Death Certificate - Boerke, Jack H_6/2/2003GIBS�COUNTY DEPARTMENT O�EALTH
800 S. Prince St.
Princeton, Indiana 47670
812-385-3831
RECORD OF DEATH
THIS IS TO C6RTIFY
that according to the recorda of the Gibaon County Department of Health,
JACR H. BOSRKB
Died on 04/07/1996 at 1:55 PM
ForreSt Del Hedlth & Rehab Ce
1020 West Vine St.
PrinCetOR IN 47670
Age at death . 94 Years
Marital Status: Married
Sex: M
Color: White
Cause of death: Cachexia after Hip Fracture
Hip Fracture and Pinning
Signed by: Hassan Rayes, hID
1814 Sherman Drive
Princeton ZN 47670
Place of burial Oak Hill Cemetery
or removal:
Patoka ZN 47666
Date of burial: 04/10/1996
Funeral home:-�='�COlvin Ftuieral Home, Znc.
\�_
� . - 425 N.. Main St.
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JUN 2 2003
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_ � _-Princeton IN 47670
� -. � Signed by ` G �/���
� Gibson County Health Commissioner
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S E A li �.'-'-- .
' .- Princeton, Indiana 06/02/03
Address Date
Recorded locally in Book No. 13 Page No. 9 Filed: 04/10/1996