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Affidavit - Besing, Larry_10/15/2023
No MMII - 1 • I.'A-\ INDIANA STATE DEPARTMENT OF HEALTH 4147011 • .ti CERTIFICATE OF DEATH . Local No 000137 • EDR No 000011597960 State No 2023-043307 1.Decedent's Legal Name(First,Middle,Last) 1a. Maiden Name(II female) 2.Gender 3.Time Of Death 10.If Death Occurred In A Hospital: 10a. If Death Occurred Somewhere Other Than A Hospital 0 Hospice Facility E Decedent's Home 0 Nursing Home/Long-term Care Facility 0 Yes..'E No ❑Unknown ❑Inpatient ❑Emergency Department Outpatient 0 Dead on Arrival ❑Other(Specify) t i.Facility Name(If Not Institution,Give Street and Number) 8910 S 950 E �a I - 12.City Or Town,State,And Zip Code 13. County Of Death 14.Marital Status At Time Of Death Elberfeld,Indiana 47613 Gibson 0 Married Married,But Separated 0 Divorced El Widowed ❑Never Married 0 Unknown 15.Sunivina Spouse's Name 15a.Lest Name Before First Marriage 16.Decedent's Usual Occupation 17.10nd Of Business/Industry - • Farmer Agriculture 18.Residence-State 13a. County 18b. City Or Town - IN Gibson Elberfeld _ Sec.Street and Number 18d.Apt.No. 18e.Tip Code 18t. Inside City Limits? : E910 5 950E 47613 ❑Yes ❑No 1Is.Decedent's Education 20. Decedent Cl I--spanic Origin 21. Decedent's Race High School graduate or GED completed I Not Spanish/HisparJdLatino White I 22.Parent's Name(First,Middle,Last) 23.Parent's Name(First,Middle,Last) 23a.Parent's Last Name Before First Marriage - Nerman Basing Thelma Besing Grimwood 24.In'om•an1's 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 ,'•l�' 25a.'.1atit0d Of Disposition 25b.Place Of Dl spesecr. (Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State E E!.rlai 0 Cremation n Donation 0 Entombment - • .0 Removal From State St.John's Cemetery 0 Other(Specify): • Buckskin,IN Ii.,. 1 126.'Wes Cs.user Contacted? ' 27.Name Ar,d Complete Address O'Funeral FaciLty 27e.Funeral Home License Number: • Com-Colvin Funeral Home, ❑"us NO . Inc.323 N.Main St. Po Box 278,Oakland City,Indiana,47660 FH19400002 27b.Signature Of Indiana Funeral Service Licensee: 27e.License Number(Of Licensee):FD21800025.7c3 ''ac�n Electronically Signed Cause Of Death (See Instructions And Examples) Approximate 28 Fist' �Y,arTine Chain Of Events -Diseases,Injuries,Or Cemp cal s That Directly Caused The Death.Do Not Enter Terminal Events Interval:Onset such As Cardiac Arrest,Respiratory A-rest,Or Ventric.ilar F,oritlas0r, -,silowing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death _tre. .Acd Additional Lines It Necessary. 11'1' aspiration pneumonia days Immediate Cause(Final Disease Or CcrcCion Res..a 1 it C°a-.) A. Du.to iOr A.A Con...u.no.CO): Parkinson disease • Seq..er,1.s'iy List Conditons, If Any,Leading To The Cause Listed On °• years 1...,-.9 A. -vier The Under)y:ng Cause(Disease Or Injury That Initiated a.mlaa Ac.n.....k.an: Tne Events Resulting In Death)Last C. i O.to(Or As A Cowgomo.on: Part ll.Enter Odner Sienificant Conditions Centributino to Des'?Out Net Road:-; -.Tie Liner 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? 0 Yes 0 No 31.Cl-crrnoc Use Cortfbute To Dear? '32. I•=emcee: 0 33. Manner Of Death: - ❑•.- ..;n,,a•':-.PgYear P,ryn.ia,mr.ofo..m 0 NASPAssprst,Els4n,.pr,ntMIAs42G001o.ah El Natural 0 Homicide 0 Accident 0 Pending Investigation C•: = .eel E I]hrkn;N, 0 Na P,.pnant,eut Novara AO toys-..1 year astir.Nan ❑Crkrows r Pr.pn.nt Wipe Th.Past Yeas 0 Suicide 0 Could Not Be Determined- 34.Date Ct ::y(L cntfsCay;Year) 35.Time Of Injury 36.Place Of Injury(E.G.,Decedent's Hone,Construction Site,Restaurant,Wooded Area) 37.Injury At Work? - ❑Yes ❑No c.Lx_.r C :..,t.^•-5:,? 13Ea :1/O''c.v- --- 3Eb. St•ee:a Number `` L. 38e.Apt.No. 38d.Zip Code -- • �,ll 3s. -2 icr__.-.es in;ury G:,:..:r3O 40.If Transportation Injury,Specify: ❑D1rar w e.,.r,r ❑Panpw❑P.darrYn❑oih.lse.dryl .- 41.5.t-e Cf.°ennui:at'-.yr.;Caine Of Death: 42.Certifier(Check Only One) 9areea aca5?(pcher - Electronically Signed ©CertiyingPhysician 0 Coroner 0 Health Officer 43.Name,-':'ass And Zip Code O1 Person Certifying Cause Of Death: 44. License Number 45.Date Certified Jere::Jacob Kocher 802E Oak Street,For:Branch,IN 47E48 01071228A 08/23/2023 46.Accit c-.3 Funeral Service Provider: • 47.'Aims: , 48Vicar:.,T.;ili 49. For Reiiiatrer Only-Dale Fled(Month/Day/Year): `'_-__ :. 7' Electronically Signed - • 08/25/2023 - AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) - • • • • i 5G. F Cpr Cc Lt E 1- - L Ca '_KGROUND ON SPECIAL WHITE SECURITY.PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK-THATp WwR � 1,J r ; , OAN -...