Death Certificate - Parker, Kenneth A Jr_6/24/2013 •r.,° INDIANAS ED-113 - 896761
cc' .i , CERTIFICATE OF DEATH
4 / Local No 000228 EDR'No 000000295009 State No 055533
' 1.Decedents Legal Name(First Saddle.Last) -'Ia. Maiden Name Of female) 2.Sea 3. Tune Of Death 4.Data 01 Death(SbrMUDayrYear)
KENNETH ARTHUR PARKER JR. 1 - . MALE 04:40 AM 12/13/2012
hospital
0 Hospice FaciLty 0 Decedents Home 0 Nursing Hdme,Laytetm Care Fatty
0 Yes 0 No 0 Unknown 0 Inoa:ent 0 Emergency Determent Outhatent 0 Dead on Arrival D Other(Specify)
11.Fealty Name(If Nor last:tat,Give Steed and Number)
104 NORTH WALTERS STREET
12.City Or Town.Sias.And Zip Code 13.County Of Dean 14. Mantel Stn Al Time Of Dean
0 Mamed 0 Madded,But Separated 0 Divorcee
FORT BRANCH, IN,47648 GIBSON D Wit wed 0 Never Mamed D Unknown
15. Staving Spouse's Name 15a. (If W.fe)Give Maiden Last Name 16. Decedents Usual Occupation 17. KAM Of Bustne sflndtmty
DEEANN M.PARKER SCHMITS SUPERVISOR STEEL INDUSTRY
18.Residence-State 18a. Carry 180.City Or TOrm
INDIANA _ GIBSON FORT BRANCH
18c.Street And Number 18d. Apt.No. 18e no Code 181. Inside City Limas?
104 NORTH WALTERS STREET 47648 0 Y« 0 No
19. Decedents Educabm 20.Decedent Ofl4tpauc Orgn 21. Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Fathers Name(First.Middle,Last) 23.Mothers Name(First Middle.Last) 23a Mother's Maiden last Name
KENNETH ARTHUR PARKER Sr. DONNA PARKER INGRAM
24.L fomant's Name 24a.Retatonstup To Decedent 24b.Wang Address(Street And Number,City,Sale,Zip Code)
DEEANN PARKER SPOUSE 104 NORTH WALTERS STREET, FORT BRANCH, IN 47648
25.Place Of Deposition
25a.method Of Depositor _ 250.Place Of Dis-aiton(Name Of Cemetery,Crematory,Other Race) 25c.Location-Cit.Tom.And State
El Burial 0 Cremation 0 Dona:on 0 Entombment
0 Removal From Sate -
0 other(Sited)* WALNUT HILL CEMETERY FORT BRANCH, IN
26.Was Carver Contacted? 27. Name And Complete Address Of Funeral Facility - 27a. Funeral Horne License Number
0 Yes ®No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671
•
270. Signature Of Indiana Funeral Service Licensee: 27c. License Number(Of Ucenseep
RICHARD DEAN HICKROD, BY ELECTRONIC SIGNATURE FD01012153
- Cause Of Death (See Instructions And Examples) Approximate
28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Combinations-That Directly Caused The Death.Do Not Enter Terminal Events Interval:Onset
Such As Cardiac Arrest Respiratory Arrest Or VertnMar Fibnla:it.Without Snowing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Addi,inal lines If Necessary.
Immediate Cause(Final Disease Or Conduce Resulting In Death) A. METASTATIC CARCINOMA OF UNKNOWN PRIMARY 17 MONTHS
• ul.4.4 .caw.
Sequentially List Conditions, If Any.Leading To The Cause Listed On B. p.0 ta A.Acon..a,.e on
line A. Enter The Undel3 ng Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last C.
Dn iv Me A.A ca.a.aw D9
D.
Pan II.Enter Other Svnhant Gadi3bns Cot- -tea to Dealt But Na Restate In The Underlying C.P,v.Gisin In Pan I 29.was An Autopsy Performed? Yes 0 No
30.were Autopsy Fidvg Available To Complete The Come Of Deer-? 0 Yes 0 No
31.Del Tobacoo Use Conthbt:e To Dean? 32. If Female: 33. Maier Of Dean:
❑Y« ❑Probably®No❑Unknown D wen.a.wwt..e..r.. D r....4.,r...or D..., 0 sot Per..NA ev.7.8 we.,.2 D.,.a own 0 Nadtral 0 Homicide 0 Accident 0 Pending lmsogaoon
❑wtn.a..e..P„.a..0.3 D..T.,,.,ew.b... 0 ire...,if Penvw..,n..e.., 0 Suicide 0 Could Not Be Determiner]
34.Date Of bury(MaMT/Day/Year) 35. Tone Of Injury 36. Race Of Injury(E.G.,Decedent's Home,Construction Site.Restaurant Wooded Area) 37. Injury At Woo?
0 Yes 0 No
38.Location Of Injury•State 38a. City Or Town 380. Sweet 8 Number 38c. Apt No. 38d. Zip Code
39. Deseret Mow Injury Occurred - 40-If Trans:cc: en Injury, Y
00nnOwec D.....,. Doe-ne- ,s
41.Signamue,•O'Person Cettfydg Case Of Death: - - - 42. Center(Check Only One) -
MICHAEL LOUIS TITZER ,BY ELECTRONIC SIGNATURE 0 Centying Physician 0 Coroner 0 Heat Officer
43.Name,Address And Zip Code Of Person Certfyng Case Of Death: 44.License Number 45.WY Cer6ed
MICHAEL LOUIS TITZER , 3699 EPWORTH ROAD,NEWBURGH, IN 47630 01041826A 12/17/2012
46.Add:tonal Funeral Service Provider - - 47. 'Akas:
48.Signature e of Loin heath Otter: 49. For Registrar Only -Data Fdec(MantNOayfYetl
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE DEC 17 2012
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
td-S,to Fon,
,�?0 Say.e��Fgqa l 53395 ATTENTION ESTATE:The Social Sewnry u a being requested by this state agency in order to pursue r«pmsibiliry_ Disclosure is voluntary and there veil be no penalty for refusal.
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