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Affidavit - Besing, Larry_10/11/2023 (2)
.. . _ _ •_- - e:.4: \, INDIANA STATE DEPARTMENT OF HEALTH 414 7 O,• %��'f j 7 CERTIFICATE OF DEATH 1 �\--i Local No 000137 EDR No 00oo115s7sso State No 2023-043307 _ 1.Decedent's Legal Name(First,Middle,Last) I la. Maiden Name(If female) 2.Gender 3.Time Of 84 Months Days Hours Minutes 08/16/1939 Evansville,Indiana 9.Ever in G.S.Armed Forces? 10.If Death Occurred In A Hospital: 10a. If Death Occurred Somewhere Omer Than A Hospital , • ' Y [s]No0 Hospice Facility ID Decedent$Home 0 Nursing Home/Long-term Care Facility • 0 es 0 Unknown 0 Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival 0 Other(Specify) • - • 11.Facility Name(If Not Institution,Give Street and Number) 8910 S 950 E '''h^: _ 12.City Or Town,State,And Zip Code 13. County Of Death 14,Marital Status At Time Of Death Elberfeld,Indiana 47613 ', Gibson CI Married❑Manled,But Separated 0 Divorced ®Widowed 0 Never Married 0 Unknown ' 15,Surviving Spouse's Name 15a.Lest Name Before First Marriage 16. Decedenra Usual Occupation 17.lend Of BusinessAndustry - • Farmer Agriculture 16•Residence-State 13a.County 18b. City Or Town IN Gibson Elberfeld 18c. Strati!And Number / led.Apt.No. lee.Zip Code 18t Inside City Unlit*? - 8910S950E 47613 ❑Yes ❑No 19.Decedenrs Education 20. Decedent Of F,spanic Origin 21. Decedenrs Race High School graduate or GED completed I Not SpanlshiHspanic/Letino White 22.Patents Name(First,Middle,Last) 23.Parent's Name(First,Middle,Last) 23a.Parent's Last Name Before First Marriage - • NclTnan Besing Thelma Besing Grimwood 24.In'orm5nPs Name 24a.Relationship To Decedent 24b.Mailing Address(Street And Number,City,State,Zip Code) . Anthony Besing Son 8518 S 950 W,Elberfeld,IN,47613 25.Place Of Disposition • i1" 25a,l.letnoo Of Disposition 25b.Place Of Dapcs:ror, ,Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State ®Et.r's. 0Cremation fl Donation 0 Entombment.0 Removal Removal From State St.John's Cemetery 0 Otner(S2vdfy): Buckskin,IN . 26.Was Cancer Contacted? 27.Name And Complete Address Funeral:Facility 27e.Funeral Home License Number: Com-Colvin Funeral Home, 0 ire= No Inc.323 N.Main St. Po Box 278,Oakland City,Indiana,47660 FH19400002 27b.Signature Of Indiana Funeral Service Licensee: 27c. License Number(Of Licensee):FD21800025 ?=3='=:=-�iackffri Electronically Signed • Cause Of Death (See Instructions And Examples) Approximate 28 art' altar The Chain Of Evente -Diseases,Injuries,Or Camp'cn s-That Directly Caused The Death.Do Not Enter Terminal Events Interval:Onset c ,a As Cardiac Arrest,Respiratory Arrest,Or Ventric;lar Fiorular:ar. _-S lowing The Etiology.Do Not Abbreviate.Enter Oniy One Cause On To Death A_ir.e. .Aao Additional Lines If Necessary. Immediate Cause(Final Disease Or Ccr3i:ion Res.!ti-:p in 0ee.r.) A. aspiration pneumonia days 011.to to As A Camas..0e: Parkinson disease Seq,iec!,f"y List Cond:tons. If tray,Leading To The Cause Listed On ° years ne A. 7t:r The Urdcriy:ng Cause(Disease Or Injury That Initiated a"°Pr Acomyues a.bq:L Tne Events Resulting in Death)Last C. Du.to(Dr A.A Cam.pa.na 01): . L. Part ll.Enter Other Sionificant Conditions Ccntributinp to Death Sc:Not Rani.,: Tr,e Under'iing Cause Given In Part I 29.Was An Autopsy Performed? ❑Yes El No . Diabetes Mellitus type 2 30.Were Autopsy Finding Available To Complete The Cause Of Death? ❑Yes 0 No 31. DN Tccnnce Use Cortrbute To Dear-? 32.If vernal.: 33.Manner Of Death: Y ° r_ _,.cam, t El .;na'-''K,P.Year ❑a,e2nar,:vinn 01CHA, 0 Nuiteraxa:,PrivAntWe,..A2canaown NaturalHomicide 0 .y 0 LrKn,w. r©--� 0 ❑Acddent ❑Pending Irtveallgatton ❑ha:Pregnare,am Pregnant A Cay,--t yearaebes D.W ❑ure,oAn.Pregnant We.,En.Poe Y.. ID Suicide 0 Could Not Be Determined • 34.Da:e Cli,try(f'onthIDay;Year) 35.Time Of Injury 36. Place Of Injury(E.G.,Decedent's Hone,Construction Site,Restaurant,Wooded Area) 37.Injury At Won? • ❑yes ❑No c.Lxa::c. C .)i.r:-5:s P 13°-. :173 .-r n-. --- 3 S Eo. -ee:&Number ` 38c.Apt.No. 38d.Zip Code 'i l 39. Cesar__raw IN ury iwai:.'atl 40,If Transportation Injury,Specify: ❑p,tyump.,are ❑Pawnees❑P.eeehn❑an.lspawit 41.S:71.-,1 Cl Person_Pr.Ing Cease Of Death: 42.Certifier(Check Only One) •JoneaJeco6?(pcier - Electronically Signed El Certifying Physician 0 Coroner ❑Health Officer 43.Name, -dress And Zip Cede Of Person Certifying Cause 01 Death: 44. License Number 45.Date Certified Jere:Jacob Kocher 802 E Oak Street,For.3ranch,IN-c•48 01071228A 08/23/2023 ' 46.Acd:=-s F_neral Serv;ce Provider. - • 47.'Alas: - 48. -a-...'a_'_cc>:Fez-.r C:cer: ___ 49. For Re(llalrar Only-Date Filed(MDnthiDay(Year): -. :,:'' Electronically Signed - 08/25/2023 AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) OF 3'q ,_n,'n0:EPIT HAS=.!.!U_-IC urn:r. .CKGROUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK-THAT TI :..:�:ne•nQAA,I"C Tn V°�,n.n,,Arurrn:n. .�r-.�.. r�nrn,.,., ..........�..�...., .'...___...._._ _..___.._-.