Death:
0 Nei P,.tne,e wMn Put Ye.l 0 P,.emnt At Tree010earn ❑Net eram N,Our enm,er saku.4n Defy.Cl Deal, ®Natural 0 Homicide 0 Accident 0 Pending Investigation
❑Yet ❑Probably®NO ❑Unknown 0 so Pnennm.nut rnenanr.9 nnye Tel year Se,,.Ds-t1, 0 rinL,oan PP.ea,v,rvvv.v To.Psa Y.sr 0 Suicide 0 Could Not Be Determined
34. Date CN Injury(Month/Day/Year) 35.Time Of Injury 36,Place Of tninry(E.G..Decedent's Home,Construction Site.Reotnurant,Wooded Area) 37.IMury At Work?
❑yes ❑No
• 'it' 'ry 38b.Streeta Number • 38c.Apt.No. 38d. Zip Code
38.Location Of Injury-Stale 38a. City Or Town
39.Describe How Injury Occurred 40. If Transportation Injury,Specify:
❑eco.or.•.•. ❑eo.ante,Deocknonn❑om«rs..cerr
41.Signature,Of Person Certifying Cause Of Death: 42.Certifier(Check Only One)
ZaftieSa 6 Electronically Signed I$I Certifying Physician ❑Coroner 0 Health Officer
43.Name.Address And Zip Code Of Person Certifying Cause Of Death: 44.License Number 45.Date Certified
• Zahid Sagib 251 In-66,New Harmony,IN 47631 01086674A 01/28/2022
46.Additional Funeral Song eFrev2Zr, ,_ 47.'Akas:
' 48.Signetme of Local Health Officer. 49- For Registrar Only-Date Filed(Month/Day/Year): 01/28/2022
xy&wopr Electronically Signed
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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''1 �Ett�att @ Off.553395 ATTENTION ESTATE:The Social Security a Is being requested by tills elate agency In order to pursue responsibility. Disclosure le voluntary and there will be no penalty for refusal.
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