Death Certificate - Holder, William H_12/18/2012Local
CERTIFICATE OF DEATH
eoR No 000000230964
�.r..
635610
11l24I2071
Fwces? 10.II OtdT OcameC N A Hmp W: 10a. Y DtaC� OmirteE Some�M�ere ONC T�dn R HOSpW
❑ Hospice Faatiry ❑ �emOenCS Flame ❑ Nurs'vg Hum�lag�ertn Care Faa'ity
� ves p no ❑ u�w,o«n O��oa�eo� � EmcgmryDepanmem0uyatlem O oGao�.cm�..i ��,a�s�;y�
7888 E. 300 SOUTH ROAD
19. oeceoenraEOUCaxn
HIGH SCHOOL GRADUATE OR GED
HOLDER
I� r.�ameaO nw�.�ea ans�oarz:w ❑ o�w�cof
❑ vnawea ❑ Nern Marnea ❑ unw�w*�
16. DeroCmfsUSUalOCCVp�on ti.l(viCCfBUmeWM�aby
RETIREDCORRECTION
❑ Yes � No
IN 47660
� guiy � C�ema�,ion Q Oma�on O Entambment
❑ R¢earel Rom Statt
❑ oma (sc�myz MONTGOMERY CEMETERY OAKLAND CITY, IN
�s. wm earma Conacc.o? 2). Nane Nk Gompe'.e AOtlress Of F�nsal Fatl6ry
� �« 0 Na LAMB BASHAM MEMORIAL CHAPEL, INC., 226 E. WASHINGTON STREET, OAKLAND CITY,
ini n�aan
23. Pan I. Enter Ttie Gain Of Events - Useases. 4qunes. Or Com0liratlaa - 7hai OirecUy Causetl Ttie Deatn. Do Not Entu Te`minal Evenu
$urn Ac CaNiac Mes� Respva;ory Mesl Or Venaicular FldiDaGm WiJwut 5�w.ing Tne Etldogy. Do Not MWe�riata. E`vrr ONy One Ca�e On
A Line. A00 Atld;inzl Linrs If Necessary.
ImmeEia:a Cause (Final O¢ease O� Contlipon RrsWCrg In DeetJi) A CARDIAC ARRHI'THMIA
ei �..�a..ap
SeQuuuaDy list CmEi;ims, tt My, LeaCing To The fause Listea On 8. ACUTE MYOCAftD1AL INFARCT
Line A. En:er The Uncei�ing Causa (Oisease Or Injvy Ttut IniGateE e� �
Tlx Even�s RaN'.'ug In DeaN) last C. CANGESTNE HEART FAILURE
vIP 4 � Cu�we
D
❑ Va ❑ P�oezM' � No � unlviwm
W
520
IVRH-:
nmc�
Apywimate
Intwdl: Oreel
To DeaN
Ves � No
❑ ranvwwe..rmr.. ❑ A.w.ur...o�o�n ❑.nr+w�s.n.w��wm.�..xo.nuc.r. I� Navrzl � Vbmicitle ❑ ncaoent ❑ PewqNV'sueation
flranwiana�w+vo.nre+w�e.n.wm ❑u.w��nw+wrm.a.crs ❑S�vsCeOCauNNUBaDeremtine0
The Sotlal Secunty
requestea oy mn
pursue respmsiWtiry.
Cerffia
mere.,m oa �o
❑ Yes ❑ No
pou.ia.wi