Death Certificate - Bass, Harold R_8/23/2013 THIS IS AN OFFICIAL COPY OF RECORD OF DEATH.ORIGINAL COPY ON FILE AT INDIANA STATE DEPARTMENT OF HEALTH C n
y_ • /.1'?' • .,. , • - T - 6 4•
• q,�? CERTIFICATE OF DEATH �(+ <
• Local No 000186 EDR No 000000223388 State No 04 1 O r Y
1.. - • Lee hate(FR Meea let) It Man Nee(e female) 2.Sa 3.Taw 0/BUOY 4.Deo Of Dee(WeiCeree)
HAROLD RICHARD BASS MALE- 11:55 PM 10/09/2011
0 Impo Fade 0 Co nn Ilene 0 Nurse ltcerea iben Care Fame
' 0 Ya 0 No Cl'uomoon 0 es 0'ladle'Mann 04170F4 0 Deap n Mural 0 Dpe(sPeeer)
11.Fac a Nate(E Na teen.GM Stan as Neabe)
GIBSON GENERAL HOSPITAL 4
12 Ca Orton Sa.M,0 210 Oa • 13.Casty Of Dee 14.Meer Slay At lie Cf DIO
• • 3 mane 0 Maap.E MSq>®0 0 Divorced
PRINCETON,IN,47670. •• . GIBSON 0 Weed 0 Neer Mane 0 Nap.m
It Sale;%nee None , 15a.Of Wae)GM Seddon Lae Mn It Dement Usual Ocoee= 17.Kid d ammfa69y
JANE BASS't - COLLINS COMPUTER NETWORKING COMPUTERS
te.Rose n= lea Cosy lm City Or Tee,
, INDIANA - GIBSON OAKLAND CITY
Is.Seer And enter - tea AU.Na the.Zip Coe - 19L tree Oty Lantz?
• 5128 SOUTH LINCOLN 47660 0 Yes ®No
• to Deaden Sumba a Maxie d tic Oe n 21.Dasee,n Race
ASSOCIATE DEGREE(M,AS) ' NOT HISPANIC White
22.Falls Ned(Fat ea lac) 23.Malws Nee(FYIt Ledsa tnt 23a Mdlr(a Made last Nana
HAROLD BASS MELBA BASS LEWIS
24.afeaa[l Nee eel RebaaWp To Deem 241s.asee9 Aden(Shea Aid Neer.as.S .DO Car)
JANE BASS WIFE 5128 SOUTH UNCOLN,OAKLAND CITY,IN 47660
• a wee a Derefee
Me.Meted Of Deposes mwYe Of DbOalae(Nate Of Cemetery.Crematory.oar Fre) 2J.Keen-CLy.Tan,And San
0 aml 0 Cretan 0 Onto"0 En:Mi ed
0 Reel Free Sizes
0 Omer(heyt HIGHLAND MEMORIAL PARK CEMETERY MOUNT CARMEL,R
26.We Caere Came? 22.Pine MCI Crrs.Alfas Of FSrr Faoey . 2h Fusee line tan New
0 Ye ®w COLVIN FUNERAL HOME INC,425 N MAIN ST.,PRINCETON,IN 47670 FH83005671
27h Seers Of burr FATS Sone Metes I 2/c Liana tam(U lacer
MARK R WALTER,BY ELECTRONIC SIGNATURE IFD01013010
Cana Of Dee(Sol flrbuelas And Example) Appraynay
28.Pert I.Ender The Clem Ol E-an -Met a•V$ma,Or Competed-Thal Olney EMERY.The Dash Co Na Ear Twifl Ewe tree Omet
Such As Cartac Mast Rspeeay Mitt.Or Veto FOHabm Wee Shen The Etbbpy.Db Na Abtrsstte•Etrir 0 ey Om Casa On To Dam
A the.Add Adele Line V Neaffey.
aeeedee Cane(Frei Obese Or Corded Reatelp In Dan) A. ACUTE MYOCARDIAL INFARCTION A)0091
C-'ta A.A Cawed
SSSOpalall• Caaeeaa. V Any. To Miry m esddb B. ARTERIOSCLEROTIC HEARS DISEASE sw,... •aece MANY YEARS
flat Ewe ;In Dee)Last C. -
13..w0.4A0awae
D.
Pet L Eetr OM f Ra Not RRlte In The tfeaale;Cam G✓a'in Pod I 29.Wn M Mee Pertradt O Yes allo
DSUI➢t-0EPQmEM TYPE 2 DIAffTES MELLITUS WITH NEPHROPATNY,HYPERUPDEAM,HYPERTENSION, So.Wee Ateay Fief;At>eare To Coopaa The Cauca OL Dee?
HYPOTHYROIDISM 0 Yea 0 No
31.tic T Late Coleus To One 32 a Fame 31 Mane Of Doles
❑Ye ❑Paddy®No ❑Lamm
0,e.nr.St Pare 0 P.wee.,lraor 0 r-ea le4..s-„r.r e..00.r IS Naas 0 Ha*+a 0 baled 0 Perna Immapan
O rnaA U Pena cnw w 9 a anon 0 tee.metewr 44.449 r- 0 SA•Ml O COII Na Be Damned
a Oa Of ear(iAsSVs9f.0 a Tan U afby a Rea Or thillY(E.G..Deednn land Cannon,so,Rosario moss Ala) 37.ere At WatT
0 yes 0 It
a Loam Crary-gas Ma 04 Or Ton Sae Sal B None Sec APL NO 390 Zip Co*
3-Merle low et yOmre 40 If Tie ague,
❑o,no9a L?aew flee men
41.Sena W Peat Calf"Cans a Dab[ 42 Crew(01s11 Only Ore
WILLIAM R WELLS,BY ELECTRONIC SIGNATURE a Cayip Preen 0 Corms 0 Heel Dal,.
41 lea Adore And Zr Cale Of Peel Cerra Cana Of Dee 44.Mean Neer 45.Dos Cate
WILLIAM R WELLS ,510 NORTH MAIN STREET, PRINCETON,IN 47670 01017790A 10/11/2011
ae Si Farr Sewn Pete 47.Was
4e Se-n eta Heed U6>r 149. For RIghltrZt Only -00 Red(Ma,nWyWset
BRUCE BRINK JR VIA ELECTRONIC SIGNATURE F I Crib
AMENDMENT TO CERTIFICATE OF DEATH(Emma'ORIGIIIAL)
ab - 3O-ea - you - aDb' 0015-CO3 AUG 232013
San Fan 57395 ATTENTION ESTATE Mu Sod Sealy a b term rerun by Mb bile eery n Caere Mae reoalLDBly. Obdoaae b einee are Roo al a r peaky baaria
171051 igir_' m:our
GIBSON COUNTY AUDITOR