Death Certificate - Schwartzlose, Myrtle_12/5/2022 INDIANA STATE DEPARTMENT OF HEALTH -711
(0, -7:kg-,
1 CERTIFICATE OF DEATH0
... t 000158 EDR No 000011430852 State No 2022-051354
Local No 2.Gender 3. Time Of Death
Myrtle Jane Sc ose Ibbotson
10.If Death Occurred In A Hospital: 10a. It Death Occurred Somewhere Other Than A Hospital
0 Hospice Facility Isi Decedent's Home 0 Nursing Home/Long-term Care Facility
0 Yes ail No 0 Unknown ❑Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival ❑Other(Sperity)
'rt.-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 Married 0 Married,But Separated 0 Divorced
W 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
farmers wife agriculture
18.Residence-State 18a. County 78b.City Or Town
IN Gibson Patoka
78d. Apt.No. 18e. Zip Code 18f. Inside City Limits?
18c.Street And Number
47666 ❑Yes ❑No
3071 N 150 W
19.Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedent's Race
8th grade or less
Not Spanish/Hispanic/Latino White
22.Parent's 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,State,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): 27a. Funeral Home License Number:
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility
Colvin Funeral Home Inc 425 N Main St.,Princeton,Indiana,47670 FH83005671
El Yes ®No11110
27b. Signature Of Indiana Funeral Service Licensee: 27c. License Number
M FD01013010
farkfR,'Wa1'ter Electronically Signed
Cause Of Death (See Instructions And Examples) ' Approximate
Interval: Onset
28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Event To Death
Such As Cartliac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One 0 �1�1
A Line. Add Additional Lines If Necessary. rlO{�V 1 hour
A myocardial infarction 9 L
Immediate Cause(Final Disease Or Condition Resulting In Death) Dpe rota As A co . . . C►.
Sequentially List Conditions, If Any,Leading To The Cause Listed On ,/a �-(
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated //!} PLO
The Events Resulting In Death)Last C. Due to(Or As Aco...w.emon: "NA 4
D. LL 4tOv
Part II.Enter Other Significant Conditions Contributino to Death But Not Resulting In The Underlying Cause Given In Part I 29.Was An Autopsy Pe
� ❑Yes ®No
30. Were Autopsy Finding Available To Complete The Cause Of Death? 0 Yes 0 No
33. Manner Of Death:
37.Did Tobacco Use Contribute To Death? 32. If Female: wev,etr At r.,e a ❑
❑nwr Pregnant worse cur Year 0 Death Ha P..oP.pL aA Pr.aA.pr wnrr+A sz om or o..m ®Natural 0 Homicide 0 Accident 0 Pending Investigation
0 Yes 0 Probably MI No 0 Unknown ❑Not wene.e ear cr.a,,.er 43 Days to I year eeto..Derr, 0 Unknown s Pr.ze.nl Name n,.Pas Year 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 0 No
38. Location Of Injury-State
38a. City Or Town 38b. Street&Number 38c.Apt.No. 38d. Zip Code
40. If Transportation Injury,Specify:
38.Describe How Injury Occurred ❑Deye.roper.v ❑P.eaargw❑P.ew.w❑oor..lspeu»
41.Signature,Of Person Certifying Cause Of Death: 42.Certifier(Check Only One)
Larry William Lutz Electronically Signed ®Certifying Physician 0 Coroner 0 Health Officer
44. License Number 45. Date Certified
43.Name.Address And Zip Code Of Person Certifying Cause Of Death:
Larry William Lutz 802 E.Oak St.,Fort Branch,IN 47648 01027538A 09/15/2022
47.'Akers:
46.Additional Funeral Service Provider:
48. Signature of Local Health Officer: 49. For Registrar Only -Date Filed(Month/Day/Year): O9/15/2022
Bruce Brinkyr Electronically Signed
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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0 26-D - _ -300- 00S . O18 - old -
i State Form 53395 ATTENTION ESTATE:The Social Security 8 is being requested by this state agency In order to pursue responsibility. Disclosure is voluntary and there will be no penalty for refusal.
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