Death Certificate - Schwartzlose, Myrtle_11/29/2022 TF
INDIANA STATE DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
0
Local No 000158 EDR No 000011430852 State No 2022-051354
1.Decedent's Legal Name(First,Middle,Last) Ia. Maiden Name (If female) 2.Gender 3. Time OI Death
Hospital -
ID Hospice Facility IE Decedent's Home 0 Nursing Home/Long-term Care Facility
0 Yes IA No 0 Unknown ❑ Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival ❑other(Specify)
It-Facility Name(If Not Institution,Give Street and Number) 3071 N 150 W
12. City Or Town,State,And Zip Code 13. County Of Death 14. Marital Status At Time Of Death
Patoka,Indiana 47666 Gibson O Married❑Married,But Separated 0 Divorced
®Widowed 0 Never Manned 0 Unknown
15. Surviving Spouse's Name 15a.Lest Name Before First Marriage 16. Decedent's Usual Occupation 17. Kind Of Business/Industry
farmers wife agriculture
18. Residence-State 18a. County 16b. City Or Town
IN Gibson Patoka
18c. Street And Number 18d. Apt.No. 18e. Zip Code 181. Inside City Limits?
3071 N 150 W 47666 ❑Yes ❑No
19. Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedent's Race
8th grade or less Not Spanish/Hispanic./Latino White
22.Parents Name(First.Middle,Last) 23.Parent's Name(First,Middle,Last) 23a.Parent's Last Name Before First Marriage
-
Arch James Ibbotson Sarah Jane Ibbotson Kincaid
24.Informant's Name - 24a.Relationship To Decedent 24b.Mailing Address(Street And Number,City,Slate,Zip Code)
Judy Dossett Daughter 1460 W 450 N,Patoka,IN,47666
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 Oak Hill Cemetery Patoka,IN
❑Other(Specify):
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility 27a_ Funeral Home License Number:
Colvin Funeral Home Inc 425 N Main St.,Princeton, Indiana,47670 FH83005671
❑Yes II No
27b. Signature Of Indiana Funeral Service Licensee: 27c. License Number 111; FD0101 3010
Wark cR'Walter Electronically Signed
Cause Of Death (See Instructions And Examples) Approximate
28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Event Interval: Onset
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One -0 To Death
A Line. Add Additional Lines If Necessary. 1 r�
Immediate Cause(Final Disease Or Condition Resulting In Death) A. myocardial infarction q 9�Q{� 1 hour
D..to(Or As a Do . •; .\ V //�-l'
Sequentially List Conditions, If Any,Leading To The Cause Listed On B. Do.m la As s c.r..ws„v cc \O 1�� U�
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated �Y Off'(
The Events Resulting In Death)Last C. (I,. t+.v
....to fora AD.,.eyema On: -�1
D.
Part II.Enter Other Sianiticant Conditions Contributing to Death But Not Resulting In The Underlying Cause Given In Part I 29. Was An Autopsy Pert ds
C..?"-
la ❑Yes ®No
30. Were Autopsy Finding AvailableTo Complete The Cause Of Death? ❑Yes ❑No
1 31. Did Tobacco Use Contribute To Death? 32. If Female: 33. Manner Of Death:
0 Yes 0Probably®No ❑Unknown 0 so,Pr.,.win.,,Pat Tear ,,
0
eeuv,nt at T.e aB.Death 0 Nut Pregnant e P.a..,,wins c,,.z y am pia o. Natural 0 Homicide 0 Accident 0 Penang Investigation
3 ❑not Pregnant.B.Pregnant 43 sex To,year.fore Death 0 Unknown it Pregnant Within Ti,.Par Tar 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?
❑Yes ❑No
38. Location Of Injury-State 38a. City Or Town 38b. Street 8 Number 38c. Apt.No. 38d. Zip Code
f
39. Describe How Injury Occurred 40. If Transportation Injury,Specify:
❑D,uwoe..sr ❑P......r❑P.6rn.n pother lsoer/yi
1 4Larry1. Signature,Ofm.PersonLutz Certifying Cause Of Death: 42. Certifier(Check Only One)
/ a Electronically Signed ®Certifying Physician 0 coroner 0 Health Officer
43.Name,Address And Zip Code Of Person Certifying Cause Of Death: 44. License Number 45. Date Certified
Larry William Lutz 802 E.Oak St.,Fort Branch,IN 47648 01027538A 09/15/2022
46.Additional Funeral Service Provider: 47. 'Alt s:
I 48.Signature of Local Health Officer: 49. For Registrar Only -Date Filed(Month/Day/Year):
BruceBrink,7r Electronically Signed 09/15/2022
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
02(- Ou-26- y .e. -000 -6-7-- - ok$ -
i
agency in order to pursue responsibility. Disclosure Is voluntary and there will be no penalty for refusal.
WARNING- ORIGINAL. TURNS FROM ORANGE TO YELLOW WHEN RDUBBED.ORIGINAL DOCUMENT AS ASHIDDEN PON FRONT THAT APPEARS WHEN PHOTOCOPIED.IINDIANA ON BACK THAT