Death Certificate - Peed, Bernice_5/9/2011534052
CERTIFICATE OF DEATH
9ERNICE B PEED BRITTINGHAM FEMALE 12:30 PM 04/01/2011
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❑ Hosyce Faz�ry ❑ DeceCenfs Hpne � fNrsvg Hma�vqRtm Care Fao4ty
❑ res � No ❑ unwbwn ❑ mcz�mi O e�c�,ryoroam��o�amaxm O owoo�amai p rn,g(so�Yl
NORTH WESTSTREET
eceaeirs Eaucawn
NELOR'S DEGREE (BA.
Tefs Name (First ASbe, Lat7
iERT BRITTINGHAM
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❑ Remwa� Ran sfa;e
❑�� O Mar�ee. an seorr.ea ❑ awRea
� Nww.ca ❑ Newr Mareiea ❑ unMw.,�
� Yes 0 No
❑ res � No COLVIN FUNER4L HOME INC, 425 N MAIN ST., PRINCETON, IN 47670 FH83005671
2]�. Sid�u'�R Of InNata F�r.eal5enice Licwx: 2)c. Licnse NumCC (Of lxwmk
RICHARD DEAN HICKROD , BY ELECTRONIC SIGNATURE FD01012153
Cause Of Ueal� (See Insb�ctions Antl Erzamples) Appr�mmate
28. Pxrt I. Enter The Gain O( Even� - Diseases, tryunes. Or Complicauons - Tt�at D'veaty Causetl The DeaN. �o Not En;er Temtlnal Even's Intrval: Onet
Sum Ac CaMix Mes� RPSpird:ory Mgt Or VeM,nwlar FiGnAaUm WiNwt Stiowing TTe Eudogy. Do Not AbweNate. Enter ONy One Cause On To Deas
A Line. AtlC AEEifinal Lines H Necessary.
ImmeCiare Cause (Final Disease Or CorMiGOn Re5iA5eg In D¢eJi) A. HYPO%EMIA SEVERAL HOURS
a».,�a..n�sas
SequentialtyListContll6ms.IfMy,leatlingTOTheCa�aeListedOn B. REURALEFFUSION �b0. SEVERALYEARS
LineA. EnterTheUntleth/ingCause(DiseaseO�ln'ryryihatlnlSatetl � y��� �
T�e Events Resultvg In Dea;h) Last C. CHRONIC O&STRUCTNE PULMONARY DISEASE SEVERAL YEARS
o�.,�u...n�ew
SEVERAL
D. PROTEIN MALNUTRITION MONiHS
PanREnxrONaSUnfrantCaq:�onsCOnbiOU:mroOeaNBucNal3cWOnpinTlieUMCryvqCauuGiWnlnPart� 29.WasMAV.opsY��' ❑Yes �No
ARTERqSCLEROTICVASGULARDISEASE �.WereA�r,m,syFirALgAVaaa0leTOCmpr.eTneCauuOfDerJ�? �Yes ❑No
31. G1 ioerm Use CanYOU�s io Deatn? 32. It FertW e: 33. Mama Of DlY.�:
❑ ve ❑ ameaeN � No O unFnwm ❑"•"•w+"a.�=mn. ❑ n.v..+u.�.ac..n ❑.:a».:.az.n.v�.�w.-...:o...«o..: � Nawa� O nonadae O nccaem � Pmmq�mer,ga�m
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3<. WbIXLiNrY(MOn:YDaylYear) 35. Tme01�^ry7 36. PlaceOflniurylE.G..DecetlenYSHane.Ca:s7uc9on5i'.e.Resaivaritwm0.URma) 3). �^N7AtWoMT
❑ Yrs ❑ No
BRINK
BRINK
(7/OS)
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CeRic (ClixkONyOne)
Certt.vn Plrvsioan rl Caanc .❑ M'aT 03cc
IN 47670
The Sodal Secunry e is Ceng requeste0 Cy t�is state agency in oNer to W rsue respmsidtiry. Distlosure is vduntary arM Nere will be no penalry
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CERTIFICATE OF DEATH
State No
534048
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❑FbSpfreFaa3ry ❑DersMnfsHOme �NUesinSFim.:ertmg�mmCareFao�ty
❑ Ves � No ❑ Unknv.m ❑ inorJ<nt O E�eC�'oeoarmcnaaacmi � oeaaon.vema� � oa�rlSO�N)
825 NORTH WEST STREET
BRITTINGHAM
� 9wa1 � Lmnwa+ � Dwwn � En:amdxm
❑ r�emv+al From Sp�e
❑ Ves � No
425
❑.Llanietl0 Mamea. dut cros+:ed ❑ Di�arcM I
� WMq.vM ❑ NEVtt MamGC ❑ Unknwm
� Yes ❑ No
FH83005671
--� Gause Of Dw[h (See Inswctions AM Ezam0�es) Approxima:e
29. Pan I. Enter TTe Cnain Of Evenu - Diseazn, Iryunes, Or CompGwoms - That DirecUy CauseE Tiie Deafi. Do Not Emu Temtlnal Evenu Imer21: Oiuet
Sucn As CarEiac Mest Respvatory Mesl. Or Ven(MWar Fibnllatim W J�out SM1Vxing T�e Etidogy. Do Not AEMeviate. Enler ONy One Caise On To OeaN
A Line. A04 AaCitinal Lines If Neceuary.
ImmeCia:e Cauze (Fmel Disease Or Contli4m ResWting In Dea',h) A HYPoXEMIA - u $EYERAL HOUF
Secuenua0y List Contli�ms. If My. Leaaing To Tne Cause Listea On B. ?�EURAL EFFUSION e•�e SEVERA� YEAa
line A. Enter The Weefy'ug Cause (Disease Or Injury Ttut Irii•va:e0
P.x Even6 Rrsultvg In DeaN) lasl C. CNRONIC OBSiRUCTIVE PULM.ONARY DISEASE SEVERAL YEAP
•� ••• SEVERAL
9. PROTEIN AMLNUTftfiION MONTHS
r.Y_sterONCSUnf.hanlCOMi�M3S:_P1�C�?�NIXe��l.:nglni:eU.MelyvgCauseGiwilnPanl 29.WmMAVSpSYPUfameG? nYes 1�N0
p v< ❑ Prmadr � no p u�ww«n
(7/OS)
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I�lranwuana�.vu+n=m=��e.e.�w ❑ur��Aw�w�.�:i.n.�r.. ❑SUtl0e0Cad]NceBeOeas:unec
410
iTe SodalSewnty=ls De.'g
❑ Ye5 ❑ No
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47670
Oy Vus sta:e agenty in onler to pursue re5pwi5iD&ly. Distlosure is voluniary aM inere wui ce r.o penary �x �c��x�.