Death Certificate - Krieg, Reina_7/1/2022 ..... .. ..... .
\ INDIANA STATE DEPARTMENT OF HEALTH
t CERTIFICATE OF DEATH
N.jo,. EDR No 000000692318 State No 006289 0
Local No 000025Lest) 2.Sex 3. Time Of Death
0 Hospice Facility ®Decedents Home 0 Nursing Home/Long-term Care Facility
0 Yes ®No 0 Unknown 0 Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival ❑Otter(Specify)
11. Facility Name(If Not Institution,Give Street and Number)
592 SOUTH CONCORD DRIVE 13 Countyath 14. Marital Status At Time Of Death
12. City Or Town,State.And Zip Code
®Married❑Married,But Separated 0 Divorced
PRINCETON, IN,47670 GIBSON 0 Widowed 0 Never Married 0 unknown
15. Surviving Spouse's Name 15a.Last Name Before First Marriage 18. Decedents Usual Occupation 17. Kind Of Business/Industry
NURSERY SCHOOL
ROBERT KRIEG TEACHER EDUCATION
18. Residence-State 18a. County 18b. City Or Town
• INDIANA GIBSON PRINCETON 18d. Apt No. 18e. Zip Code lark Inside City Limits?
18c. Street And Number
❑Yes ❑No
592 SOUTH CONCORD DRIVE 47670
19. Decedents Education 20. Decedent Of Hispanic Origin 21. Decedents Race
BACHELOR'S DEGREE(BA,AB, BS) NOT HISPANIC White
22.Parent's Name(First,Middle,Last) 23.Parents Name(First.Middle.Last) 23a.Parent's Last Name Before First Marriage
WILLIAM DAVIDSON SHEILA KNIGHT _PRICE
24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address(Street And Number,City,State,Zip Code)
ROB KRIEG _SPOUSE 592 SOUTH CONCORD DRIVE, PRINCETON,IN 47670
25.Place Of Disposition
25a.Method Of Disposition 25b.Place Of Disposition(Name Of Cemetery.Crematory,Other Place) 25c.Location-City.Town,And State
®Burial 0 Cremation 0 Donation 0 Entombment
❑Removal From State
❑Other(Specify): COLUMBIA WHITE CHURCH CEMETERY PRINCETON, IN 27a. Funeral Home License Number
26.Was Coroner Contacted? 27- Name And Complete Address Of Funeral Facility
❑Yes EI No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 0
R. , Licensee: 27c. License Number(Of License -
05671
27b. Signature Of Indiana R Se Licensee: FD01013010
MARK R.WALTER BY ELECTRONIC SIGNATURE Cause Of Death (See Instructions And Examples) Approximate
tterva l: Onset
28
Part I.Enter The Chain sOfp Eventsry -Diseases,tric tar Orib Complicationsti000 -That Directly The Caused The Death. ao Not Enter Only Events C' G /#Death
Such . Cardiac Arres Respiratory Necessary.
Or Ventricular Fibrillation Without Showing Etiology.Do Not Abbreviate.Enter Only One Cause On /t y
A Line. Add Additional Lines If Necessary. e, ��
1
Immediate Cause(Final Disease Or Condition Resulting In Death) A. OLIGOASTROCYTOMA Due w(Or ft w cor.w..nr,orl: tiC
`ir
Sequentially List Conditions, If Any,Leading To The Cause Listed On
B. awmca w.w wr..w.nv orl: 0 �- �O'
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated .
The Events Resulting In Death)Last C. Dc.to for As A Compose.OD: #' •S
D.
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 IN No
30. Were Autopsy Finding Available To Complete The Cause Of Death? 0 Yes 0 No
33. Manner Of Death:
31. Ditl Tobacco Use Contribute To Death? 32. If Female:
®Not Pregnant vstxn P.Year ❑Pregnant Wit ro,.or swain ❑not Pr.a,.rn.e,n Pr.9r,a^t vNn+n az o.y.or o..tn Ell Natural 0 Homicide El Accident 0 Pendng Investigation
0 Yes 0 Probably®No ❑Unknown ❑Not Pm..u.Bin Pregnant et o.y.To 1 year e.r.r.oath ❑unknown n Pregnant vans The Par var 0 Suicide 0 Could Not Be Determined
34. Date Of Injury(Month/Day/Year) 35. Time Of Injury 36. Place Of Injury(E.G.,Decedent's Home.Construction Site,Restaurant Wooded Area) 37. Injury At Work?
0 Yes ❑No
36. Location Of Injury-State
38e. City Or Town 38b. Street&Number 38c.Apt No. 38d. Zip Code
40. If Transportation Inluuy ''.d y
39. Describe How Injury Occurred ❑Dr If Tra.ek,r ❑o...jurr LI^ai n❑omwlsgdy)
• 41. Signature.Of Person Certifying Cause Of Death: I 4:2.Certifier(Check Only One)
i Certifying Physician 0 Coroner 0 Health Officer
EDWARD PATRICK FOX, BY ELECTRONIC SIGNATURE 44. License Number 45. Date Certified
43. Name,Address And Zip Code Of Person Certifying Cause Of Death:
02/1 1/2019
EDWARD PATRICK FOX ,3699 EPWORTH ROAD, NEWBURGH, IN 47630 01038620A47. 'Akers:
46. Additional Funeral Service Provider
49. For Registrar Only -Date Filed (Month/Day/Year):
48.BRUCEgnature of Local JR,VIAficer FEB 12 2019
BRINK ELECTRONIC SIGNATURE AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) -
, c( _ � 1 _ ) 4 10\ - 0 O
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' State Form 53395 ATTENTION ESTATE:The Social Security#is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary there,...,_
here will be no penalty for'Otal.
WARNING: ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT
TURNS FROM ORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUMENT HAS A HIDDEN VOID ON FRONT THAT APPEARS WHEN PHOTOCOPIED.
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