Death Certificate - Gordon, Betty_6/27/2012�
Local No
CERTIPiCATE OF DEATH
: No 000000266564
896152
30&30.1126 83 �� oan �o�rs nwm� 10/03/1928 PRINCETON, IN
9. Ever m U.S. MnM Foeces? 10. if Dea� OmirteC In R liasqlal: t0a. If DeaN OcrurreG Somewfiue ONe� Tnan A Hosphal
❑ Hospice FaaLry ❑ DereOem's Home � Nursvg HamNLwgWm Care FaaSry
❑ ves � No ❑ unkno� ❑�oc�em O Emd9mcY���em0uYa5ent p oe�dw�a,;�i p oma(sc�r)
47670
9 EAST OAK STREET
oeceomrs =_euw5w,
GH SCHOOL GRADUATE OR GED
TUCKER
EMERSON
� aunaw p cremr.;on O oauoon O�,:a,�cmPm
❑ RemwalFmnSah
❑ nwmea0 nwnea.e�iswara�� ❑ o-n�
� WqoweE ❑ NewrMarr W ❑ Unlv�wm
� res p No
❑ ves � r+o COLVIN FUNERAL HOME INC, 425 N MAIN ST., PRINCETON, IN 47670 FH83005671
le. s4^an,reoru,�aruFUnea�servi«LCensee: z)c lienur.'umw(alicenseet
ICHARD DEAN HICKROD BY ELECTRONIC SIGNATURE FD01012153
Gause O( Dwth (See InsWCtions AM Examples) Approtima[e
28. Part 1. En:er The �hzin Of Events - Diseazes, lnjunes, Ot CanpGwtims - Tha� DirecUy GauseC The DeaN. Do Not ErGer Temtinal EvenLS ��tervaL OraN
Such As Ga�ac Mesl Respiratory A+res4 �r Vemnwlar FDnAaum NhNOUt Shoning The Etidogy. Do Not AEbreNate. Enter ONy One Cause On To DeaU
ALine. AadAdditinallinesltNecesury.
Immetliaie Cause (Final Disease Or ConCitlm Rr5ul5ng In DeaN) A RENAL FAILURE MONTHS
y.vi �.. oR
SequentlaP/ List CmCitlms, If My, Leading To The Cause LisreE On B. CNRONIC KIDNEV �ISEASLS YEAiiS
LinaA. En;erTheUMgtyinqCausel0.seaseOtlnl�7T�tlnitia:e7 �'��~�
The Evenfs RrsN:irig In DeaN) Last �
❑ res ❑ F�maNY O No � unMam
P PATEL . 685
VIA
�
Yes � No
❑ raA.P....,.,v...� ❑=�.a�.��un,.«o..., ❑ wi=�.v..wa.n.w.....�.:o.Y.ac I� Namai O Honw,ae ❑ amaem p a«navg �mctgaxn
flran.m.a�A«a�.r�o.r.m�we.e,.ow fl�w�nv�.owwan*wr.vr�, I�lS�ritlCel-lCOUYJNMBeOe�rtrvneC
JUN 25 2012
❑ Ye5 ❑ No
Qa+ISOYht
�6�25�2��2
��� �T7ENTION ESTATE: The Sodal Sewnty p is beng requestetl by this state agem.y in wder m pursue responsiEitiry. Disdosure is wNntary and Nere wi0 be ro pe^alry fw refusal.
(7los)
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