Death Certificate - Deputy, Harold_9/13/2022 (2) Ara:1,MkT- v,atrV :`.. Li=eleeeies '►Nia,,`"L Annee\_I=Mdi3.:GVIPsiei rru"Y.i.- _ - _.. =4.,..-3 rereir-... v.,.r_iis. __.-_-___..
r 4 INDIANA STATE DEPARTMENT OF HEALTH II
0, 4441 CERTIFICATE OF DEAT0
H
Jf000011423991 State No 2022-048558
fec d i Local No 000149ast) EDR No
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
Hospital
0 Hospice Facility ®Decedent's Home 0 Nursing Home/Long-term Care Facility
®Yes 0 No 0 Unknown ❑Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival 0 Other(Spevity)
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 At Time Of Death
Oakland City,Indiana 47660 Gibson Married Married,But Separated 0 Divorced
nWidowed 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?
1 ec. Street And Number
47660 0 YeS El 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.Parents 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,Zip 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
all 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
p Yes IIII No Inc.323 N.Main St. Po Box 278,Oakland City,Indiana,47660
27b. Signature 01 Indiana Funeral Service Licensee: 27c. License Number(Of Licensee). FD01012153
,Rjclard1D.2Cckrod Electronically Signed
Cause Of Death (See Instructions And Examples) Approximate
Interval: Onset
28
Part I.Enter The Chain p Eventsry -Diseases,Injuries,Orib Complicationstio -That Directly Caused The Death.Dore Not Enter Terminal Events To Death
Such As Cardiac Aries[,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. ova,.roe P.wcoe.aw«,>on;
Sequentially List Conditions, If Any,Leading To The Cause Listed On
B. a»to l0,As•Consequence on:
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last C. Duo to for As A co,,..a,e„ce an,
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 IIII No
30.Were Autopsy Finding Available To Complete The Cause Of Death? ❑Yes ❑No
33. Manner Of Death:
31. Did Tobacco Use Contribute To Death? 32. It Female:
❑rag,v,ey,.,a wmv„Pea Year ❑Pregnant At r.a death ❑rvo,v,.sasta.eon vrw,um wsav•z dada or ossn ®Natural 0 Homicide 0 Accident 0 Pending Investigation
• 0 Yes 0 Probably I»No 0 Unknown 0 rad vregnen.avi rceo1e„r as oey,Vol year senor.deem 0 Unkno.e,n Pregnant Wigan The vast veer 0 Suicide❑Could Not Be Determined
34. Date Of Injury(Month/Day/Year) F35.Time Of Injury 36. Place Of Injury(E.G.,Decedent's Home,Construction She,Restaurant,Wooded Area) 37. Injury Al Work?
38 a' �L ❑Yes ❑No
1 38. Location Of Injury-State 38b. Street 8 Number I �'Apt.No. �' Mp cog.
40. II Transportation Injury,Specify:
39. Describe How Injury Occurred S E P 1 3 2022 ❑oo.oe-om ❑` nee❑ruu.e 'Donee`a°""'
41. Signature,Of Person Certifying Cause Of Death: 42.Certifier(Check Only One)
I 7folly Lee 9feicfie(6ec/ii / Electronically Signed ®Certifying Physician 0 Corona 0 Health Officer
. ie� 44. License Number 45. Date Certified
- 43. Name,Address And Zip Cafe rT��7bL•c�-/7!(L �
Holly Lee HeichelbechOlekSM atilliN62oNYJ4iA3-Ifidit Street,Oakland City,IN 47660 02003241A 09/01/2022
47. 'Akers:
..I 46.Additional Funeral Service Provider:
1 49. For Registrar Only -Date Filed (Month/Day/Year):
48. uce Bre of Local Health Officer 49.
Signed 09/01/2022
Bruce rittk,ir
2_6-\• - 3 - Li 0 0 --000 ,3 - -0 0 G.
' State Form 53395 ATTENTION ESTATE:The Social Security 4 is being requested by this state agency in order to pursue responsibility. Disclosure Is voluntary and there will be no penalty for refusal.
WARNING TTURNISN FROM ORANGE TO YELLOW WHEN RUBBED.ORIGINALL DOCUMIEN HAS ASHIDDEN VOID ON FRONT THATEAP EARS W ENEPHOTOCOPIED ANA ON BACK THAT