Death Certificate - Payne, Gloria E_2/9/2012CERTIFICATE OF DEATH
State No
534390
Famsl f0. If DeYJ� OawN N R Hosp'at t0a 1f DraT OttvrteE SmieM+ae O.:a iTan A Hospi;al
❑ Hospice FabLry � DcrNeiu's Hane ❑ Nurstrg Hamulang�tum Care FavFty
❑ v� � No ❑ urwo.,� ❑��ro:+eM � Emepmry DMZamnrmU:7�eN p o�e o� a�..� p ou,a�soemvl
INDIANA
�509 S. MAIN ST.
is. o«a�rsee�xas�
HIGH SCHOOL GRADUATE OR GED
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❑ Remwal From 53:e
n on,g �so�.we MAPLE HILL CEMETERY
❑ ManfeEO MaMeO.BUtSWm'+:e0 ❑ DM1OrcM I
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� �� � NO COLVIN FUNER4L HOME INC, 425 N MAIN ST., PRINCETON, IN 47670 FH83005671
]E. SGw�xe O( In��a FserzJ Service Lksnsee: 2)c Lkerx Nur.�Oer (Of Lice�eey
DHN W WELLS BY ELECTRONIC SIGNATURE FD01009940
Cause Of Death (See Instr�ctbns Antl Eaamples) Apprmuma:e
28. Part 1. Ent_r The (Tan Ot Events - Disezses. 4qunes.Or Comp6ra�ons - TTxt Di:eNy Caused The PeaN. Do Not En;er Terminal Evenis In;er21: Or�sM
Surn 0.s Cardiac ATest Respvatory Artal Or Vauiwlar FlCn11aUm W t�ou� Stowing The Etidoyy. Oo Not AObreNala. Emer ONy One Cause On To DeaJ�
A line. Atltl AES:inal Lines lf Necessary.
ImmWa;e Cause (FU:zI DiseaSe Or CoMition Res�d�tg In DeaUi) A. PNEUMONL4 DAYS
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$¢qum:id0y List ConO::imS. If My. LedOirg TO TtiO Cause Listetl On e� ��SED ADENOCARGINOMA OF THE LUNG IN THE MEDIASTINUM 15 MONTHS
Line A. En:er The Ukerlying Cause (Diseace Or tnjiuy That hJ:iateE e�6 �•
Tlre Evenn ResU9�g In DeaN) Lest G ADENOCPRCINOMA OF THE LUNG. STAGE IIIA 29 MONTHS
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0
JONE ...��e��wwr �.,.y,. a�.� ��.....w�.� ���e.,a,�...,.�,.� � Ves 0 No
31.OqToDacooUUConSibS,eTODeast 32.IfFmWe: - �� �mP+a���
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TURE
4055 GA
❑ YPS ❑ No
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�� ATTENTION ESTATE: TTe Saial Sewnry Y a Eei`g repuestetl by Ws sta;e agercy in adu to pursue rrsponsibLry. Distlosure is wlurary aM Nere.�+A be no pma�.y fw rehisal.
NRA-20
(7/G5)