Death Certificate - Stuckey, Alan_4/25/2022 (2) ?4, INDIANA STATE DEPARTMENT OF HEALTH
ti CERTIFICATE OF DEATH
S
• - Local No 000150 EDR No 000011164276 State No 2021-052108 1
1.Decedent's Legal Name (First,Middle.Llet) 1 a. Maiden Name IN female) 2.Gender 3. Time Of Death
Alan Hargrove Stuckey
I
Princeton,Indiana
9. Ever In U.S.Armed Forces? 10.If Death Occurred In A Hospital- 10e. If Death Occurred Somewhere Otter Than A Hoepkat
❑Hospice Facility ❑Decedents Home ®Nursing HonreLatp-temp Care Facility
❑Yes ®No In Unknown 0 'neediest 0 EmergencY Defect set Wtpaliem 0 Deal en Anita p Olha(Specify)
11.Facility Nerve(e Not Institution,Give Street aid Number) Rivefoaka Health Campus
12.City Or Town.Slate,And Zip Code 73.Count Of Death 14. Manta Status At Tens Of Death I
Married,But Separated
ivorced
Princeton,Indiana 47670 Gibson Married 0® Never Married ❑0
15.Surviving Spouse's Nan. 15s.Last Name Bofors Fast Manage 16- Decedents Usual Occupation 17. Kind Of Busaeaa1Mustcy
Patterson Railroad Conductor Transportation
Donna Stuckey
18.Residence-Start 18a_County 18b.City Or Town
IN Gibson Princeton
18c. Street And Number led. Apt.No. 113e. Zip Cora 1st. treble City Limas?
1015 Mill Street 47670 ❑Yes ❑No
19.Decedents Eaton 20.Decedent Of Hispanic Origin 21.Decedents Race
Some college,but no degree Not Sperrishibilepanickedno White
22.Parents Name(Fka.Middle.Last/ 23.Parent's Name(First,Middle.Laid) 23a.Parents Last Name Bebre Firid Marriage
Orrin Cleveland Stuckey Barbara Stuckey Burbank
24.Informants Name 24a.Relationship To Decadent 24b.MailIng Address(Street And(Somber,City.Slate.LP Code)
Donna Stuckey Wife 1015 Mill Street,Princeton,IN,47670
25.Prow Of Disposition
25a Method Ol Deposition 25b.Place Of Disposition(Name Of Cemetery,CremeSiry,Other Place) 25c.Location-City,Town,And State
❑Burial El Cremation 0 Donation❑EMomMne t
❑Fleminnl From State Evansville Crematory,!lc Evansville.IN
❑Other ISpecity):
26.Was Coroner Contacted? 27.Name And Complete Memos Of Funeral Facility 27a Funeral Home License Number:
Colvin Funeral Home Inc 425 N Main St.,Princeton,Indiana,47670 FH83005671
0 Yes ®No
27b. Signature Of Indiana Funeral Serves Licensor 27`i"'�.�1°"'r"(or e�°ngel-��y 012153
4ticharetpNicltrtld Electronically Signed �-wl ■1 L lr"'J ,l"/�
Cause Of Death(see Instructions And Examples)
j, Approximate
28.Part I.Enter The .in.0 vents -Diseases,injuries,Or Complications-That Directly Caused The Death.Do Not Enter Tempnal Events Interval: Onset
Such As Cardiac Arrest,Respiratory Arresl,Or Ventricular Fibrillation Without Showrnp The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Additional Lines If Necessary. 2Itn22 4 months
Immediate Cause(Final Disease Or Condition Resulting in Death) A. Cerebrovascular Accident A P R
Me n XI.As A LmMyws OS.
Sequentially List Conditions, If Any,Leading To The Cause Listed On B. ra...s for w.woaew..ee.De17..., `•' '"""'TO
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated / �714.'^'-'RSON COUNTY AU ',net)
The Events Resulting In Death)last C.
rare to wow
D.
Part II.Enter Otto But Not Resulting In The Underlying Chas Given In Pat f 29.Was An Autopsy Performed? 0 Yes ®No
So.Were Autopsy Finding Avow.To Complete The Cane Of Dean? ❑ve ❑No
-31-Did Tobacco Use Contribute To Death? 32.r F«nw: 33.fauna Of Death,
❑eon axe*lama... ❑O'sa*Mnrara.ar, 0 manw.o•alcii.reer.waraatasa Den. ®Naarta❑Homicide ❑Accident 0 Pending InveetIgaion
0 Yes ❑Prnbetty®No ❑ ^ 0 rashrmor.an vn.a-as ore*la a vas Wien O.. 0,ire.a.a0-t..n ear ere real NW ❑Suicide El Could Not Be Determined
34.Date Of Injury(MonhlDsy/Yea) 35.Time Of Mryry 36,Mace Of Injury(E.G.,Decedents Hum..Construction Site,Restaurant,Wooded Area) 37.Injury At Work?
❑Yes ❑No
38.Location Of Injury-Store 38a.City Or Town 36b. Street 8 Number 38c. Apt.No. Sad"Zip Code
40. a Tranepata on Wuy.Specify:
39.Desarbe How Injury Occurred ❑ile r+a. ❑passes,❑realer.Dome Lomas
41.Signature,Of Person Certifying Cause Of Death' 42 Certain(Check Onty Ore Cuxaw 0 Health Officer
matt Ise Carter Electronically Signed ®Certifying Physician DI
- 43.Name,Address And ZIP Code Of Person Certifying Cause a Death- 44.License Number 45. Dar Certified
Adrian Lee Carter 1808 Sherman Drive,Princeton,IN 47670 02002691A 09/21/2021
47- 'Alias:
46.AdditionalFuneral Service Provider:
49. For Regla/er Only--bide Fetid(MaelDayiVeer): 09/22/2021
: lase Signature Brinkyr grrred Local Health Officer-. Electronically Signed
rEltres
- AMENDatENT TO CERTIFICATE OF DEATH(ENTRY OR
requested by this state agency intt order to pursue r '. oeloS la vo1a11189 and there wort be no penalty for refusal.
WARNING. ORRIGINAFLRODOMCOUMENNGTEHTAOS
TO ELLOW WHEN RUBBED ORIG NALL DOCUMEN HATS ASHIDDEN VOID ON FRONT THAT APPEARS WHEN HOTOCOPIEDIANA ON BACK THAT