Aff - Jones, John Denver_7/23/2013 •
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3%2)
STATE OF INDIANA
5S:
COUNTY OF GIBSON
TRANSFER-ON-DEATH AFFIDAVIT
John J.Jones (the "affiant"), being first duly sworn upon his oath, deposes and says that:
1. The affiant has personal knowledge of all matters contained herein and is in all other respects competent
to testify as to such matters.
} 2. John Denver-Jones(the"Owner")died a resident of Gibson County,Indiana,on May 7,2013. A certified copy
.r.
of his death certificate is attached hereto and made a part hereof.
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j, 3. The Owner had an interest in the following described parcels of real estate and mineral interests located
in Gibson County, Indiana,to wit:
PARCEL I
A part of Militia Donation Number One Hundred Seventeen (117),Township One(1)South, Range Ten(10)
West, described as follows:
Begin at a stone at the Southwest corner of said Militia Donation, run thence North,Seven (7)degrees East
along the West line thereof Nine Hundred and Twenty and Six Tenths (920.6)feet to an iron;thence South
Eighty-three (83) degrees East Seventeen Hundred and Seventeen (1717) feet to the East line thereof;
thence South Seven (7) degrees West Nine Hundred and Eighteen and Six Tenths (918.6) feet to the
Southeast corner thereof;thence North Eighty-three(83)degrees West Seventeen Hundred Twenty-three
(1723) feet to the place of beginning and containing thirty-six(36) acres, more or less.
ALSO, a part of Militia Donation One Hundred Seventeen (117), Township One (1) South, Range Ten (10)
West, bounded as follows:
Begin at a stone in the Northwest corner of said Militia Donation and run thence South, Eighty-three (83)
degrees East, along the North line of said Donation Seven Hundred Seventy-nine (779)feet; thence South,
Seven (7)degrees West, parallel with the West line thereof,Seventeen Hundred and Eighty-nine and Four
Tenths(1789.4)feet to a stone;thence North, Eighty-three(83)degrees West, parallel with the North line
thereof, Seven Hundred and Eighty-five (785)feet to an iron in the West line thereof; thence North Seven
(7)degrees East, along the West line, to the place of beginning, containing thirty-one (31) acres, more or
less.
FILED
JUL 2.3 2013
GIBSON COUNTY AUDITOR
PARCEL II
Part of Lot 6 in Fractional Section 1, Township 1 South, Range 10 West, and described as follows:
Begin at a point in the West line of said Lot Two Hundred Twenty-six(226)feet South Six and One-half(6'A)
degrees West from the Northwest corner thereof, and from said point run East Two Hundred Seven (207)
feet; thence South Three (3) degrees West One Hundred Twenty-nine (129) feet to an iron; thence South
Seventy-three(73)degrees East One Hundred Seventy-one and Two Tenths(171.2)feet to an iron;thence
South Eighteen (18)degrees Forty-five (45)minutes West Five Hundred Ninety-six (596)feet an iron in the
center of the Buena Vista Road;thence along said road North Thirty-four(34)degrees Fifty-five(55)minutes
East Three Hundred Sixty-two(362)feet;thence South Eighty(80)degrees Thirty-six(36)minutes East One
Hundred Thirty-eight (138) feet to an iron in the East line of said Lot, Six Hundred Ninety-two (692) feet
South of the Northeast corner thereof; thence South Six Hundred Fifty-two and Forty-two Hundredths
(652.42)feet to the Southeast corner thereof;thence West Six Hundred Forty-three and Five Tenths(643.5)
feet to the Southwest corner thereof; thence North to the place of beginning, EXCEPT the following
described part thereof. Begin at the Southwest corner of said Lot 6, and run thence East Eighty-two and
One-half(82'A)feet to the Buena Vista Road;thence North along said road about Two Hundred Forty-seven
and Five Tenths(247.5)feet;thence West to Shawhan's Lane (the West line of said Lot 6);thence South to
the beginning and containing.50 of an acre,more or less,and containing exclusive of said exception Eleven
and Sixty-four Hundredths (11.64) acres, more or less.
AND FURTHER EXCEPTING THEREOF part of Lot 6 in Fractional Section 1,Township 1 South,Range 10 West
in Washington Township, Gibson County, Indiana, and more particularly described as follows:
Beginning at an iron in the East line of Militia Donation#123,Township 1 South, Range 10 West, North Six
degrees East (N 6° E) Four Hundred Eight and Thirty-five Hundredths (408.35) feet from a stone at the
Northwest corner of the South Half of the South Half of said Fractional Section and from said place of
beginning run thence South Eighty-four degrees East (S 84° E) Two Hundred Twenty-four and Fifteen
Hundredths (224.15) feet to an iron in the West fence line of a County Road; thence continuing on said
bearing Twenty-seven and Ten Hundredths(27.10)feet to a 5/8 inch iron in the center of a blacktop County
Road; thence South Twenty-nine degrees West (S 29° W) along the centerline of said road Two Hundred
Thirteen and Forty-Hundredths(213.40)feet to a 5/8 inch iron;thence North Eighty-four(84)degrees West
(N 84° W)Twenty-four and Twenty Hundredths(20.24) feet to an iron in the West fence line of said road;
thence continuing along the same bearing One Hundred Forty-six and Zero Hundredths(146.00)feet to an
iron in the West line of said Lot#6;thence North Six degrees East(N 6°E)along the West line of said Lot and
the East line of said Militia Donation#123, One Hundred Eighty-seven and Thirty-five Hundredths(187.35)
feet to the place of beginning and containing 0.9063 acres.
PARCEL III
A part of Militia Donation Number One Hundred Fifteen (115), Township One (1) South, Range Ten (10)
West, bounded as follows:
Beginning at a stone at the Southwest corner of said Militia Donation and running thence North,Seven(7)
degrees East,along the West line thereof 19 chains and 9 links thence South, Eighty-two(82)degrees East,
11 chains and 74 links to a ravine commonly known as Goose Creek; thence down said ravine with the
meanderings thereof in a Southwesterly direction to a point where said ravine crosses the South line of said
Militia Donation;thence North, Eighty-three and One-half(83'A)degrees West,along the South line of said
Militia Donation 2 chains,more or less,to the place of beginning,containing eleven(11)acres,more or less,
subject to a right-of-way Fifteen (15) feet in width along the south side thereof.
.Z.
ALSO, a part of Militia Donation Number One Hundred Fifteen (115),Township One (1) North, Range Ten
(10)West, bounded as follows:
Begin in the West line of said Militia Donation One Hundred Fifteen (115) at a point 19 chains and 9 links
from the Southwest corner thereof and run thence North,Seven (7)degrees East, 14 chains and 88 links to
a stone in the West line; thence South, Eighty-two (82)degrees East, 19 chains and 82 links to a stone in a
ravine;thence down said ravine South,Thirty-five(35)degrees and Thirty(30)minutes West,16 chains and
75 links;more or less,to a stake;thence North, Eighty-two(82)degrees West, 11 chains and 74 links to the
place of beginning, containing Twenty-three and Forty-eight One-Hundredths (23.48) acres, more or less.
ALSO,part of Militia Donation Number One Hundred Fifteen(115),Township One(1)North, Range Ten(10)
West, described as follows:
Begin at a point which may be located by running South Six(6) degrees West Two Hundred Forty and Two
Tenths (240.2) feet;thence North Eighty-two (82)degrees West Two Hundred Thirty-six and Three Tenths
(236.3)feet,and from said point of beginning run thence South Eight and Three-fourths(8'%<)degrees West
Thirteen Hundred Twenty-two (1322) feet; thence North Eighty-four (84) degrees West Two Hundred
Twenty-four and Eight Tenths (224.8) feet; thence North Eight and Three-fourths (8 %) degrees East Ten
Hundred Forty-eight (1048) feet; thence North Twenty-seven (27) degrees Fifty (50) minutes East Two
Hundred Ninety-one and Five Tenths(291.5)feet;thence South Eighty-two(82)degrees East One Hundred
Thirty-one(131)feet to the place of beginning,and containing Six and One-fourth(6%)acres, more or less,
and being the lands set off to Dora Degenhart in a certain partition proceeding recorded in Civil Order
Book#86 at page 200 of the office of the Clerk of the Gibson Circuit Court.
PARCEL IV
A life estate interest in and to all coal, oil, gas and other minerals underlying a part of Militia Donation
Number One Hundred Twenty-three (123), Township One (1) South, Range Ten (10) West, described as
follows, to wit:
Beginning at a point in the East line of said Militia Donation #123,which said point is North Six(6)degrees
East One Thousand Eighty(1080)feet from a stone at the Northwest corner of the South Half of the South
Half of Fractional Section One (1) in said township and range, and from said beginning point run thence
South Six(6)degrees West Six Hundred Seventy-one and Sixty-five Hundredths(671.65)feet;thence North
Eighty-four (84) degrees West Seven Hundred Sixty-one and Five Tenths (761.5) feet to a stone; thence
South Six(6)degrees West Sixty-one and Six Tenths(61.6)feet to a stone;thence in a Westerly direction to
a point in the West line of said Militia Donation#123,which point is North Six(6)degrees East Five Hundred
Twenty-two and Two Tenths(522.2)feet from the Southwest corner of said Militia Donation#123;thence
North Six(6) degrees East along said West line Eight Hundred Seven and Eight Tenths (807.8)feet;thence
in an Easterly direction One Thousand Six Hundred Ninety-one and Five Tenths (1691.5) feet to the point
of beginning, containing Twenty-eight and Ninety-five (28.95) acres, more or less.
EXCEPT Commence at the Southwest corner of Lot Six(6)in Section One(1),Township One(1)South,Range
Ten (10) West and measure North Six (6) degrees Thirty (30) minutes East, along the East line of Militia
Location 123, a distance of One Thousand One Hundred Twenty-four and Ten Hundredths (1124.10) feet
to a 5/8 inch iron found;thence measure North Eighty-one(81)degrees Twenty-seven(27)minutes Twenty
(20)seconds West, a distance of Five Hundred Nine and Sixty-four Hundredths (509.64) feet to a 5/8 inch
iron set at the TRUE POINT OF BEGINNING; thence measure North Eighty-one (81) degrees Twenty-seven
(27) minutes Twenty (20) seconds West, a distance of Three Hundred Three and Forty-nine Hundredths
(303.49) feet to a sucker rod set; thence measure South Eight (8) degrees Thirty-two minutes Forty (40)
seconds West,a distance of One Hundred Forty-three and Fifty-three Hundredths(143.53)feet to a sucker
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rod set; thence measure South Eighty-one (81)degrees Twenty-seven Minutes Twenty (20) seconds East,
a distance of Three Hundred Three and Forty-nine Hundredths (303.49) feet to a 5/8 inch iron set;thence
measure North Eight(8)degrees Thirty-two(32)minutes Forty(40)seconds East,a distance of One Hundred
Forty-three and Fifty-three Hundredths(143.53)feet to the point of beginning and containing 1.000 acres.
The above tract also includes a driveway and utility easement Fifteen (15)feet in width and the center line
is described as follows:
Commence at the Southwest corner of Lot Six(6)in Section One(1),Township One(1)South,Range Ten(10)
West and measure North Six(6)degrees Thirty(30)minutes East,along the East line of Militia Donation 123,
a distance of One Thousand One Hundred Twenty-four and Ten Hundredths(1124.10)feet to an iron found;
thence measure North Eighty-one (81) degrees Twenty-seven (27) minutes Twenty (20) seconds West, a
distance of Five Hundred Nine and Sixty-four Hundredths (509.64) feet to a 5/8 inch iron set; thence
measure South Eight (8) degrees Thirty-two (32) minutes Forty (40) seconds West, a distance of One
Hundred Eight and Fifty-three Hundredths (108.53)feet to the point of beginning; thence measure South
Seventy-five(75)degrees Nine(09)minutes Fifty-three(53)seconds East,a distance of Two Hundred Eighty-
three and Eighty-seven Hundredths(283.87)feet;thence measure South Sixty-three(63)degrees Thirty-six
(36) Minutes Thirty-eight (38) seconds East, a distance of One Hundred Fifty-eight and Forty Hundredths
(158.40) feet; thence measure South Seventy-nine (79) degrees Forty-one (41) minutes Twenty-six (26)
seconds East, a distance of One Hundred Ninety-two and Eighty-three Hundredths (192.83) feet; thence
measure South Fifty-seven (57)degrees Forty-five (45) minutes Thirty-five (35) seconds East, a distance of
Forty and Forty-seven Hundredths(40.47)feet;thence measure South Twenty-two(22)degrees Twelve(12)
minutes Six (06) seconds East, a distance of Thirty-one and Twenty-six Hundredths (31.26) feet; thence
measure South Seven (7)degrees Twenty-three(23) minutes Four(04) seconds East, a distance of Ninety-
one and Fifty-five Hundredths(91.55)feet;thence measure South Two(2)degrees Forty-three(43)minutes
Thirty-one(31)seconds East, a distance of One Hundred Eighty-one and Twenty-five Hundredths(181.25)
feet; thence measure South Seven (7) degrees Nineteen (19) minutes Seven (07) seconds East, a distance
of One Hundred Thirty-three and Sixty-six Hundredths(133.66)feet;thence measure South Forty-seven(47)
degrees Thirty-six (36) Minutes Seventeen (17) seconds East, a distance of Thirty-eight and Twenty-eight
Hundredths (38.28) feet and thus terminating in the center of a county road.
ALSO,a part of Militia Donation Number One Hundred Twenty-three(123),Township One(1)South,Range
Ten (10) West, described as follows:
Beginning at the Northeast corner of said Militia Donation and running thence South Six (6) degrees West
Eighteen (18) chains and Eighty (80) links; thence North Eighty-four (84) degrees West to the line of said
Militia Donation; thence North Six(6)degrees East to the Northwest corner thereof; thence South Eighty-
four(84) degrees East to the place of beginning, containing Forty-seven (47)acres, more or less.
ALSO a part of Militia Donation Number One Hundred Twenty-three(123),Township One(1)South, Range
Ten (10) West, described as follows, to wit:
Beginning at a stone which is North Six(6)degrees East Three Hundred Forty-six and Seven Tenths(346.7)
feet and North Eighty-four(84) degrees West Seven Hundred Sixty-one and Five Tenths (761.5) feet from
a stone at the Northwest corner of the South Half of the South Half of Fractional Section One (1), and run
thence South Six(6)degrees West Two Hundred Seventy-five and Seventy-five Hundredths(275.75)feet to
a stone; thence North Eighty-four(84) degrees West Nine Hundred Twenty-three and Five Tenths (923.5)
feet to a point in the West line of said Militia Donation One Hundred Seventy-nine (179) feet North Six(6)
degrees East from a stone at the Southwest corner of said Militia Donation #123; thence North Six (6)
degrees East along said West line Three Hundred Forty-three and Two Tenths (343.2) feet; thence in an
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Easterly direction Nine Hundred Twenty-three and Six Tenths (923.6)feet to the beginning, containing Six
and Fifty-six Hundredths (6.56) acres, more or less.
PARCEL V
Militia Donation Number One Hundred Twenty-four(124);
Militia Donation Number One Hundred Fifteen (115);
Militia Donation No. 98;
Militia Donation 110;
Militia Donation 123;
Militia Donation 117;
Fractional Section 1,Township 1 South, Range 11 West;
Fractional Section 1,Township 1 South, Range 10 West; and
Fractional Section 6,Township 1 South, Range 10 West.
PARCEL VI
A part of Militia Donation Number One Hundred Twenty-four(124)and One Hundred Fifteen(115)described
as follows, to-wit
Beginning at a point in the South line of Militia Donation Number One Hundred Fifteen(115),twenty-three
(23)chains and thirty-two(32)links North,eighty-four(84) degrees West,of the Southeast corner thereof
and running South, eighty-four(84)degrees East, along the south lines of Militia Donations Numbers One
Hundred Fifteen(115)and One Hundred Twenty-four(124),thirty-two(32)chains and seventeen(17)links
to a point in the South line of Militia Donation Number One Hundred Twenty-four(124),which point is eight
(8)chains and eighty-five (85) links from the Southwest corner of Militia Donation Number One Hundred
Twenty-four (124), and running thence North, six (6) degrees East, parallel with the West line of Militia
Donation Number One Hundred Twenty-four(124),fifteen(15)chains and sixty-six(66)links;thence North,
eighty-four (84) degrees West, parallel with the south lines of Militia Donations Numbers One Hundred
Twenty-four(124)and One Hundred Fifteen(115),twenty-four(24)chains and seventy-five(75)links,more
or less, to a ravine; thence down said ravine along the now established line to the place of beginning, said
to contain Forty-four and Fifty-seven Hundredths (44.57) acres, more or less.
Also,a right-of-way, its East line beginning at the Northeast corner of the above described tract of land and
running thence North six (6) degrees East, parallel with the West line of Militia Donations Number One
Hundred Twenty-four (124), thirteen (13) chains and ninety-three (93) links more or less, to a public
highway.
PARCEL VII
Part of Militia Donation Number One Hundred Fifteen(115),Township One(1)North, Range Ten(10)West,
and described as follows: Begin at a point South,Six(6)degrees West,Two Hundred Forty and Twenty-four
One-Hundredths (240.24) feet and North, Eighty-two (82) degrees West, Three Hundred Sixty-seven and
Three Tenths(367.3)feet from the Northeast corner of said Militia Donation Number One Hundred Fifteen
(115),and from said beginning point run thence South,Twenty-seven(27)degrees Fifty(50)minutes West,
Two Hundred Ninety-one and Five-Tenths(291.5)feet thence South,Eight and Three-fourths(83/4)degrees
West One Thousand Forty-eight (1048) feet thence North, Eighty-four (84) degrees West Six Hundred
Sixty-eight and Six-Tenths (668.6)feet to a ravine;thence up said ravine in a northeasterly direction along
the now established line to a point Twenty-six and Seven Tenths(26.7)feet South, Eighty-two(82)degrees
East Twenty-six and Seven Tenths(26.7)feet to the place of beginning,said to contain eight(8)acres,more
or less.
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ALSO,part of Militia Donations One Hundred Fifteen (115) and One Hundred Twenty-four(124),Township
One (1) North, Range Ten (10) West, bounded as follows:
Begin at a point on the West line of Militia Donation One Hundred Twenty-four (124), 240.24 feet South
6 degrees West of the Northwest corner of said Donation and run thence South 84 degrees East 1672.1 feet
to the East line of said Donation;thence South 6 degrees West along the East line of said Donation 857 feet
thence North 84 degrees West 1120 feet; thence South 6 degrees West 481 feet thence North 84 degrees
West 857.5 feet; thence North and parallel to the East line of Militia Donation One Hundred Fifteen (115),
1322 feet;thence South 84 degrees East 236.3 feet to the place of beginning, said to contain Forty-six and
Sixty-two Hundredths (46.62) acres, more or less.
EXCEPTING THEREFROM, a part of Militia Donation One Hundred Twenty-four (124), Township 01 North,
Range 10 West in Gibson County, Indiana, and more particularly described as follows:
Commencing at the Southeast corner of Donation 124;thence North 06 degrees 00 minutes 00 seconds East
along the East line of the said Donation a distance of 1677.56 feet thence north 85 degrees 13 minutes
28 seconds West a distance of 900.43 feet to the point of beginning; thence North 85 degrees 13 minutes
28 seconds West a distance of 200.00 feet;thence North 04 degrees 55 minutes 40 seconds East a distance
of 305.41 feet thence South 83 degrees 06 minutes 01 seconds East a distance of 200.00 feet;thence South
04 degrees 54 minutes 18 seconds West a distance of 298.00 feet to the point of beginning and containing
1.38 acres, more or less.
4. The Owner signed a Transfer on Death Deed on February 17, 2011 ("Deed 1"),to transfer his interest in the
real estate hereinabove described as Parcels I through Parcel IV upon his death,which Deed lwas duly recorded on March 3,
2011, in the office of the Recorder of Gibson County, Indiana, as Instrument No. 201100001210.
5. The Owner signed a Transfer on Death Deed on February 1, 2011 ("Deed 2"),to transfer his interest in the
real estate hereinabove described as Parcel V upon his death,which Deed 2 was duly recorded on March 3,2011,in the office
of the Recorder of Gibson County, Indiana, as Instrument No. 201100001214.
6. The Owner signed a Transfer on Death Deed on February 1, 2011 ("Deed 3"), to transfer his interest in the
real estate hereinabove described as Parcel VI upon his death, which Deed 3 was duly recorded on March 3, 2011, in the
office of the Recorder of Gibson County, Indiana, as Instrument No. 201100001213.
7. The owner signed a Transfer on Death Deed on February 1, 2011 ("Deed 4"), to transfer his interest in the
real estate hereinbove described as Parcel VII upon his death,which Deed 4 was duly recorded on March 3,2011,in the ofice
of the Recorder of Gibson County, Indiana, as Instrument No. 201100001212.
8. The John DenverJones Testamentary Special Needs Trust for the Benefit of Evelyn F.Jones,the designated
primary beneficiary in Deed 1, Deed 2, Deed 3, and Deed 4 did not come into existence because of the death of Evelyn F.
Jones on July 9, 2011. The contingent beneficiaries survived the Owner and their names and addresses are as follows:
John J. Jones Faith K. Clark
1832 Shannon Lane 501 West Church Street
Evansville, Indiana 47725-9006 Haubstadt, Indiana 47639-8116
Timothy P. Jones
6795 North Nixon Road
Hazleton, Indiana 47640-9325
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9. Affiant makes this affidavit to comply with the requirements of I.C. 32-17-14-26(b)(20) to transfer the
Owner's interest in the above-described real estate and mineral interests upon the Owner's death to the designated
contingent beneficiaries in Deed 1, Deed 2, Deed 3, and Deed 4.
AFFIRMED UNDER PENALTIES FOR PERJURY THAT THE FOREGOING REPRESENTATIONS ARE TRUE THIS &1 St—
DAY OF JULY, 2013. 1
//, �� /
tin J.Jones 0 /)
STATE OF INDIANA, County of �tCOYIi(:'C�9u'L.`9�- , SS. `/ (J
Before me,the undersigned,a notary public in and for said county and state,personally appeared John J.Jones,who
acknowledged the execution of the Transfer-On-Death Affidavit to be his voluntary act and deed for the uses and purposes
expressed therein.
WITNESS my hand and notarial seal this�ISf day of July, 2 3.
1 ( tafvt Notary Public
D/A&k: a - kleturr Printed Name
Lid rtd&-/ urrrc7 County of Residence
c1 27-10 My Commission Expires
This instrument was prepared by Randall K.Craig,#3421-82,Attorney at Law,5000 East Virginia Street,Suite 1,Evansville,Indiana 47715-
2642;Telephone: 812/477-3337; Fax: 812/477-3658.
Address of Real Estate: Hazleton, Indiana 47640
Send Tax Duplicates to: John J.Jones, 1832 Shannon Lane, Evansville, Indiana 47725-9006
I affirm,under the penalties for perjury,that I have taken reasonable care to redact each social security number in this document,unless
required by law: Randall K. Craig.
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7.
_ 952207
i . .. ' - INDIANA STATE DEPARTMENT OF HEALTH
/. ') CERTIFICATE OF DEATH
-,La, Local No 000971 EDR No 000000323276 State No 022577
1.Decedents Legal Name(Fist,Middle,Last) • la. Maiden Name (If female) 2.Sea 3. Time Of Death 4. Date Of Death(MordNDayryear)
JOHN DENVER JONES MALE 07:00 PM 05/07/2013
5. Social Security Number 6a.Age-Yrs fib. Under 1 Yea 6c. Under 1 Month Sd. Under 1 Day Be. Under 1 Hour 7. Date of Binh (MontIVDaylYear) B.Birthplace (City and State or Foreign County)
- 99 Maths Days Horns Minutes 01/14/1914 MT OLYMPUS, IN
9 Ever in U.S.Armed Forces? 10.If Death°correct In A Hospdat 10a. II Death Occurred Somewhere Other Than A Hospital
❑Yes 5 No ❑Unknown ❑Irnpt en❑Emergency Department Outhapen S Hospice Fatality 0 Decedent's Home 0 Nursing Home/Long-term Care Fealty
0 Dead on Amval 0 Other(Specify)
11. Facility Name(II Nov Insttr on,Give So-eel and Number)
CHARLIER HOSPICE CENTER
12.City Or Town,State,And Zip Code 13. County Of Death 14. Mantel Status At Tune Of Death
0 Marred 0 Mamed,But Separated 9 Divorced
EVANSVILLE, IN,47715 VANDERBURGH S Vadowed 0 Never Marred 0 Unknown
15. Surviving Spouse's Name 15a. (Ifw:e)Give Maiden Last Name 16. Decedents Usual Mmtup^tion 17. Kind Of Busiress4MUstry
FARMER LIVESTOCK
la. Residence-State lea. Courxy 18b. City Or Town
INDIANA GIBSON MOUNT OLYMPUS
15c. Steel And Number 18d. Apt No. lee. Zip Cade ( 18f. Inside City Cans?
4344 EAST JOHN FORD ROAD ROAD 47640 0 Yes S No
19. Decedents EoLCatot 20. Decedent Of Hispanic Ongin 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 Mothers Malden last Name
JACOB JONES MAUDE JONES COLLINS
24.1 damns Name 24a.Relationship To Decedent 245.Mailing Address (Street And Number,Ciy,State,Zip Code)
FAITH CLARK DAUGHTER 501 WEST CHURCH STREET, HAUBSTADT, IN 47639
25.Place Cf Disposition
25a Method Of Disposmon 25o.Race Of Disposition (Name Of Cemetery,Crematory,Other Place) 25c.Locabon-Cry,Town,And State
5 Bridal 0 Crematgn 0 Donation 0 Entombment
0 Removal From State
0 Other (Specify): SHILOH CEMETERY HAZELTON, IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Faofry 27a. Funeral Home license Number.
❑Yes 0 N DOYLE FUNERAL HOME. 520 S MAIN ST, PRINCETON, IN 47670 FH10400010
27b. Signature Of Imdana Funeral Service licensee: 27c. License Number(Of Licensee):
BARRETT W. DOYLE , BY ELECTRONIC SIGNATURE FD29500009
Cause Ot Death (See Instructions And Examples)
Approximate
On
28.Pan L Enter The Chain R ReOf spiratory Events - s,Or Diseases,e Injuries, ib Or llation athou-That ng The Caused The Not Ab re Do Not Enter Terminal Events To Interval: Onset
Alan As Cardiac Arrest,L Rs If Neces Arrest Or Ventricular Fibnlladon Vflhout Showing The Etiology.Do Not Abbevale.Enter Only One Cause On To Death
A Line. Add Additmal Lines If Necessary.
2 YEARS,5
Immediate Cause(Final Disease Or Gorltlrtian Resulting In Death) A METASTATIC TRANSITIONAL CELL CARCINOMA CoOF ma THE URINARY BLADDER MONTHS
o.mla a.cww.w.we or.
Sequentially List Conditions, If Any,Leading To The Cause Listed On B.
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated ownsaa�.aaw�M
The Events Resulting In Death)Last C
Da.mro a A a,.ew.a ere
D.
Pat II.Enter Other Siovficant Conditions F,onnbttnq to Death But Not Restiang In The Unaerryig Cause Gives In Part I 29. Was An Autopsy Performed? 0 Yes S No
CARDIOMYOPATHY 30. Were Autopsy Finding Avaiade To Complete The Cause Of Death? Gres 0 No
31. Did Tooacor UseCcnthbute 10 Dealt? 32. If Female: 33. Manner Of Death:
❑Yes ❑Probably S No 0 Unknown
0 ra eer..ve.w Pa.Ye., 0 erege t a rat.erbean 0 NN .ww.04 nrer.wvta.,42 one o Date, S Natural 0 Homicide 0 Accident 0 Pendng Investigation
Osee Pwrw.A a7 ewr..neon Tot yea,eau.lean 0 u»,wwa Perwnawr.,m.P..Yea 0 Stidde 0 Cord Not Be Dettemined
34. Date Of Injury(Mo tnDaynear) 35. Time tat Iryury 36. Place Of Injury(E.G.,Decedent's Home,Construction Site,Restaurant,Wooded Area) 37. Injury At WYxk?
0 Yes 0 No
38. Location Of Injury-State 38a. City Or Town 380. Street&Number Sec. Apt No. 38d. Zip Cade
39. Describe How Iryury Occurred 40. II Transportation Specify:
Injury, ev
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41.Signature,Of Person Cenlyig Cause Of Death: 42. Ceniter(Check Only One)
PATRICK C. FLAMION, BY ELECTRONIC SIGNATURE ®eertf,irg physician 0 Coroner 0 Heath Ofscer
43.Name,Address Ara Zip Code Of Person Certyi g Cause Of Deady 44. License Number 45. Date Cer-ted
PATRICK C. FLAMION , 801 ST.MARYS DRIVE# 110 EAST, EVANSVILLE, IN 47714 01027520A 05/13/2013
46.Additional Funeral Service Provider 47. 'Alas'
48. Signature of Local Heath Ottcer. 49. For Registrar Only .Date Fled(Month/Day/Year):
RAYMOND W. NICHOLSON,JR.,VIA ELECTRONIC SIGNATURE MAY 13 2013
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
`a °e
fp Stale Form 53395 ATTENTION ESTATE:The Social Secunty 4 is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary and there will be no penalty for refusal.
j NRA-20
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