Death Certificate - Nelson, Frederick_7/9/2013 HIS.IS AN OFFICIALCOPY OFHECORD-0FDEATH 0RIGINAI:C0RYON FILE AT It/DIANA-STATE DEPARTMENTOEHEALTH,.
r F -. . ... IN1• 1 • ; - • - t i• . 897207•
CERTIFICATE OF DEATH
as Local No 000119 EDR No 000000330526 State No 029650
1.Decedents Legal Name(Fbq IS Last) it Rfden Name(If female) 2.Set 3. Time Of Death 4. Dab Of Death (terxet/Dayfrear)
FREDERICK J NELSON MALE 08:00 PM 06/24/2013
80 Months Days lwa ATSUea
natal
0 Yes 0 No 0 Unknown 0 Inman 0 Emergency DepaMare Outdate 0 De an MPYa a (5 ®DeamYS Non. ❑Nun;Hametapiern Cad,Fa�gr odw
11. Facia Nene 01Not edMdm aid,Cho Street a Number) -
2826 EAST 100 NORTH
12 City Or Twig Sate.Md ip Cade 13.Cant/Of Deal 14. Man Stale Al Tine Of Death
0 Married 0 Marred,But Separated 0 Olwrced
PRINCETON fN,47670 GIBSON 01+1e•T.ed 0 NeserMarbd O Unlearn
15. Suvivbg Spaaaa New 15a (d WdePlw I .IS Name 113. Decedent.LAtsal Occupation 17.lad Of Busetminmmy _
LUCY NELSON KESSLER MAINTENANCE •MANUFACTURING
IS.Residence-Stun lm Cant/ Ira City Or Town
INDIANA GIBSON PRINCETON
lac Street And Narita led.Apt Nat lee iCode fit.Inside City Una -
2826 EAST 100 NORTH 47670 0 Yes ®No
It Decedent%Educam 2.Depdert Of aapant Orlan 21. Dec to Rap
SOME COLLEGE CREDIT, BUT NOT A
DEGREE NOT HISPANIC White
22.Fathers tare(Fine Mme Last) 23.Mother.Nate(Rat.Mme Last) 23..MOMS Maiden Last Nana
.SAMUEL NELSON VELMA NELSON SINKHORN
24.I(dprrrnn Name 24a.Raiment To Decedent 24b.Malang Aden(Street Antietam.City,Sate 71p Cob)
LUCY NELSON WIFE .2826 EAST 100 NORTH,PRINCETON, IN 47670
23 Paw Of(L.aMn
25a.Method Of Capo56m 25n PI> •Of Olspptem(Name Of Cemetery.Crematory,Other Rte) 25c snp5m•Oty.Town,MI Sam
®Buda 0 Oceanian 0 Dann 0 Event
0 Remora Farm State
0 Other(GPatifft FAIRVIEW CEMETERY PRINCETON,IN
29.War Can Cantacted7 27. Nato AM Cnn at Address Of Fan Faring 2aa Funeral Mane License Mmbe;
.0 Yes 0 No COLVIN FUNERAL HOME INC,425 N MAIN ST.,PRINCETON,IN 47670 FH83005671
ran SLlrmtn 01 fan Funeral Sevte Licewe 27c. License .nber(01 Uceoee):
JOHN W WELLS,BY ELECTRONIC SIGNATURE- I MFD01009940
Cane Of Death (See Instructions AM Examples) Approxlmithe
28.Part I.Etch The Gana Evens -Diseases.barn.Or Canpbce5as-That Meaty Caned The Death.Do Nil Enter Terminal E'senb InWenaF. Oyer
Such As Cardiac Mast Rapraay Arrest Or Ventricular Fiadtatlm Want Sllcairlg The Eddogy.Do Not Abbreviate.Esc Orly One Cause On To Death
A Una. Add Manna!Unes If Necessary.
Immeaam Cause(Feel Oeease Or Canon Rating In Death) A. ADENOCARCG1OAV1 GALLBLADDER METASTATIC 8 MON714.9
O. WOO.Atar..rOtt
la & o.•IOrAO,.,.e Os Lne A. E t 1M Underlying ma O Si S Initiated
The Evens ResMOnp At Death)Last C.
O.I.IO N A G a m e r 05
D.
Pala Enter Other B.Iflattatimlatka But Not Rena In The Lldayip Caw Gat In Pan I 29.War M Autry Performed?
0 Yes 0alb
JIRDMC ARREST 30.Wens Autopsy Cane Aut psy Rah;Available To Complete T Ca Of Den 0 Yes ❑No
31.Dd Tabamo Use Contribute To Death? 32. If Femur: 33. Mama Of Death:
❑Yes ❑PabaMy®MM ❑Unknown
0 W n••.•ww.r Y.. a w.ew Nnw.a or a W'.P.4 W new war u D.,.ao.e. 0 Natural 0 M onne 0 Aaided 0 Pm659 bwaegxon
❑WRertuneera Owls Mt vow ban Noilt a use...•Pagrannrilsa n.e.. • 0 Wade 0 Card Net BeDetermined
-
34.Dab Of Iryry(MadNDw t Yea) 39.In 01 flat/ 3e. Rea MAWS(ES.Decededa Hare.Cmntudtn Sun,Restaurant Wands Anal 37.array N Wort?
0Ya 0 N ..
W.Lopton Of Injury-Stab 38a.City Or Town 38n Street a Number 38e -
AplNe 386 no Code
-
39.Desoto Now Iryuy Occund 40. If Tia.ww�mn.ty...
0ow.m..r Lh•w�L7 0001*ned .
Al.Signature,Of Person CerUyIng Caul Of DwlM1 42. Ce (Check( ly One)
ARRY WILLIAM-LUTZ, BY ELECTRONIC SIGNATURE I Odr 0 Castes-ea Physical 0 Came 0 bath Dace
13. Name Ames Mil$Code Of Person Cana Cause Of Oealt 44. License Mat 45.Data Called
ARRY WILLIAM LUTZ ,802 E. OAK ST., FORT BRANCH,IN 47648 01027538A 06/26/2013
IB Addtbnal Funeral Salty Roeder. - 47. 'Ass:
La.Slgumm of Ladd Neat Ofha 49. For Replant Only •Date Feed(McM/VDayflSa7
TRUCE BRINK JR,VIA ELECTRONIC SIGNATURE JUN 27 2013
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
gt9Fnn 1 53395 ATTENTION ESTATE:The Social Security e u bang rtgoated by rids State ageay in order m pursue responsibility. Disclosure Is voluntary and dune MP be no penally for refusal.