Death Certificate - Deputy, Harold_9/13/2022 ri Y I - /.. .. -- .. �. y r•vtr .. ..- .,, .,. ...(-:„.-i.:"...
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�.,t INDIANA STATE DEPARTMENT OF HEALTH
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CERTIFICATE OF DEATH
�" Local No 000149 EDR No 000011423991 State No 2022-048558
1.Decedent's Legal Name(First,Middle,Last) 1 a. Maiden Name (If female) 2.Gender 3. Time Of Death 4. Date Of Death (Month/Day/Year)
Male 11:30 AM 08/27/2022
Harold Ray Deputy
92 Months Days Hours Minutes
9. Ever in U.S.Armed Forces? 10.If Death Occurred In A Hospital: 10a. If Death Occurred Somewhere Other Than A Hospital
0 Hospice Facility ®Decedent's Home 0 Nursing Home/Long-term Care Facility
I$Yes 0 No 0 Unknown ❑Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival ❑Other(Specify)
11. Facility Name(If Not Institution,Give Street and Number) 4448 S State Road 57
12. City Or Town,State.And Zip Code 13. County Of Death 14. Marital Status Al Time Of Death
Oakland City,Indiana 47660 Gibson Married 0 Married,But Separated 0 Divorced
Widowed 0 Never Married 0 Unknown
15. Surviving Spouse's Name 15a.Last Name Before First Marriage 16. Decedent's Usual Occupation 17. Kind Of Business/Industry
Grant Excavating,Miner,Farmer Excavating,Mining,Agricul
JoAnn Deputy
18_ Residence-State 18a. County 18b. City Or Town
IN Gibson Oakland City
18d. Apt.No. 18e. Zip Code 18f. Inside City Limits?
18c. Street And Number
47660 El Yes 0 No
4448 S State Road 57
19. Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedent's Race
Spanish/Hispanic/Latino Whiteanish/His
High School graduate or GED completed Not S P P
22.Parent's Name(First.Middle,Last) 23.Parent's Name(First,Middle,Last) 23a.Parent's Last Name Before First Marriage
Paul George Deputy Bertina Wilma Deputy Case
24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address (Street And Number.City,State,Tap Code)
JoAnn Deputy Wife 4448 S SR 57,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
®Burial 0 Cremation 0 Donation 0 Entombment
❑Removal From State Forsythe Cemetery Oakland City,IN
❑Other(Specify): 27a. Funeral Home License Number.
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility
Com-Colvin Funeral Home, FH19400002
❑Yes Cii No Inc.323 N.Main St. Po Box 278,Oakland City,Indiana,47660
27b. Signature Of Indiana Funeral Service Licensee: 27c. License Number(Of Licensee): FD01012153
4?;chard/DHiickrod Electronically Signed
Cause Of Death (See Instructions And Examples) Approximate
Interval: Onset
Part I.Enter rdia The Chain Of Eventsry -Diseases,Injuries,Orib Complicationstio -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. COLITIS 3 WEEKS
Immediate Cause(Final Disease Or Condition Resulting In Death) A On.no la A.A c..,.w..o.p);
Sequentially List Conditions, If Any,Leading To The Cause Listed On B. Dvo m(Or n.A Consoomme on:
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last C. Duo to for A.A cw,e.aue,c.OD:
D.
Part II.Enter Other Sionificant Conditions Contributina to Death But Not Resulting In The Underlying Cause Given In Part I 29. Was An Autopsy Performed? ❑Yes ®No
30.Were Autopsy Finding Available To Complete The Cause Of Death? ❑Yes 0 No
33. Manner Of Death:
31. Did Tobacco Use Contribute To Death? 32. If Female:
0 rut P..ran..n wm,m Pw r..r ❑Pr.snem am..Or...en 0 not r+es.w.an Preplan,ww+r•z o.ys or own ®Natural 0 Homicide 0 Accident ❑Pending Investigation
0 Yes 0 Probably DC No ❑Unknown 0
rvw pawn.a t P.M.*.a oaya to r yoo,Bel,,.Don, 0 Unknown n of.v..m Within n»Past roof 0 Suicide 0 Could Not Be Determined
34. Date Of Injury(Month/DayNear) 35.Time Of Injury 36. Place Of Injury(E.G.,Decedent's Home,Construction Site,Restaurant,Wooded Area) 37. Injury At Work?
❑Yes 0 No
Ta
FI
38 Or �L//JT� I
38b. Street 8 Number r 38c.Apt.No. 38d. p Code
38. Location Of Injury-State
40. 11 Transportation Injury,Specify:
39. Describe How Injury Occurred S E P 1 3 2022 ❑c,n_on°"" ❑P ❑°*000.
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41. Signature,
t nature,Of Person Certifying Cause Of Death: 42.Certifier(Check Only One)
?forty Lee Jfeichelbech 1 Electronically Signed ®Certifying Physician 0 Coroner 0 Health Officer
ne s _l ` 1 44. License Number 45. Date Certified
43. Name,Address And Zip Code �� n!L
Holly Lee HeichelbechPl5Sfikt*4kTaUH620M(J WI310*1 Street,Oakland City,IN 47660 02003241A 09/01/2022
47. 'Akers:
46. Additional Funeral Service Provider:
48.Signature of Local Health Officer: 49. For Registrar Only -Date Fled (Month/Day/Year): 09/01/2022
Bruce Brinkjr Electronically Signed
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
D,�,\) _ 5_tA OO -O 00.3,6 >-OD G
WHITE URNS FROM ORANGE TO YELLOWSECURITY THE INDIANA WHEN RUBBED.ORIGINAL DOCUMENT A HIDDEN VOID ON FRONT THAT AP EARS WH NPHOTOCOP ED 0-NBACK THAT