Death Certificate - Winstead, James_5/6/2022 L
°ix' �,.-. I.CMDBAINA STATE DEPARTNIENTO='1-iEAL if'Fl
.�} ". . CERTIFICATE OF DEATH ---�!
Local No 000051 EUR No 0000112ai776 State No 20 -018330'
7Decoderra lanai Name(Fire.wo:b,Lean fa L1at«.n tit .Y'aY.aa•; ' 2.C-0oer 3. Tana 01 Death
®Yes 0 No Cl Unknoen CIIrg.XSers 0 Emergency Department Cutasler4 ClDemon Arrkw El Hp,...c Fac>Ny 0 Decedents Horne tie Nlirseg 11ome+lapnrnl Care Facility❑orfl.r te,‘,„.*�ri
11.FaGiy Name Ix Nor IrlmersIIn,I Give 5 a.t and tattier) Transcendent Healthcare Of Owensville.LJo
122 City Cr Town State.And 21p Code 13.County Of Deans 71.).brat sass At Time 01 Licari II
Owensville,Indiana 47665 Gibson Et wti0d❑Maeda!,But separaUd ❑Der_nxd
❑Widowed ❑Never Slanted ❑Creexwn
tT Srytsveg Spouse's Name 154.last Name serene Fist Marriage 1 16 Decedent's :uol Compasbn I?.Kind Of Suaricssaita ei
Pa6ir,ia Winstead Fine Supervisor Whirlpool
Id. Reactance Sete 18a.Courty 18D.City OtTown
IN Gibson Owensn-ice
•
18C Seat And temroer 18d.Ape No- 18e.rp cot. 18L inside sty Limits?
105 Thompson Lane 47665 . Dye. ❑No
G; '9.Decedem•s Education 20. Decaoonl Or Hispanic Crays 21.De8e0enrs Rea
9th-12th grade,No Diploma Not Sparashallspericilawlo White
22 Forams Name(Fist.)451cl1e.cast) 22 Perna.Nave(Fist.Hipdb.Last) 233.Perenrs Last Name Senn,First honing.
Strother Winstead Edna Winstead Adamson
24.t8enrtanrs Name 24a Relationship To Deedmu 280.M9.r9 ABC!Spin AM Numbs.Coy.Slate,27p Cod.)
Patricia Winstead Wife 105 Thompson Lane,Owensville,IN,47665
25.Place 01 0hpos.on
25a.We1o0 Of Disposition 25b.Place Of Disposition(Name CM Cemersy,Crematory.goes Face) 25c Location-CS).,Town,Am State
iiti suss!❑Cmmatien ❑opdanon 0 En0mbmeru
Cl Removal From State Owensville Cemetery Owensville,IN
0 Omer tS.etsot.
• 26.Was Coroner Coe::.-tad' Z7 Nome And Conghe Amasses Of Funeral FaC2y 27s.Funeral Horne Lkansa Number
Holders Funeral Home 319
0 Yes Da No South Main Street,Owensville,Indiana,47665 F1111700008
271, Sig aare 01 Indiana Funeral Service Licensee= 27c_Licence Number(OI Ltynw.):FD2140006Sx
Bf rlGreer Electronically Signed 1
. Cause Of Death(See instructions And Examples) •
26.Part 1"Enter The Chan t7 Events -D:uases,(r -bets,Cr Cram Ttat M01Dsinsto
Mastics, ;arltihrs- 0.recdy Caused The Death Do Not Enna Terminal Everts 'dent Onset
• se>cn As Carciac Arrest.Respiratory Arrest.Or V mtralar Faonttafirnl:Without Showiq The Etiology.Do Not Attreviata Enter Only One C.y.On To Death
A Line. Add Adationat L.r. a Necessary.
h.,.,.ntate Cam IF,nr,Disease Cr Concflbn Rosu)enC In Dart.) A. Congestive heart failure tmkrnolNn
Sequentially List Cendtoes. 1 Arry.ISC Lat-e To The Cause od 0. .
Line A.Enter The Unt:ertyoig Co.v'(O esSe 0.fryeay That initiated Fi.weoh♦,:w..w..a..x
The Events ResLittre Jn Death)Lao C_ }
o.wno A.a ee _
0.
Pan a.Enter Other .c rgra C.ondtio a rorrrit,a-e a Garr,Bat Not R•aq in The Ur em,u g Case Given i Pont 29.Was An Autopsy PaAmreed7
❑Yes ®No (i(
30 Were Autopsy Funmrg Avaistef To Connate a The Cause Of Dears? ❑Ye-s E31,...
31 Did Tobacco Use Cor8R.To DeaT1? 32 it Female: 33. Manner 01 Death:
ID sea El ProbapNy El No gel Ua.a.-n i7•e....v...w......•.... ID rive-...,-_trp.r, El Lea.,.v-s.a....sore m.w<t a...oa.,., iigl Nitsas 0 Npnliote El Accident 0 Pet 5 eneao•on
_ ❑............a.nw..•t ow.n1...a.e.a..., Era......,1...........:-..in.i.... ❑asd.s.❑Coati Not BeDemoralised
34.Date Of rosy! arhDsy+Year% 35.Tine 01 awry 78.Plate OI Olio!:ES_De M Ss Perna Consaunaon Site Restauzm.Wooded Me) 37.Stray At Week?
Elves ❑No I i
;.35 Location Of trpay.S',ate 38a Coy Or Town LY1
I 3 .S:ter&tezroer 38a $Apt No. 36d Code
39 DesoSe 14pw*Soy Occurred I 40.C Tnmaport♦tt0'Ingot,Speedy:
.. `od-c v❑r..w-..❑"wa.w..❑o.w s .l
41. Synatte.Cl Person Caren. r0 Cause°[Death- 142.Candor(Check Only One)
BI11CG Brlre4r Electronically Signed Et C4retyina Physician ❑Coroner 0 Heald.after
45 Name.Address Am Zip Code Of Person C*.ytng Cane C[Death: Gunge
tier 46.Deis Csed
Bruce Brink Jr 410 North Main Street,Princeton,IN 47670 1 et 02000610A 1f03/24/2022 ___I
.6.Addatonat Funeral Serb.,?.civet: - I 47.-Aka:
i
48.'Slgreso s of L.01"eaats.^t.::cer as near Registrar OnlyDate Fisa;n 1AprstvDay.•Y.sri:
i. Bnvs 4Hinkir Electronically Signed I o3/25/2022
AMENOMEHT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) ------
!1 D.C..--.4.
l'g -O 6 - 3 O3-� 0, c 22 -0 2- Z.L___ __
I , e Su tr Pine._•.ion ATT=NT•t;ra EST AT=_•T^c.SGCa1 Security rl Is bolssx)Requested'ty:Nu.0 0e=:esc?'r..cr.:a':oes.m..e re or-:..50Gt/. Chctc.rre s+0Smtat'and steno Ire be no penalty mutual
III.•
WARNING: N r t 4 JOLC ' CA ?JUND ON S?EC•AL WHITE SECURI i'P5PER GREAT SE.1L CF T-c 57A E .:.0 a1.A CN B..1<'=,.,•e
.=..s .� •s-__:_•.____.: _P.GINAL DOCUI.tE^T HAS A F)I3i2EN•I- ID 07,Fr` , _=A'APE •EARS 4HEfv P.-1G'JC0-cD
1
ke-CY Osf\
u \,..\\(\
�,� CAN ke