Death Certificate - Stuckey, Alan_4/25/2022 (3) annce.w
....r-1" i Cal.".-raw-C-f/. cafe : 7194"9t r +7.PS' T►'''"4"''r".r . .__ C=AS7r,s[r.Ina ..IVIrnacwrsa-.w� d.wian _0
---
r* INDIANA STATE DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH I
_,_.., / Local No 000150 EDR No 000011164276 State No 2021-052108
1.Decedents Legal Name(Fist,kiddie.Last) is.Maiden Name Of female) 2.Gender 3.Ties Of With 4.Doe Of Decent(kbr*vDsy/Ywr)
Male 01:10 AM
Alan Hargrove Stuckey
78 Months Day I
s Hours Minutes Princeton,Indiana
9. Ever in U.S.Armed Posies? 1O.If Death Occurred in A Hospital: Vie. If Death Occurred Somewhere Ohs Than A Hospital
p Hospice Facility p Decedents Home ®Nursing Hon t ng-ierm Cars Facaity
❑Yes ®No ❑Unknown ❑Inpeter4❑Emergency oesertnert Outer 0 Dead es Arfival p Oster(Specify)
11.Pacify Rent.(It Not Institution,Give Street and Number) Riveroaks Health Campus
12.City Or Town,Sate,And Zip Code 13.Cranny Of Death 14.Mental Stars At Time Of Death
•
Gibson Minted❑Married'But Separated 0 Divorced
Princeton,Indiana 47670 ®Wid01Med ❑Never Married ❑Unknown
15.Surviving Spouse's Name 15a.Last Name Before First Menage 16. Decedent's Usual Oc«4a5on 17.Kind Of Susineetalndustry
Patterson Railroad Conductor Transportation
Donna Stuckey Ieb City Or Town
15.Residue-Sate lea.Canty
IN Gibson Princeton
led.Apt.No. 18e.Zfp Cods 181.Inside City Lays?
tea Saar And Number
13 Yes 0 No
1015 Mill Street 47670
19.Decedents Education 20.Decedert of Hispanic Origin 21.Decedent.Race
Some college,but no degree
Not spanlM lHlsPenk/Launo White
22.Parents Name(Fran.Mddle.Last) 23.Parents Marne(Prat.Mddfe.(.eal) 23a.Parents Litt Writ Before Pint Manage
Orrin Cleveland Stuckey Barbara Stuckey Burbank
-24.Informant's Name 24a.Relationship To Dncadsrt 24b.Ma ring Address(Steel And Number.City.Sale.Zip Code)
Donna Stuckey Wife 1015 Milt Street,Princeton,IN,47670
25.Pace Of Depoetion
25a.Method Of Diepoeibon 25b.Paw Of Disposition(Name Of Cemetery,Crematory,Other Place) 25c.Location-Ci y,Town,And Stet*
p Burial I.Cremation 0 Doration❑E,4u..b.nent
❑Removal From Sate Evansville Crematory,tic Evansville,IN
❑Other 48pecly) 27.Name And Complete Address Of Funeral Facility 27a Fune
ral Hoare Lin NumberensNumber26.Was Coroner Contacted?
Colvin Funeral Home Inc 425 N Main St.,Princeton,Indiana.47670 FH83005671
p Yes ®No
27b. Signature,Of Indiana Funeral Service Licensee: 27. (« 012153
(Richard-TA Efci<:mif Electronically Signed
Cana.or Death(see instructions And E:esnptea) Approximate
Everts Diseases, ,Or Complicabons-That Directly Caused The Death.Do Not Enter Terminal Events interval:Onset
2u.Part I.Enter The r - t,OreTo Death
Such As Cardiac Arrest Respiratory rree,Or Ventricular FiDriMetioru Without Showing The Etblogy-Do Not Abbreviate.Enter Only One Cause On
A Line.Am Additional Lines tf Necessary. a Cerebrovascular Accident APR 2 5 202Z 4 monthsirrnnediele Cause(Foal Disease Or Condition Resulting In Death) era r«A.A ay...e...son
Sequentially list CondiOone. B Arty,Leading To The Cause Listed On B- a.r w tor ArAcw.w.re/fmY)..., � Z. A �T OR
Line A. Enter The Underlying Cause(Disease Or Injury'That initiated (��gar SOON COU
NT
The Everts Resorting in Death)Last C. ou.at«w.Aca.w+.�lr'
D.
Pact II.Emir Other Significant Conditions Gorartrusnr b Dash But Not gseulbnp In The Underlying Cause Given In Pat I 29.Was M Auto sy P•rian reed? p Yee Ili No
30.Were Autopsy Finding Available To Compfets The Cerise Of Dead,? ❑Yes ❑No
xi.Manner Of Dealt:
31.Did Tobacco Use Canalboat,To Death? 32. i Female:
0 mnr..o.r•mown awe vest 0 mvy,r..err.«or, p rind ra.•••t 1........Oa.011.8. ®Naar*0 tfornidde p Acddet 0 Pwmdfrng lrwe.li9.b.n
❑Yes ❑Probably®No ❑llNanovrn 1C]vier•..e+r-nu w.o,...o Do.To it n+seavo.r. 0 1............T.r..evw ❑Stickle In Could Not Be D.Isrnined
. 34.Dais Of Injury(aorthlDey/Y.a) 35.Time Of Injury 36. Place Of bury(E.G..Decedents Home,Costrueaan Site,Rostrum*Wooded Area) 37.Injury At Work?
❑Yes CI No
•
9e.Location Of Injury-aisle
38a.City Or Town 39b. Street S Number Sac.Apt-No. glide Zp Comb
40.M Transprblbn Inky,Specify:
39.Desabs How Injury Occurred ❑qer„ap.sv❑e..wn..❑n•....ane DO.,M..r.
41.1.`SignaRre.Of Person Certifying Cats Of Death: i� 4_ Certifier(Check Only One)___
fid,i 0 Coroner Health OIicR
art Lee Carter Electronically Signed ®candying Physician [�
M.lacerate Number43.Name,AddressAnd
d Zip Code Certifyingres d Of Person Cq Ce Death': 02002691 A I 45.Deis Cedfl.d
09/21/2021
Adrian Lee Carter 1808 Sherman Drive,Princeton,IN 47670 � 'Alum46.Additional Puna rw
*Service Pklr e
r 49. For Registrar Only-Daft Filed(MonSoDaylYer): 09/22/2021
48.Sigmas.of Local Hearth Oftbe: Electronically Signed
Bruce Bri11�7f
AtsElt WnENT TO CERTIFICATE OF DEATH(ENTRY OR
26-11-I1---A0L-I--oo .661-OZg •
•
being requested by this state agency in order to pursue re pomaleitity. Dine is volutary and there will be no penally for refusal.
WARNING ORRI
FROMCORANGE TA EILLOW WHEN RDUBBED.ORI G NALL DOCUM H iEN ATS ASHIDDEN VOID ON FRONT THAT AP EARS WHEN PHOTOCOP ED!ANA ON BACK THAT