Death Certificate - Stuckey, Alan_4/25/2022 (0"-' INDIANA STATE DEPARTMENT OF HEALTH
riop,,,)' CERTIFICATE OF DEATH0 I
Local No 000150 EDR No 000011164276 State No 2021-052108 l
1.Decedents Legal Naar(Fast.luifldls.Lest) la.Malden Name Of female) 2.Gender 3.Time Of Death
Alan Hargrove Stuckey
Princeton,Indiana 1
9.Ever in U.S.Armed Forces? 10.If Math Occurred In A Hospital: 10s. If Death Occurred Su.,,...:rore Other Than A Hospital i
El Hospice Facifly ❑ r
Decedent's Horne CM Nursing Horne/Long-termCare Ce Facility
❑Yes El No 0 unknown 0 Inpatient❑Emergency DeParunat Oo4awrt 0 Dead on Arrival Q Other(Specify)
11.Facility Nana to Not Institution,Give Street and Number) Riveroaks Health Campus f
12.City Or Town,Stale,And Zip Code 13.Comity Of Death 14. Mantel Statue N Time Of Death
0 Merced
Princeton,Indiana 47670
Gibson ®WidowedEll ❑Heuer MrlYd ❑tranown
15s.Last Name Batons Fist Mamrp.
16.Decedent's Usual Occuparcai 17.Kind Of�y i
15.Surviving Spouse's Name Patterson Railroad Conductor Transportation
Donna Stuckey 1eb.City Or town
18.Residence-Sag a-e le County
IN Gibson Princeton
led.Apt.No. 18e.Zip Code 18i. betide City Lk ats?
18c.Streit And Number
47670 ❑Yes ❑No
1015 Mill Street
19.Decedent's Education 20.Decedent Of Hispanic Odpin 21.Decedent's Race
weave
Some college,but no degree Not
Spanish/Hispanic/Latino
22.Parent's Name(First.Middle.Last) 53.Parents Nana(Fed.Middle,Lest) 23a.Panacea Last Nana Before First Merriam,
Orrin Cleveland Stuckey Barbara Stuckey Burbank
24.ktomarws Name 24a.Relationship To Decedent 24b.Mmting Address(Street And Number,City,Sate.Zip code)
Donna Stuckey Wife 1015 Mill Street,Princeton,IN,47670
25.Plaice Of bliripoeilion
25s_Meted Of Disposition 25b.Place Of Disposition(Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State
Cl Burial®Cremation❑Donation 0 Entombment
❑Ren ival From state Evansville Crematory,Llc Evansville.IN
❑Other(Specify): 27.Name And Complete Address OfFuneral Facility27a Home
Funeral Hoe License Number
26.Was Coroner Contacted? ,
onfect W.
Calvin Funeral Home Inc 425 N Main St.,Princeton,Indiana,47670 FH83005671
El Yes ®No ED012153
27b.itatSandi-re a Indiana Funera Service Licensee: 27a��
4tr7b. atd D1fic liana Etectronic�ly Signed
Came Of Death(sea ratrveuows And Examples) Appr°simile
28r:h o Of Fverta -Diseases. ,Or Compkcations-That Directly Caused The Death.Do Not Enter Tern final Events Interval-Onset
hart I.Enter The Injuries, To Death
Such As Ceniiac Amast.Respiratory Arrest,Or Ventricular Fbniration Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On 2 5 20�� 4 monthsAtw f kne.Add Addltlonal Lines n Necessary' Cerebrovascular Accident APR
knedlate Cause(Final Disease Or Condition Resulting In Death) A. Due r0 to iwwceve,. w,..cis
Sequertlaly List condition. If Arty,Leading To The Cause Listed On B- o,,..w..Aod...,.,4 ,( �. p1TOR
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated g S ON COUNTY AU
The Events Resulting In Death)Last C. 4r to(Or N A Gvt•M.enectk
D.
Pat e.Enter Odor Sot Not Resulting M The Underlying Came Given In Pan I 29.Was An AM.:ai y Performed? Q Yes ®No
90.Were Autopsy Finding Avasrbls To Complele The Cause Of Math? ❑Yes ❑No
93.Renner Of Death'
31.Dig Tobacco flee Contribute To Death 7 32.s Female: Accident p Pending MveeNpaion
0 nsrv.trw.wer..,r yr El v,.v,a•we Tim. 0 naa►,.rwia•ns.nw..s.vra+..z o.rsaoies. ®Nrrat❑Homicide 0
❑Yes 0 Probably®No ❑Unknown ❑raw•,rvw.It.n..*.Own,.rr rw.keen. Q u+wwat s n.swswrr."..err cure ❑Suicide❑Could Not Be°Hemli del
34.Dale Of Nam/(MontNDey!ler) 35.Time Of kijsy 36. Pero Of Injury(E.G..Decedent's Hann,Construction Sal..fledurrt.Wooded Ana) 37.Injury At Work?
❑Yes CI No
I 38.Location Of Wary-State
36a.City Or Town 38b. Street a Number Sec.Apt.No. 38d.Zip Code
p.If Transfiorrlim 04*y,Specify,
39.Describe How Injury Occurred ❑oe'.non.'w°'❑oswww'❑P•e•e•••❑at',tswern
• 41.Signature,Of Person Certifying Cause OfDeath: 42 Certifier(Check Only O la comi.ne) Q Health OliverOliverian Lee Carter Electronically Signed ®Csddyln9 PhydMarh
44.miasma Number 45.Data Certified
43.Herne Address And Zip Code Ot Pere°"Calaying Cause a Death- 02002691 A 1 46.09 Dear
Adrian Lee Carter 1808 Sherman Drive,Princeton,IN 47670 47.2 026
48.Addtaml Furwrd Service Provider-
n sIDary/Yw): 09 021
' 4e- ucrtrre of Local Health Officer. Electronically Signed
148. For Registrar Only-Data Filed(Mo
`ei"`rets�' AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
-2.6_Oy-1- O0- 000 .0(52 -O\g.
-, Form 53395 ATTENTION ESTATE: Security SocialSecurity a is being requested by this state agency in order to pursuetr reepootRy. D tr iscloee is vof nfewillY and Were w be no penalty for refusal.i
WARNING. TORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON URNS FROM ORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUMIEN HAS ASHIDDE VOID ON FRONT THART AP EARS W EN PHOTOCOPIED.INDIANA ON BACK THAT