Death Certificate - Sensmeier, David_5/6/2022 es
•R n INDIANA STATE DEPARTMENT OF HEALTH �^
s; CERTIFICATE OF DEATH 3 7 2 6 17 6
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`fa 000955 EDR No 000011182574 State No 2021-059217
Local No la. Maiden Name (If female) 2.Gender 3. Time Of Death
David Lee Sensmeier
10.If Death Occurred In A Hospital:
1 Oe. 11 Death Occurred Somewhere Other Than A Hospital
0 Hospice Facility 0 Decedent's Home ❑Nursing Home/Long-term Care Facility
❑Yes IXI No 0 Unknown ® Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival ❑Other(Specify)
11. Facility Name (If Not Institution,Give Street and Number) Deaconess Gateway Hospital
12. City Or Town,State,And Zip Code 13. County Of Death 14. Marital Status At Time Of Death
Warrick ®Married❑Mbried,But Separated ❑Divorced
Newburgh,Indiana 47630 ❑widowed ❑Never Married ❑unknown
15. Surviving Spouse's Name
15a.Last Name Before First Marriage IB. Decedent's Usual Occupation 17. Kind Of Business/Industry
Baize Batchmaker Paint
Kreesa Sensmeier
18. Residence-State 18a. County 18b. City Or Town
IN Gibson Oakland City
18c.Street And Number
18d. Apt.No. 18e. Zip Code 18f. Inside City Limits?
1976 S Whispering Hill Road 47660 ❑Ves 0 No
19. Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedent's Race
ani&Latino White
High School graduate or GED completed Not Spanish/His P
22.Parent's Name(First,Middle,Last)
23.Parent's Name(First,Middle,Last) 23a.Parent's Last Name Before First Marriage
Alvin Sensmeier
Anna Mary Sensmeier Freudenberg •
24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address(Street And Number,City,State,Zip Code)
Kreesa Sensmeier Wife 1976 S Whispering Hill Road,Oakland City, IN,47660
•
25.Place Of Disposition
25a.Method Of Disposition 25b.Place Of Disposition (Name Of Cemetery.Crematory,Other Place) 25c.Location-City,Town,And State
NI Burial 0 Cremation 0 Donation 0 Entombment
❑Removal From State Nobles Chapel Cemetery Elberfeld, IN
❑Other (Specify): 27a. Funeral Home License Number:
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility
Corn-Colvin Funeral Home, FH19400002
❑Yes 0 No Inc.323 N.Main St. Po Box 278,Oakland City,Indiana,47660
27b. 27c. License Number(Of Licensee): FD21 800025
Jayanna naturs Indiana Funeral Service Licensee; Electronically Signed
MacFCtn Approximate
"Cause Ot Death (See Instructions And Examples) Interval: Onset
28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events To Death ,
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On
A Line. Add Additional Lines If Necessary. 1 week ,
Covid pneumonia
Immediate Cause(Final Disease Or Condition Resulting In Death) A. a,e to to AswConsequence al:
na
B. na
Sequentially List Conditions, It Arty,Leading To The Cause Listed On Due Clt o Pa A cnnaeaernur co-
Line A. Enter The Underlying.Cause(Disease Or Injury That Initiated na na
The Events Resulting In Death)Last C. o,.to to As A cou.w.M.Oil: f.
D. na
na
Part II.Enter Other Significant Conditions Contributing to Death But Not Resulting In The Underlying Cause Given In Part I 29.Was An Autopsy Performed? ❑Yes 0 No
.30-,.Were Autopsy Finding Available To Complete The Cause Of Death? ❑-Yes ❑No
obesity,diabetes - --- .., _ .. ..
31. Did Tobacco Use Contribute To Death? 32. If Female: 33. Manner Of Death:
0 Not Pregnant Witten Pa,Year ❑Pregnant et ,n.or wet, 0 NotP,as,.et.art Pregnant wnNn 42 Der.of Death IN Natural 0 Homicide 0 Accident 0 Pending Investigation
❑Yes ❑Probably 0 No ®Unknown ❑Not P,egna,v.But Pregnant 43 oar,Tel l year Bator* earn ❑Unknown If Pregnant whin Th.Peet Year ❑Suicide❑Could Not Be Determined -
D 36. Place Of Injury(E.G.,Decedent's Home.Construction Site,Restaurant,Wooded Areal 37. Injury Al Work? ;
34. Date Of Injury(Month/Day/Year) 35. Time Of Injury
❑Yes ❑No
38a. CityOr Town FiLstr t 8J1uII) 38c. Apt.No. 38d. Zip Code '
38. Location Of Injury-State
39. Describe How Injury Occurred MA'( 0 6 202Z 40. If Transportation Injury,Specify: .3CIe o.arr0Perelor ❑Pa .r❑P.e.etn.n ❑otner lsw.aryi j
41. Signature, Of Person CertifyingCause Of Death: ,Ar,�- 42. Certifier(Check Only One) ❑Health Officer
Casana Sie6ert ,c44�/ �ti E I�S1gned 131 Certifying Physician 0 Coroner
43. Name.Address And Zip Code Of Person Certifying Cause Of Death; COUNTY AUD11 VR 44. License Number 45. Date Certified
GIBSON
Casana Siebert 601 West Second st,Evansville, IN 47747 01074372A 10/20/2021 �
47. 'Akas:
46. Additional Funeral Service Provider:
48. Signature of Local Health Officer: 49. For Registrar Only -Date Filed (Month/Day/Year): 10/21/2021
RiclyB'Yeager Electronically Signed
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
6 7 23 ____Lo i a • g3 6 __ Oa() ..
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State Form 53395 ATTENTIOONRE TAT DOCUMENT HAS AIIY4ULT COLORED BACKGROU NIT 0NgSPEC IAL WHITE PSECURIaT\ PAPERYAND THE GREAT iSEAL DF THE fiTAITF e1FiNn IAN foNr Rfusal THAT
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