Death Certificate - Richardson, Randall_8/20/2024 ... -
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INDIANA STATE DEPARTMENT OF HEALTH i
. CERTIFICATE OF DEATH 4 6 0 4 4 2 5 i
Local No .000127 EDR No 000011746574 - State No 2024-035777
1.Decedent's Legal Name(First,Middle,Last) ' la.Maiden Name (If female) 2.Gender: . 3. Time Of Death
...,- ,
bHospice Facility 0 Decedent's Home 0 Nursing Home/Long-term Care Facility
El Yes 0 No 0 Unknown 0 Inpatient 0 Emergency Department Outpatient E]Dead on Arrival LIr-I
Other(Specify)
. .,
11. Facility Name(II Not Institution,Give Street and Number) ..
Riveroaks Health Campus" ,:•,..,,,,
12.City Or Town,State,And Zip Code 13. County 7f.)„,,,,,,.• 14. Marital Status At Time Of Death
: •
Princeton,Indiana 47670 Gibson • .,, Ill Married 0 Married,But-II\ ,...,Separated L.,Divorced
• El 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
. Richardson , Truck driver / Transportation
Wilma Clark .,
18.Residence-State 18a.County 18b. City Or Town
IN Gibson , ' Princeton
. ,-. •
18c,Street And Number • ... 18d. 44.No. 18e.Zip Code 181. Inside City LirMts?
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107 N Second Avenue-- 47670 i ID Yes 0 No
19.Decedent's Education 20. Decedent Of Hispanic OriginDecedent's' , ., 21, Race '9th-12th grade,No Diploma 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
Burch Richardson " Hazel Richardson . ' Britton
24.Informant's /Name 24a.Relationship To Decedent 24b.Mailing Affdress:(Street And Number,City.State,Zip Code)
Wilma Richardson Wife 107 N Second Avenue,Princeton, IN,47670
25.Place 01 Disposition
25a.Method Of Disposition 25b.Place Of Disposition (Name Of Cemetery,Crematory,Other.Place) 25c.Location-City,Town,And State
Et Burial 0 Cremation El Donation 0 Entombment \'
0 Removal From State
Calumet Park Cemetery ' Merrillville,IN
El Other(Specify): I .
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility / 27a. Funeral Home License Number:
• Colvin Funeral Home Inc 425 N Main St.,Princeton, Indiana,47670 I --
p Yes CI No •' :[ 0 •l' FH 2200018
...
27b.Signature Cl Indiana Funeral Service Licensee: 27c. 'ense Number(Of Licensee):
,....\\ FD01113010
iMark,W,Wafter - Electronically Signed
Cause Of Death (See InsfructInns And Examples) _ -
• Approximate
,,,
28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Even. / Interval: Onset
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Ca ise On (V To Death
A Line. Add Additional Lines If Necessaiy, 4'
Dementia .
'Gnknown
Immediate Cause(Final Disease Or Condition Resulting In Death) A. .44m..... _
- Due to(Dr As A Consep,
IIMAJIMFBrir
. .
. malnutrition ' ' unknown
Sequentially List Conditions, II Any,Leading To The Cause Listed On B. Dr,rato Or As a Corsao ence Oh
, . Line A. Enter The Underlying Cause(Disease Or injury That Initialed . ;
t The Events Resulting In Death)Last c., 7 ,,
. Doe to(D.As A Conseque co Or).
D.
Part It.Enter Other Signif icent Conditions Contributing to Death But Not Resulting In The Underlying Cause Given In Part I 29.Was An Autopsy Performed? 0 Yes El No 30.Were Autopsy Finding Available To Complete The Cause Of Death? up-,
• , Yes 0 No
31. Did Tobacco Use Contribute To Death? 32. If Female: • 33. Manner Of Death:
1
0 Not Pregnartnin Past Year/0 Pregnant At Senor Death 0 Not Pregnant.But p.reorrarlrAkthn 42 Days Of Death D Natural D Homicide 0 Accident 0 Pending Investigation
0 Yes 0 Probably El No 0 Unknown
El Not Pregnant.But Pregnant 43 Days To 1 year Beare Death D Unknown II Pregnanr.rthro The Past Year 0 Suicide n 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 Al Work?
ayes 0 No
. .. .
38. Location Of injury-Stale 38a, City Or Town 38b. Street&Number
• 38c.Apt.No. 38d.Zip Code
.: .
4 39. Describe How Injury Occurred 40. It Transportation Injury,Specify:
..,
I:Driver:Operator OPassonger OPeder.rian I:10111er(speelyt
41.Signature,Of Person Certifying Cause Of Death: i I
I:' 'i '''' 42. Certifier(Check Only One)
ru-e-6-(Britikir Electronically Signed El Certifying Physician 0 Coroner El Health Officer
43.Name,Address And Zip Code Of Person Certifying Cause Of Death: 44. License Number I 45. Date Certified
Bruce Brink Jr 1808 Sherman Drive,Princeton,IN 47670 02000610A 07/12/2024
46.Additional Funeral Service Provider: - ' 47. rAkas:
48. Signature ot Local Health Officer: ,
49. For Registrar Only .Date Filed(Month/Day/Year)!
(Brue,Brinkyr ,
\ Electronically Signed 07/15/2024
. . AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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Slate 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
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