Death Certificate - Wagner, Richard Lincoln_11/21/2011634323
CERTIFICATE OF DEATH
No OOOZOt3 EDR No UUUUUULL�Jb4y State No
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❑ Mosdce:aaTM ❑ oecea�rs Mm�e � ruu�vna nmr/LwpMm care Fae�ry
❑ Yes � No � Unkno.m ❑ �roauent � EmcgmryDepartmentOuyaoem 0 Deaa«�/�mva� � ppial5�yy)
11. FaoSry Nam� (It Nd 4rsG•v]an. GivG Sbcet an0 Numper)
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� Ves � No
SOUTH WALTERS STREET q7gqg
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H SCHOOL GRADUATE OR GED
ADI FTFfI NOT HISPANIC White
�&rul Q Crematlon Q Oma�on � EnNmOmenl
❑ Renwal Fmn State
n onv �soe�t ST
❑ res � t+o COLVIN FUNERAL HOME INC, 425 N MAIN ST., PRINCETON, IN 47670 FH83005671
]C. SgnayreOflntiaiuFUneral5eniceLicensee: 11c. LksuNUmDerla�K��s"ek
'ICHARD DEAN HICKROD BY ELECTRONIC SIGNATURE FD01072153
Cauae OI Omt� (Sea Irntr�ctbns AnC Exampld) Approximate
28. Pan I. Enrer Rre Cha� Of Events - Oiseases. hyuna. Or ComWiwtions - Tliat Oveaty CauseO TTe DeaR�. Do Not Enter Terminal Events N:eval: Omet
SwY� As CarCiac Mest, Rrsp'va;ory Mest Or Vemvicular FiEnOaum W rtiwt SnoMng T1ia EUdogy. Do Na ADOre�.iate. Enter ONy One Cauce On To DraVf
A Line. PAE AEtliJnal Lines H NecPSxary.
Inmeaid:e Cause (FinalOisease Or CwiCitim ResJ.Ung In Deatn) /. /CUTE CARDIAC ARREST e MINUiES
SeQUentuAy List Canaitiaa. H My. L+aain9 To Ttie Caise Listee On B' ,
L'me A. Enter The UMalyvfg Cause (Disease Or 4y�vy itia� 4J:ia:eE e� �
Ttx EvenS RcsW.in91n DeaN) Last C.
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31. GO iaexm Use Canzidee To DeaY�i 32. If Fueule: 31. Alarna Of �exh:
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NRA-20
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