Death Certificate - Riley, Robert_3/26/2013 't I I 1 r 1 1 5 , 1 ]• , 1 1 1 ' 1
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%- Local No 000013 --• '•EDR No'000000303288 -State No 004088 -_ A'
1.Deaaerts Legal Name(Fest.Made.Last) . -tai Mateo Name 81 lamb).=,., . : .. 2.'Ses .- -3..Tme01DeaelT- :,_Dora a Dec;(Woad: Aaytteag,; t
ROBERT D RILEY-• MALE • 03:55 PM - 01/22/2013
- •
0 Hospice=:.'3t1•C. 0 Decdenfs Hare 0 Mirshg Hcme&rq-Inn Care Racily .
0 Yes 0 No 0 Unknown- 0 L'ya,em 0 EmergencyDepannen1Oursem 0 Deal an Arai 0 O.:er(So;c8it •
11.Facet'Name(II.Nat Intl^An,Give Street asa Numoer) - ,`
GIBSON GENERAL HOSPITAL • . .. . -
12.CayCr roan.Stabs.AnaZip Cole 13.Canty Of pews •..... 14. Mxml Stan Al Time Of Dens
PRINCETON. IN, 47670. GIBSON - 13 � Never 5 � Oa
0 13 Mameda ❑Ne !lamed ❑ otnt
15.Sun/or-no Spouse's Name I` .1(If Wee$3we Mach Last Name 16. De-ecerrs Usual OCNCin n t).{ie C.Buest. aao'y
• ,' FACTORY WORKER MANUFACTURING
18.Reseexe-State 18i Casty 188.CoywTCm
INDIANA IGIBSON PRINCETON
18c, Saes Ma Numoes :lb. Apt Na 1 16e. Zo Coale 1 tel.Lmce CY t4rtla?
701 NORTH HALL STREET 47670 Yes 0 No I
19. OeRaers ECucason 20. Decedent Cf:npaue Ong 21. Cececenrs Race
8TH GRADE OR LESS NOT HISPANIC White
22.=r:.ers Name(First.Mace.Last) 23.Mowers Name(First'Woe.Last) 23a.:.bmee!faxed Last.Varre
ALBERT RILEY BESSIE RUTH RILEY ADKINS
24.Intnnants Name 24a.Reasonsso To Cececent 240.llalrg:caess(Sweet Ana Mamie.Coy.Stare.Li Gee)
LISA KEY DAUGHTER 920 NORTH HART STREET. PRINCETON. IN 47670 .
I 25.Axe Cf Csoosnw: I
25a-:•e:m CI C.socvten 25o.a ace Cl Csommon(Name Cl Cemetery.Crematory.Ore r?acel 125c.'_ocaton-C.y.town.Ara Stale
-2 Sinai ❑Cremation 0 Sonata,0-^:omorne t
0 Removal From State
0 Cv:e(SreCy): COLUMBIA WHITE CHURCH CEMETERY PRINCETON, IN
26.Was Caener Comacec? 27. Name Arc Carnage Access OI Funea Faekty 27a Furst Mere Lxeme tMttoec
u Yes 0 No I COLVIN FUNERAL HOME INC.425 N MAIN ST.. PRINCETON. IN 47670 FH83005671
225. Signature Cl Insane Funeral Service Licensee: 74. e tense Numo 10t L xensttK
JOHN W WELLS . BY ELECTRONIC SIGNATURE IF001009940
Cause 01 Death )See Instructions And Examples) AP:fa:ma;e
22.737 I.Enter The C`a:n C 5ve••,' -Diseases.Irjunes.Cr Comoticatons•that Care ay Cause:The Deem.Co Not Enter iermmal E.:ens Imervac Onset
Suon As Garcia:Arrest.R?s^iracv Arrest.Cr Ven:norar F.. accr.LY.:.^.ou:Shay.ny The ECaocy.Co Not A.:.re,ate.Enter Cmv Gn_Cause Cr. To Gar.
Ir.-917. :c_7.Co:Una!LS-.es !Necessar:.
i Ir.r,eaiaeCeuse(Firal Disease C:C.ar.c:SOn Resu:•rs7.:ame3m) A. %ESPIRATCNY--ILURE !.1C:17-ri3
I c ru Lis: oers. ase Leaan'si se Cause
.. CHRONIC C?STRUCTNE PUL:ONARY._®IS'EAS , ._) YEARS
e A. E^ro r The e U : yvy Cause 1DiSeasx Cr:;ur,T-aU-:Dareo
I The E,en:s nesteYS Li Dean)Las: C.
ii - erS'r.cur•._°-f.CSC------ ----->-.EC.:IC F4.7.tr 77:4 U-:-x--Cat^.G-e-.r.=-^.1 29. .-l.._v=e-rec. .
=44.1 4.l._ a ,•.
. were Au=u-s.:.�.rg Antate to Cemr.ete The Ga.4e L!Des.
!PULMONARY FISRGS IS.VA S To Crc.. . Ores _Inc
i21. }c T=eas Use C- ..L , _esA I 32. -Fa.-ore - 33. 'tanner C.Cent
T-i Y^s ]R.-.icon 0 No i vawa..»w 4..0 0>-s.v.,:.,.c_» 0"4444-r•.a s.++v.•-4444...._...r....e IF]c natal[I Hormone 0 Acxem 0 Perim,Ln,es asn
- ❑ .+. - ❑Suoce-Coma Oa 3e Cem-ec
34. an Cr inryn(Man:•-Dayrearl I 4.5. true 01 awry :36. ?!ace C!Inpeyt=..Decedents-.wre.Cr.smxsn Ste..es2.rant.loocea Area( 7.:r4ev at wee?
I i , 0 Yes 0 Na
25.lc ton C11.-Fay-6mte I ;Ea c.6o Cr 774n I leo. Street 6 r.earaer 33c. Att NO. 364. Lo Cow
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139. =eaace 7-4.w I(p.ry Oceania 3Q.Ii:ransatatcn lr{ry.Steo.y .5444.o
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41. Sgnatre•Cl Person Centric Cave CI Dent. 42.Ceer(Gee Only One)
RAMESHBHAI P PATEL , BY ELECTRONIC SIGNATURE I r•...
0 Cen.:jag Phys.ca, 0 cane .0 Net OSv
43. Name.Maass Ara rap Cope Of Peso.Ca/'n Cause CI.Oett. 44.License Number ' 45.Dar Ceram
•- RAMESHBHAI P PATEL , 535 VAIL ST., PRINCETON, IN 47670 01040266A I 01252013
46.Aosto al Funeral Sews Provider. ` 47. 'Ala
48. Sgraue at Local Mena OCSOer. 49. For Registrar Only -Oar Fee:(MatVDay(Yea;
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE i JAN 28 2013
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
4n .. _ _ -.
;'Stare I om)53395 ATtEENT10N ESTATE:The Social Seorrty a o being requested oy tons state agency in order to pursue respaysibiliy. Disclosure is voluntary and mere wiel be no penalty for ralnaL :4.x
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