Death Certificate - Kays, Charles T_5/4/2011Local No
JR
_. . _._
INDIANA STATE DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
State No
603675
01/14/2011
❑ Mospce FaaLry ❑ Oeceaenfs Mwre ❑ Nursi�g HmAOtgium Gre FatXy
❑ Ves � NO ❑ UnMbwn � InpaOlnt Q Emerqen�y DeD�mtO�aOen� Q Oead on Nrtival � Q�H (Speaty)
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� Burw O Crcma�on O Dmaam O Enmmonent
❑ R'movdl Frdn Sta�
UNITED METHODIST CHURCH
MINER
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❑ VAtlw.etl ❑ Neve MalneE ❑ Univmm
❑ yrs � No CORN-COLVIN FUNERAL HOME, INC., 323 N. MAIN ST. PO BOX 278, OAKLAND CITY, IN
❑ res � No
..a..�....,sa.. �,...�...��....,�..,.,��... ���v�e�i MGradmate
2d. Part I. En�er Tlie Cna�n Of Eve�ts - Diseases, 4quna. Or Com0lifaYOnS - TTat OireCJy CauseE The Dflx'.�. Do Nol En�pf Terminal Even6 In;erral: Onset
$udi As CaNlac Mest Respva;ory Mest, Or Ven;,icvlar Fi0.itla'von W Jwut SMwing TTe Etidogy. Do Not Ap Wevia;e. Enter ONy One Cause On To DeaN
A line. Md AC�it�nal WfM M Necessary.
ImmeEiate Cause (FC,aI psease Or ConaWOn ResWUng In Deam) A. ACUTE LEFT ISLHEMIC CEREBRAI VASCUTAR ACCIOENT DAYS
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Se�ua�tiany lis� Cmai:i«s, if My, Lraaing To Tne Cause Us;eE On B� THROMBOEMBOL6M TO 015TAL IMERNAL CAft0T10 ARTERY DAVS
Lin_ R. Enter iTe Vncerty'vig Cause (Disease Or Inryry That IN;ia:ed
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T1ie Ev=n6 ResWiing In OeaN) las� G CMRONIC ATRIAL FIBftILLATION YEARS
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CMRONIGDIASTOUGHEARTFAIIURE.HVPO%%EIAIAREQUIRINGSVPPLEMEMAlO%VGEN,UNCAMROLLED � y��.eq�p��yFinCnpNVala�leTOCar.npebTTeUUaaOf�eaT?
�YPE II DIABETE$ MELLRUS ' ❑ Ves ❑ Ni
J1. POTOOecooUSeCOnTOUVTODeaT? 32. �IFema�e: 33. MamvOfDeaT:
❑ ves ❑ amoaM' � No � unu�w�m ❑ wn..�..w.,e..... ❑ n.w.u:...ww.n ❑ wn.s�.+wA.wiwv..,.zon.ao..n � Naaua� � tbnYdae ❑ Rcriant ❑ PeMin9 �nws%aean
❑�.A.medn.w+ao-n..+�w.a.. I—I�+�.�w.�rnv�tiw.w.h..ar� I—ISUMlEeI—ICdMNGBeDet[mvneE
❑ Yes ❑ Na
po.�.�x.a.�
Cen..er (Cneck Ort�
036958A I 01/78/2011
53395 q�7EMqN ESTATE: Th¢ $aoal5ecunry t is �ting repuestea Ey Ws ztate age�x.y in order to Wrsue respansidLry. pittlosure is vduntary aM Uiere v�T Ee no penzl.y (n rdusal.
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