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a. 11S INDIANA STATE DEPARTMENT OF HEALTH - ' . 'I I, I
- ,• 111;I - CERTIFICATEOF(DEATH ;,' , u i
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'S.•ri�e- r Local No 000042 - EDR'No•0000-00626391 state Ho 00682 '' .„
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1.Decedents Legal Name (Fast Middle,Last) - I '1 ' I la. Meldes!Na�te'(if female) ' - -1 2.Sex ' •• a Time 0f 0eath ill[ 1,41 Date Of Death (Month/Day/Year)
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1 MARILYN DALE BENSON ' II, ' 1' MCCORMICK ''. •''l l' 1 '~' 'I Ill' FEMALE -11:09 PM 'I : 02102/2018 )i
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Hospital . • , L''„, -
>� • i -. eyelid lei l,D'Hospice Faallty ' :r Decedent's Home"_ 0 Nursing Homeflang•ted111 IkeFaaly
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Yes❑ IN No I"D Unknown 0 Inpatient 0 Emergency Department Outpatient ❑ Dead I I - ' ' - II °Q► ';!Ir,�:' [] �ISP�n'r '1i II ' =• - '' " Ii�li,.ll-•"; r
11. Facili Name II Nat Institution,Give Street and Number) • ', i 4 n4, •'• ' II.
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ty' ( 11 t� 11 Ini�lt ll�r'l1 - •�'.' , 'll - �.411. 1'1 III .. "I+, ' . II 1 - - Ili)'_ ' :' 11i 81
8897 SOUTH 1075 STREET WEST 11 I'
12. CityOr Town, State,And Code „ • :. . • --. `-1 13. County -' - . -' 1
p y a�Pafn! (- 14. Marital Status At Tune Of Death
i 1 11' it• `1 - If' 1 �i 'ly'"•1 - . --''•dII lI Ir'.: ' t ®.Marled❑ Married,But Separated ', A,Divorced ti
.7 OWENSVILLE, IN, 47665 1, I',IIIL!' I 'I 1 ; ,.,'',I„' ,I GIBSONi 1i . . •'! I' I .❑ Wdowed. 'p,Never Married ,p Ugwiavin,
115. Surviving Splouse'e Name " q "" 7 , '; 15a.lest Namet5e`are First Marriage ,,:,II I11 ,t+,4 , r_`B: Decedents Usual Occvpation " ,.r .17. IGnd Of,Business•4ndustry 1i4
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TIM BENSON Ii n LJII I i ' '' " ', HOMEMAKER ' ,I. '- HOUSEWIFE' .,
e 1 B: Residence-Stale 18a. County.`- „ i kI + 4i lI';la tea City Or Town II t I I ' ',I • a\
I' ' , ...1111 Ii1 - , I 'e • _ , 1 • I'I 1 _ 'I Illn, n) fl l.I" ' 1 :2131 INDIANA 'I"'" GIBSON `' : : s `' - OWENSVI TILE 1 •- ` ' ` '�` „
18c. Street And Number n I t' ` " I I J p 1Bd. Apt Ho. _ 18e. Zip Code 18f. Inside City Limits? , ��
.. .. •' . I;Il.l: ' 't 1{II (, .I'' r ;-t', I , "I'e 1170411
ll"IIII- `11 '' 'I - :Apt,
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R 8897 SOUTH 1075 STREET WEST •
"1„ • II I' 47665 I Yes ® No J
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79. Decedents Education 20. Decedent Of HispanicOripn • �- • , I. r •21. Decedents Race - _ t
HIGH SCHOOL GRADUATE OR GED . ' ' - ;;I1'' '' `; , R ., "' - a I. " if I. L
COMPLETED NOT HISPANIC(' , .. '' ' 1' ' r IL I; 1
: �� It' wnlce: ' ' '
22.Parents Name(First Middle,Last) _ dl or r.. - -•....-,,1 dle 23,Parente Nana(Firer,Med ,Last), flit. -1 f 23a.Parent's Last Name Before First Marriage pj
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b ROY MCCORMICK C - ' ` `• - -. MARLENE�'MC.CORMICK ' - r` HEDRICK '!
t 24.Informants Name ,f ' 240,,Rol■aon■hip To Decedent', .- ._ 24b.Mailing Addreia (Street_And Number,City,State.Zip Code) " • I. I i'11'y,
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TIM BENSON HUSBAND ' --ti 8897 SOUTH .1075 STREET WEST, OWENSVILLE, IN 47665 " 1 •t
, .. „ --I- r25.Platy Of Dispodllion ,... 1/41 rl •. l - ' + '
25a.Method Of Dlspositmon 25b,Place Of Disposition (Name Of Cemetery,Cremamry,Other Baca) 25c.Location-City,Town,And State „ I ,
® Budat ❑ Cremation ❑ Donation O.Entombment ',11 u.fill-"" •'`-�i I' Iy i' .' '' 'i{ I • , '`,. - jII tI I•ItI - -
❑ Remin•el From State ' _ ;, .: ,, ,11 1 _`;I''1 _ -• 1 '1' ;'+• ' u ,, .
1 ❑ Other (Specify): SAULMON CEMETERY • `' - - ' ` POSEYVILLE, IN,jau •
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, 29.Was Coroner Contacted? 27F Name And Complete Address of Funeral Facility I,Si I' " ''1,I I 1 •. 111m11 • ' ; • : 1.11'0'jlll l 27a., Funeral Horne License Number ,
❑ Yes ®INO _ , 'lid , 1 (', -_'' j'.•I r "J.iifilf L1,'hf..W.- - , I IIL11,
HOLDERS FUNERAL HOME;' 319 SOUTH MAIN STR ,EE OENSVILLE IN 47665 FH11700008 ■
27b. Signature Of Indana Funeral Service-Licensee: I • -• - ,' - -• n '"i- ^':^' ' II - .. . 27c. license Number(Of Licensee): ;, - I. e
BRANDI MACER , BY ELECTRONIC SIGNATURE • •"II_„ . - I t II L '` I FD21400065 it, (I"
Cause Of Death (See Instructions And Examples) - V' ' , na' ;'II • ' • " Approximate •
28,Part I. Enter The Chain Of Events -Diseases, Injuries,Or Complicstioiis Thet Directly Caused The Death. Do Not Enter Terminal Events l ;l„I, ._,, .. Interval: Onset
Such As Cardiac Arrest,Respiratory Arrest, Or Verb'ictrlar Fbriflation Without Showing The Etiology.Do Not Abbreviate,-Enter Only One Ca+ se.On To Death •
r A Line. Add Addtional Lines If Necessary. II, it ' = ;ti,, rl ,
III. II • ,p'u41i,;11.1 • I'' , -
r Immediate Cause(Final Disease Or Condition Resulting In Death) ,III." t,, A. ADENOCARCINOMAOF THE COLON'MTH METASTATIC DISEASE TFIROUGHOUT THE ABDOMEN 11
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Sequentially List Conditions, If Any, Leading To The Cause Listed On B•, I G.mraaeca..�o op -',I-.;, 4
V Line A Enter The Underlying Cause(Disease Or Injury That Initialed I , l' _ . , r' • tt
The Events Resulting In Death)Lasl C, I n I I n _ III I1
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,- Pat Il.E,n.er Oo,ar,§ioni'tsom rand-dons rcntrlbtrir+o to oeot But Not RosuTng to The Undortying CnnQ Given In Part I- . '1;I 29.'Was An Autopsy Performed?' - •' - - - •
... - 'I -f l II II I•
' "1.1 i1I I l i - .11, I I1 • :- ,- • .1 1 ❑ Yes - NO
' „III ,,I I ,; +'', , , r1 30. Were Autopsy Finding AJaileble To t',ornplele The Cause Of Death'? ❑ Yes 0 No 1,
31. DdTobaccaUsaContrbutaToDeath?'' 32. If Female: .: - c'- . r,,lol� 1111 "l,;l; ' ", . 1,33.'MannerOfDeath:
14 0 xerae0lrrt ,en1Yn,- 0 Iis.y,wunn,ora:n 0 NolPinIne BJReIruA-WM1na2oereadpel lid Natural 0 Homicide 0 Accident ❑ Peridnglnvestigation
❑ Yes ❑ Probably ❑ No ®'Unk1loivn I ', , tl II ,i . i° . 't • = I1'
// ❑ wra�.ieaa.pwoa.r,lo+t.uawo.ns ® urua.wllpji�sYww it.e■ay.0 . ❑ Sudde ❑ CculdNotBeDeiermined 11 II 1
T 34. Date Of Injury(Mont DDayfYear)ill' 35. lime Ot Injury, •• ' ti 1'' 36.;.Place Of Inl+ry,(E.G.:Decedents Home,Construction Site,Restaurant VWoded Area) , .37. Ir ury At Work? 4
h, • ll L' [I t . ' ❑ yes ❑ No
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38. location Of Irtitay-State 38a. City Or Tam - I I ,I, ,'38b. Street 8 Ntmtber Ill!, �, _ •I I.,-11 38c.`A L No. 36d Zip Cade 7!
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39. -
Cesct be How Injury Occurred -1 40,:1f Transportation Injury,S f$ cell Fj
q , r - tII- ❑D1Powe. sb ❑P. 'w 'P th t.❑°' 'C&eC� ., ,I 4
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41._Signature Of person CerflfyingGeusat7fDeadr' ' ' , " ' I - 42. Certifier (Check Only One) - - 11.li l.
JULIE K. GERCIARDT , BY ELECTRONIC SIGNATURE• • I. - �'. ', : JI,iII�'I�1I @Ill _ ' };1 ' Certifying Physician ' El Coroner ❑ Healthotioer ' �
43. Name,Address And Zip Code Of Parson Certifying Cause Of Death: .•_, ,I1 „I - r _ `-_ -. 44, License N_unaer 45 [ate Certified
P.
JULUE K:'GERHARDT-,600 MARY ST- EVANSVILLE,i IN'477.13 It _ - '" ' -' i' 'I`I •' 'l - 01057271A I 02/07/2018 4''
46S. . Additional Funeral Se`:be Prodd•er -• . -. 'l,," 1:,I1 -' i1 1' , - - , I "I. '47 1 AS®s; G%
1( ' 48, Signature m Local Health Officer ,
49. For Registrar Only -Date Filed (MonthlOaylYear): R
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BRUCE BRINK JR, VIA ELECTRONIC'SIGNATURE • '' - ' . I. "' FEB 09 2018 ' II . '
r , ....,-,-1,,,,..„-i , ' AMENDMENT TO CERTIFICATE OF OEATH,(ENTRY OR ORIGINAL), _, , _ ;+11,1,a, ,y
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11 , - II Y� State Form 53395 ATTENTION ESTATE:The Social Security 0 Is being requested by this state agency In order topgstte,responsibifdy. Disclosure;I,s voluntary and there will be no penalty for refusal
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ORIGIN DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL W1•irT SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT
WARNING. TURNS FROM ORANGE TO YELLOW WHEN RUBBED. ORIGINAL DOCUMENT HAS AlHioDEN VOID ON FRONT THAT APPEARS WHEN PHOTOCOPIED. 1.1 [...iv. r
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