Death Certificate - Roach, Roy_2/10/2012
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INDIANA
11097 SALEM LANE
le. oemomrs Eauraoon
�IGH SCHOOL GRADUATE OR GED
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FRIEND
❑ 3we1 � Cremation � Donamn Q EntaMr.wd
❑ Remwal Frvn Sta:e
❑ a.ng iso�nt IEVANSVILLE CREMATORY �EVANSVILLE, IN
21. NarneMCCampCeAWressO(FUna'a�Fad[ry
DUESTERBERG-FREDRICK FUNERAL HOME, INC., 521 VIGO STREET, VINCENNES, IN
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TON
STREET
� Yes ❑ No
❑ raamea O r�. aa seoz�a�a � ona=s
❑ w��a ❑'x.ve.�,�e ❑ ww,w,
❑ ves � No
�ause v� �eam ��ee insv�cewns nna caan+a�gl ApG�mdmate
2E. PaM1 I. Enta TTe Chain 0! Events - Diseases.lrquna. Or Camptiwtioris - That dre�ly CauseO TTa Death. Oo Not Entu Temtinal EvmS Intm21: Or�sM
Swl� AS CaNiac Mrsl Rapirerory Art�t. Or VerrtnMar FiOnllatim NiNwt Shvning The EOdogy. Do NW MbeWate. En:er ONy One Ceise On To DraUi
A Line. AEE AtlCitinal Lines I( Necessary.
Im�neEie:e Cause (FU�aI pi5ease Or Corqi4on Rss�L:vg N DeaJi) A CARDIAC ARRYTHMIA SU�DEN
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SeQUenUalty List C«WiUOns. If My, Leatling To The Causa Listetl On B� e�p�.
Line A. En:er The UrWefy'vg fause (Disease Or Iryury That Nitiatetl ,
Rx Evenu ResNling � Oea:�) �� C.
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D.
Pmt II. Enier ONC SA��+�� �� Cms CaninGU'vq to DeaM BN Na ResJ�ng In Tlie lNMCI}4g Cause GMn In Part I Z9. 1Vaz M fw'sp5y PeAamMi � �.g � No
�N 30. Were AutopSy F'eMvg Av2Aade To Comp�ete TTe Cauu OI OleN? � Yes ❑ No
3f. Dq TODacao Use Can�W.e To DeY.J�? 32. it Flmdle: 3i. A1amtl Of Det.t
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II. BY
uViLLIAM C.
BRUCE
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❑ Yes ❑ No
Qaylsc.arl
COfPta . 0 H<Y.'10.:CGl
10
a�-te Fam 53395 q77EMION ESTATE: The Soaal Semr,ry Y is beng repuestetl by Uds siste agercy in wtler ro Wrsue rrsponsibi4ry. Disdosure is udunary a.�tl Nere wT De no penalry ta re4�sa1.
NRA-20
(7/�)
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