Death Certificate - Ellis, Naomi_11/26/2012CERTIFICATE OF DEATH
Local No U
!pal Name (FVSt AfiOtlle.
THERINE ELLIS
State No
10. If Dea� OmmM N N lbsqu[ t0a. H OeaT OavireE Somew�ere Ot�c itian A Hospital
� Hospke Fdtity ❑ DereOeMS Hcme � Nurs4q FlamrAOngtdm Cart Faaly
❑ Yes � No ❑ Unkno.m ❑ Inpatient 0 EmagmryDepartment Ouya:ent 0 OeaO m Mmal ��g��,)
INDIANA
�ec suenaaiwmoe,
704 KENSINGTON DRIVE
19. DeceOenCS ECUrawn
BTH GR4DE OR LESS
PRINCETON
LILLIE E PAVEY
:•..•1
� Alatne0� MdmeC. &nSeDYa'sC ❑ Divo�ce�
� VMLWeO ❑ Ne�erAtilMC ❑ IklMwm
� Yes 0 No
� 9Wal p Crema:ion Q DonaOm O En:omGmeM
❑ Renoral �rom 53',e
❑ om« Isoemyk MAPLE HILL CEMETERY PRINCETON, IN
26. wa Cama Con'aae�i 2). Nar.n ME CamPb'•e AOtlress Of Funsdi Faotiry 2]a. Funsal nane lxense Numt
❑ ro � no COLVIN fUNERAL HOME INC, 425 N MAIN ST., PRINCETON, IN 47670 FH83005671
PC. S4v:weO(InSaiaFUnadSeNCeLiCmsCO: 2TC. LkenseNUmOC�OIIJCe�ttk
RICHARD DEAN HICKROD , BY ELECTRONIC SIGNATURE FD01012153
Cause Oi Dea[h (See Instructions AM Esemplea) Apprndmate
2?. Pen L Enter Ttre Uain Ot Evena - Diseases. Irquna. Or CompGwuore - Ttiat Dveay CauseE The DeaN. Do Not En;er Terminal Events Intwal: OissM
SuM Ac CarOiac Mest R�pverory Mest Or VentnMer FOnllatirn W inwt Sha.ing The Endogy. Do Not ADCraNare. Entu ONy One Cause On To Dea�h
A Line. Mtl AOCitinal lines If Necessery.
ImmeEUte Cause (Final Disease Or Condiuon ResU�ng In Deatli) A� CJJ2DIAC PRREST M�NUTES
ei ...
S24YElIJd�' LIS� GIX'A�JOlIS. I: MY, LEd01(19 TO T}12 C8U5¢ 115f� O11 B. ISCHEAUC HEART DISEASE Y�s
LineA. EnterTTeUnEa�ingCause�DiseaseOrin]uryThatlnitlatee �� ����IX`
TTe EvenS ReSW.vg In Dea:h) Last C.
. .,i ...rawo
D. _ _
CEREBROVASCULAR ACqDEM. H1'PERTENSION.PERIPHERAL VASCULAR DISEASE OLO AGE �^e�e n,opsy ruWUy �.aoa,e �u.,.,��w=� ��,_.._�_..� �.�.... � �� � No
31. PO ToUac00 UH CanTdf.e To Oealli? 32. If F<nale: �� �m�=� ��
❑ res ❑ aimaoN O No � unwiwm ❑"•n•w+.n,.a..... ❑ c..v�-.u,�,,.oro... ❑ w�».w.a.�A.a�...m...:o.nvo..n � Nayrsi O Hmiiooe ❑ ncdeem ❑ vmaxro�n.�asaom
❑we�.v+asaAw+uo.n*=�r�e.eno-.m ❑w�.enro��+w..�:�.c ❑SUCiGeOCaWCNaBeDeRmYxC
3G. �atOflnN�YlManWDaYnw) 35. TeneOfNN�'/ 3fi. RseO(i^WYIE.G..DeceOenCSlbme.CmswcUOnSi:e.RmauaritW000e0Nea) 3i.IryuryNWM?
❑ Ves ❑ No
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. .:i[cr ���IVRP,:
(�losl
Cc�.'.Fj
Sewnry a is Deieg rcquestetl �y t�is state agency in order
is vdunary aM �ere wal Ge
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