Affidavit - Besing, Larry_10/11/2023
FILED �:NI� ... :.
NOTARY PUBL.IC
STATE OFININDIANA
Resident of Gibson County,Indiana
O C T 0 5 2023 my _orn ssion Number:68768
�y! y Commission Expires 8/6.
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GIBSON COUNTY AUDITOR
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THIS INSTRUMENT PREPARED BY Sandra L. Hicks, n34631-26, SANDRA L. HICKS LAW OFFICE, LLC,
102 N. Elm Street. Fort Branch, Indiana 47648(812)615-5044
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.>c- At INDIANA STATE DEPARTMENT OF HEALTH 4147011
CERTIFICATE OF DEATH
�` Local No 000137
EDR No 000011597960 State No 2023-
Months Days Hours Minutes 08/16/1939 Evansville,Indiana
9.Ever in C.S.Armed Forces? 10.If Death Occurred In A Hospital: 10a. If Death Occurred Somewhere Other Than A Hospital -
'Yee No 0 Unknown 0 Inpatient❑Emergency Department Out ❑Hospice Facility E]Decedent's Home El Nursing Home/Long-term Care Facility
Outpatient ❑Dead on Arrival 0 Other(Specify) ,
11.Facility Name(If Not Institution,Give Street and Number) 8910 S 950 E ,I.'q,
12.City Cr Town,State,And Zip Code 13. County Of Death 14.Marital Status At Time Of Death
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Elberfeld,Indiana 47613 Gibson ❑Married❑Married,But Separated 0 Divorced
E l Widowed 0 Never Married 0 Unknown
15,Sun„ving Spouse's Name 15a.Last Name Before First Marriage 16. Decedent's Usual Occupation 17.fOnd Of BusinessAndustry ..
Farmer Agriculture
Is.Residence-State 13e.County 18b. City Or Town
IN Gibson Elberfeld
16c. Street And Number - 18d.Apt.No. 18e.Zip Code 18f. Inside City Limits? - '
ES10SS50E 47613 ❑Yes ❑No ,;
19.Decedent's Education- 20. Decedent 01 Fspantc Origin 21. Decedent's Race .
High School graduate or GED completed Not Spanish/Hispanic/Latino White
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22.Parent's Name(First,Middle,Last) I 23.Parent's Name(First,Middle,Last) 23a.Parent's Last Name Before First Marriage • .
Ncrman Besing Thelma Besing Grimwood
24,!n'orrrart's Name 24a.Relationship To Decedent 24b.Mailing Address(Street And Number,City,State,Zip Code)
Anthony Basing Son 8518 S 950 W,Elberfeld,IN,47613
25.Place Of Disposition • .'•1.
25a.'.letnoo Of Disposition 25b.Place Of Dispas,ticn (Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State
ElEurai ❑Cremation ❑Donation 0 Entombment
.0 Removal From State St.John's Cemetery
G Oeer lS ecify): •
Buckskin,IN
. 26.Was Co:aver Contacted? ' 27. Name And Complete Address C'Fune,ul Facility 27a.Funeral Home License Number:
Com-Colvin Funeral Home,
❑Yes a...No Inc.323 N.Main St. Po Box 278,Oakland City,Indiana,47660 FH19400002
27b.Signature Of Indiana Funeral Service Licensee: 27c.License Number(01 Licensee):
J:yunr: tifac n Electronically Signed FD21800025
Cause Of Death (See Instructions And Examples) Approximate
28.Fad:.EoterThe Chain Of Events-Diseases,Injuries,Or Ccmp ca os That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset,.,:.h As Cardiac Arrest,Respiratory Arrest,Or Ventric.aar Fariilauar,. ,.._:..lowing The Etiology.Do Not Abbreviate.Enter Oniy One Cause On To Death
_inn. Ado Additional Lines If Necessary.
Immediate Cause(Final Disease Or Ccndi:ion Res...ti1L in Caa-.) A. aspiration pneumonia days
Cu.to rO,An A Conseq,.nea 00:
se Parkinson disease
q e _y List Conditons, If Any,Leading To The Cause Listed On ' years
L'rs A. Fra:, The Underlying Cause(Disease Or Injury That Initiated °a'°l0"a A c°'aq On:
The Events Resulting in Death)Last ,.
C. I Due to lOr As A C°ns.Wmu Oh: -.
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Part It.Enter Omer Sionificant Conditions Contributing to Dea:!.Sir Not Rasui:-; Tne Under ying Cause Given In Part I 29.Was An Autopsy Performed?
0 Yes El No
Diabetes Mellitus type 2 30.Were Autopsy Finding Available To Complete The Cause Of Death? ❑Yes 0 No
� 31.Did Tob=_c ✓b cc Use Conete To Deatr? 32.It':emale:
,. I r 33.Manner Of Death:
0 r..: •,,e.par we ❑P,pn.nl Atnn.et own 0 rq.sarr.v,au P,aer.rt se 42 c.y.sown El Natural❑Homicide ❑Accident ❑Pending Investigation
0 Ye5 rr-P-7bab.y El-4: ❑Lnkns',v.; .
❑No:Prepare,SW Pr.gn.rt 43:.yi 7,l rcar adore Death ❑urknon 3 Pregnant Wale Tea Past Yee ❑Suicide❑Could Not Be Determined
34.Date CI i j ry(Month Day;Year) 35.Time Of Injury 35. Place Of Injury(E.G.,Decedent's Home,Construction Site,Restaurant,Wooded Area) 37. Injury At Work?
❑yes ❑No
38.L :-iu 5'F.a 13'_7.. =i j 3, ---- 3Eo. Street 8 Number 380.Apt.No. 38d.Zip Code
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40.If Transportation Injury,Specify:
120nw op.n:m ❑P.aemee•❑eeseeil.n Clothe rse.v'yt .
4t.Si-ra._:_ Cf rr_Fe sc _e .yr;Cosa Of Death: 42.Certifier(Check Only One) .
`faros�dcu6 Kocher Electronically Signed ®certifylnd Physician ❑Coroner ❑Health Officer
43.Name,A'--dress And Zip Code Of Person Certifyint Cause Of Death: - 44.License Number 45.Date Certified
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Jars.::Jacob Kocher 802 E Oak Street,For:Branch,IN=.7c,8 01071228A 08/23/2023 ' _
46.And on!?Funeral Service Provider: - 47.'Alfas: -
48. S"-t".:•3:'Lccal He_".n Officer: 49. For Renlstrar Only-Data Filed(Month/Day(Year):
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:Si _. : 7rn Electronically Signed - 08/25/2023
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) -
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-'O c - -.I u0. ==.((GROUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT WARNING. ., t con, `ronr,:`Fnv_ ,n,^,,,u,-a-. --` ...___....'._ _ -_-.