No preview available
Death Certificate - Viehe, Gary_8/8/2023 1.keilt le41rA, 7”-MFAMIELI r.- .r.. e.,'.'VI i■11 I r L'7.. ■ �A t."1 yam\■■ 1 r ilel )/wire rice. _� _ ... a:- s r.s 1 S f�. 0` an4�L INDIANA STATE DEPARTMENT OF HEALTH 4 4 0 0119 d 4F - CERTIFICATE OF DEATH • 0.j. 0 5 75 Local No 001518 EDR No 000011579072 State No 2023-036532 . 1.Decedent's Legal Name (First,Middle.Last) 1 a. Maiden Name (If female) 2.Gender 3. Time Of Death ), • Indiana 9. Ever in U.S.Armed Forces? 10.If Death Occurred In A Hospital: 10a. If Death Occurred Somewhere Other Than A Hospital 7 Hospice Facility , 0 p 0Decedent's Home 0Nursing Home/Long-term Care Facility ®Yes 0 No 0 Unknown 0 Inpatient ®Emergency Department Outpatient 0 Dead on Arrival ❑Other(Specify) 11. Facility Name (II Not Institution,Give Street and Number) Deaconess Hospital 12. City Or Town,State.And Zip Code 13. County Of Death 14. Marital Status At Time Of Death r • • Evansville,Indiana 47747 VanderbLtrgh 0 Married 0 Married,But Separated El 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 . Barber Cosmetic Professional J . 8. Residence-State 18a. County 18b. City Or Town e 'B IN Gibson Poseyville f ec. Street And Number 18d. Apt.No. tee. Zip Code 181. Inside City Limits? 9664 S 1075 W 47633 ❑vas 0 No )J 19. Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedent's Race e. Some college,but no degree Not Spanish/Hispanic/Latino White a 22.Parent's Name(First.Middle,Last) 23.Parent's Name(First.Middle.Last) 23a.Parent's Last Name Before First Marriage '- George Viehe Mabel Viehe Unknown 24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address (Street And Number,City,State,Zip Code) - - Aaron Viehe Son 9664 S 1075 W, Poseyville, IN,47633 , . • r e 25.Place Of Disposition \_ - El 25a.Method Of Disposition 25b.Place Of Disposition (Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town.And State • ❑Burial Cremation 0 Donation 0 Entombment ❑Removal From State - \, Pillars Cremation Service Chandler, IN i ❑Other (Specify): "`((( 26.Was Coroner Contacted, 27. Name And Complete Address Of Funeral Facility 27 Funeral Home License Number' Simple Cremation Evansville /' ElYes ❑No 3101 N. Green River Rd.Ste 320, Evansville, Indiana,47715 9uci . s4 �00004 27b. Signature Of Indiana Funeral Service Licensee: t-�27c.License Numb: f icenseet: I r`Mfatt'l(opshever Electronically Signed /nS .o . l 5300V3 Cause Of Death (See Instructions And Examples) C� - --- - Approximate 28.Part I.Enter The Chain Of Events -Diseases.Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Eventr" ✓�� Interval: Onset Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One CauseQ)o To Death A Line. Add Additional Lines If Necessary. • , Immediate Cause(Final Disease Or Condition Resulting In Death) A. Acute Cardiac Arrest L)- -f minutes „e tot r s onsegaan« 9 Atherosclerotic Cardiovascular Disease GO • minutes • Sequentially List Conditions, If Any,Leading To The Cause Listed On B. �J• Line A. Enter The Underlying Cause(Disease Or Injury That Initiated uemlora.acanaegoen«on. �� , The Events Resulting In Death)Last C. Due m to as a Consequence Or( 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? 0 Yes E No 30. Were Autopsy Finding Available To Complete The Cause Of Death? 0 Yes ❑Nod 31. Did Tobacco Use Contribute To Death? 32. It Female: 33. Manner Of Death. /, LE Yes 0 Probably 0 No 0 Unknown 0 se Pregnant We.Past Year 0 Pregnant at roe OI seer 0 Not Pregnant.but Pregnant WM,a 42 Days of Death 0 Natural 0 Homicide 0 Acridrn.lt El?eniing Investigation CI Not Pregnant.But Pregnant 44 Days To I year Before Dee. ❑unknown a Pregnant within the Pea Year 0 Suicide[]Could Nit Fe Ce:eraii,ed - 34, Date Of Injury(Month/Day/Year) 35. Time Of Injury 36. Place Of Injury(E.G.,Decedent's Home,Construction Site,Restaurant v'yced Area) 37 :npun F,t Work, Y E2Yes ❑No J 38. Location Of Injury-State 38a. City Or Town 38b. Street 8.Number 38c. Apt.No. 33d. Zip:Doe -- 39. Describe How Injury Occurred 40. If Trznsportehon Injury,SDecify: • 00..0..cot [Bass •• ❑,eoas,.en Dorn ,a.ecayl 41. Signature, Of Person Certifying Cause Of Death: -- r. 42. Certifier(Check Oni�One, Steve TVLockyear Electronically Signed ❑Certifying Physician EJ r:, r a ❑Hea'h Officer 43. Name,Address And Zip Code Of Person Certifying Cause Of Death. 44. License a •-ne` I 45 Date Certified Steve W Lockyear 201 S Morton Avenue, Evansville, IN 47713 1 07/18/2023 .0 46. Additional Funeral Service Provides - 47. 'Akas' `\ 48. Signature of Local Health Officer: 49. For Registrar Only -Date Filed (Month/Day/Year): 4. ,g6ert'K,Spear jr Electronically Signed 07/19/2023 AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) Decedent-Date of Birth- amended on JUL-24-2023; formerly JUN-28-1939; -) a()_ F-J------- 2___ ,0 - 000si\-0 tx State Form 53395 ATTENTION ESTATE:The Social Security#is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary and there will be no penalty for refusal. F E E WARNING. TTURNIS FROM O ANGE TOS YELLOW WHEON RUBBED.ORIGUINALL DOCUMIEN HATS ASHIDDENII T VO DPON FROD NT THAT AP EARS WHEN PHOTOCOPIEDANA ON BACK THAT 1." .li' .l .V a\-vIl✓ "\�,aefa. !._ .acadh - a - - • .a,• -ubY'e3a I. A SIl 'A Jl\'rAl .4'.;......- A'. A-•.11ama