Death Certificate - Smith, Betty C_10/24/2012NA S ATE DEPAR
CERTIFICATE OF DEATH
eoR No 000000145932
FEMALE
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85 "'°^� °a� Mp1°' "�"W� 04/28/1925 SULLIVAN, IN
B. Ever In U.S. NnroE Fattsi 10. If Dea� OavrteO N A HrapltaF. 10a. H Oaath OmireE SomewTem ONa Ttian A Xospital
❑ Hosdce FaaSty ❑ Dxe0enl's Hame � Nurs'ug Mme�Lm¢krtn Care Faoiry
❑ ves � r+o ❑ unr„a�„ ❑ i�wa�i 0 e��cyowaru��iamsjem O o�ao�ama p on,g�so�r>
PRINCETON
3752 SOUTH SMITH DRIVE
CHAMBERS
❑ 9uia1 � uenuun, O o«�+ O�:o^�
❑ aeiwm vrom srr.e
❑ omc ISpeayk
26.WaSCamcCanGMOi 21. NameM
❑ Yes � No nnvi c v
ARFiETT W DOYLE SIGNATURE ON FILE I FD29500009
Causa Ot Deat� (S¢¢ InsWCtions AM Ezamplas)
28. Pan I. Entu The Gain 01 Even6 - Useases, Injunes, Or ComD���� - mat Oiredy CausM TTe Dea:h. Do Not Enter Term'vial Even¢
Sut'h As CeNiac Mesl Resp'va:ay Mest Or Ven7icular FibnAa'�im Wi:l�art S�on+ng The Etidogy. Do Not AbNeWate. Enter ONy Ona Ca�sse On
A Line. AEd Atic44nal IJntS H Necessary.
4nmeEata CauSe (FUaI Disease Or Condi;im RrsNC(g In Deatn) A. CEREBRO VASCUL4R ACCIDENT
.i
Sepu�n:aP/ List ConEi:imu. tl My. Leaaing To The Caute ListeO On B' .
line A. Ent2� iTe UMety'vfg Ca�se (Oisease Or Lryury That Irtitia:ea �� �
ina Ewnn ResWlin9 In DeauQ last C.
D. v' •
�yb�rr
❑ �rameo O�. an sewrr.ea � o�vv�
❑ wmowea ❑ r�e�auarnea ❑ wmw..�
a� t). Kvq Of BuuKSNnrnsOy
E HEALTHCARE
❑ Yes � No
Appmdmate
In(cvai: Orttel
To Deat�
Part11.EnMOtlflt � F"'� N� DeaM9�tNdliGSUICnBInIneUMM�W�BLausetamn�nran� �v...m.��..u:walrc��.i�m...� �Y¢5 �No
JIABEfES ITYPERTENSION 30_ Wert Rutapsy Fu�C'vg Fradade To Com0lett Tlfe Cauu Of DeTJ�i � Yg ❑�
31. pC iWacm Use CanmW:a To Dea'J�? 32. If Female: �. �^^g a ce�':
❑ v's ❑ a�madr � w� u�knw.n ❑"°'"v""�•••.••••••• ❑"•°'•••�r.,.ao�.� ❑�«_,.,.-.a.A.P..w.�.�o-,.ao...� � Hayai � Nm.aaae ❑ ncaa�i p vanavq �uyaam
❑raa,.a�.+wn.w��ao.r...��e.e.o.n, ❑•.��an.oww�.,*r.c.+r.. ❑SUidae�COUNNaeeDetemw�ea
N. Da:e OI InNiY (MOnW�aylYear) 35. Tme Of NN�Y 3fi. Place Of NN�Y (E.G.. OeceEenfs Home. Cons•.NCbm Si;e. Restaurant WootleO Rma) 3�. �V��Y At worki
❑ Yes ❑ No
�
1.
NORTH
EONFI
TTe Social
m
repuestW Oy Utls siate agency in eNe* lo W rsue responsiE3ry.
o.'u>su� Qan.l#�hl
Cq[.fIG . ❑ il�11�KGf
Ee no penelry for rNusal.