Death Certificate - Smith, Roy K_12/10/2001GIBSON �UNTY DEPARTMEN�"JF HEALTH
800 S. Prince St.
Princeton, Indiana 47670
812-385-3831
RECORD OF DEATH
THIS IS TO CERTIFY
tkiat according to the records of the Gibson County Department of Health,
M�ii)'i;f �i�h�:ii�:�'1wM�Y�i
Died on 11/06/2001 at 9:30pm
Gibson General Hospital
1808 Sherman Drive
Princeton IN 47670
Age at death . 83 Years
Marital Status: Married
Sex: M
Color: White
Cause of death: Cardiac Arrythmia, Ischemic Heart Disease,
Severe COPD
Signed by: Arun C. Kumar, MD
105 N. 2nd Ave.
Princeton IN 47670
Place of burial Walnut Hill Cemetery
or removal:
Date of burial:
Funeral home:
S E A L
Ft. Branch IN 47648
11/10/2001
Holders Funeral Home of
Gibson County, Inc.
P.O. Box 518
Owensville IN 47665
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Signed by
Gibson County Healt Commissioner
Recorded locally in Book No. 14
6 l � - �o�q9� a�
Princeton, Indiana 11/14/Ol
A ress� Date
Page No. 25 Filed: 11/14/2001
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