Death Certificate - Bryce, Raymond L_10/18/2013 • .1 . . __ __r ne a >•r:•ran- r. . . ..r.... -�.•__•.._ .. _ _ n
� � INIIANASTAICDEPARI ENT OhNtALIM 1092990
__ CERTIFICATE OF DEATH /J I. L�4 -
W1 Local No 000148 EDR No 000000339632 stat a No 038800
I.Deccderts Legal Name(Fes.Lida last) la. Maiden Name(If female) 2.Se, 3.line Of Death 4. Data Of Death(Math/Day/Year)
RAYMOND L BRYCE MALE 103:53 PM 08/21/2013
CHICAGO, IL
9. Ever n U.S.Mined Fames? 10.11 Death danced n A HHMpitat 10a. If Death Occurred Sanerter,Other Than A Hdapla
0 Noedre Farley 0 Decedents mane 0 Nursing Hccralnpbrm Care Far9ty
0 Yes 0 No 0 Wyraen O Inpatet 0 Emergency Depanentoutpaient 0 Demon Arrival 0 oa,a(suwfy)
It Facility Name Of Not 6rstt`van,Give Street and Number)
503 CHERRY TREE LANE
12.City Or Town,Stab,AM Zip Cede 13.Canty Of Death 14. Marital Steam Al line Of Death
0 Married 0 Mated,But Sepaded 0 Divorcee
PRINCETON, IN,47670 GIBSON 0 Widoied 0 Never Married -:l anioxn
15.Suniig Spousal Name 15a M Wde)Give Maiden Last Name 16.Decedent's Usual orapabn 17. KM Of BusnessAnKis y
LADONNA BRYCE POOLE TRUCK DRIVERI MANUFACTURING
18.Resaele-Seta 18a.Canny lab.City Or Tarn
INDIANA GIBSON PRINCETON
18c.SRC And Number tea AP.No. 18e.Zip Cara 18f.Inside City Limits?
503 CHERRY TREE LANE I 47670 0 Yes 0 No
19.Decedents Edradm 20. Decedent Of NSpaic Orgn 21. Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
72.FaLYfs Name(RM.Made.Last) 23.Mathes Name(Fat,MEde.Last) Zia Mathes Maiden Last Marne
CHARLES BRYCE MILDRED BRYCE 1 IRELAND
24.hmma:ts Nene 24a.RitaimstR To Olcment 240.Maisg Address(Street And Number.City,State.Zed Code)
LADONNA BRYCE WIFE 503 CHERRY TREE LANE,PRINCETON,IN 47670
25.Race Of Daman I
25a Melded Of Olapasten 22i.Peace Of wsyceiaon(Name Of Cemetery.Cremator/.ONC Batt) 25c.Laatm-City.Tam,Am Stale
0 Baal 0 Grander 0 Dothan 0 Enactment
0 Removal Fran State
0 Other(Spetat/ EVANSVILLE CREMATORY EVANSVILLE, IN
29.Was Cams Catactm? 27.Name And CamdCe Address Of Funeral Fealty 27e Funeral Mane Lic'mse Morten
0 as 0 No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON,IN 47670 1 FH83005671
270.Sgnebaa Of Inane Funeral Service Licensee: 27c.License Number(Of Lieeeb
JOHN W WELLS,BY ELECTRONIC SIGNATURE I rm
FD01009940
Cause Of Death(See InabucLiorn And Examples) Apprmdmate
28.Pan I.Enter The Chain QtEverts -Diseases.Injuries.Or Complications-That Directly Caused The Death.Do Not Enter T¢mbW Events aerial Onset
Such As Cardiac Arrest.Respiratory Arrea.Or Ventliaar FbMadon Without Showing The Etiology.Do Na Abbreviate.Enter Only One Cause On To Death
A Line. Add Maine Lines It Necessary.
Immediate Cause(Final Disease Or Caallon Revolting In Death) A. CARDIAC ARREST MINUTES
o."(a As A a.-e-m m
B. ISCHEMIC HEART DISEASE - YEARS
Line A. Ilsee Underlying Maus Leading To The Cause
Th Listed On w.nla A.A o.�..e+M
Line A Enter The Untlerfyirg Cause(Disease Or Injury That Initiated
The Events Resulting In Death)last c. Doe WIG u.a..wm
D.
Pan II.Enter Oho SdrS it C i C b n.., Death But Not Resulting In The UnderlWV Came Glen In Part I 29.Was An Autrey Performed?, 0 Yes 0 No
30.Were Autopsy Hoag Avalable To Carded The Cause Of Dealt? 0 Yes 0 No
CHRONIC OBSTRUCTIVE PULMONARY DISEASE,DEMENTIA,CEREBROVASCULAR ACCIDENT 33. Mamer aDeadu
31.OE Talfacgo Use Coaled To Death? 32.If Female: 010.4. 0,r maw.r e.n.+Ms a on.a 0.a, 0 wend O Homicide 0 Amdet 0 Paring laesegaden
0„ar.,,..vr,crr.. ❑,.q.NS.
0 Yee 0 Probably 0 No 0 unknown Na P.7.4.Sal Comie r,..eare o.a, ❑une.rma.eww Tn.,vr.. ❑Setltlde 0 caw Na Be Detained
34. Date Of Injury 0.4catirDayff ear) 35.Time Of Injury 36.Piece Of inlay(EG..Decedents tame.Construction Sie,i at Wooded Area) 37.Irytay At woo?
❑Yea 0No
3$.Laotian Of Injury.Stab 38a.City Or Tam 38b.Street&Nanba+ 38c.Ape.NeO..yy SBd Zp Code
39.Desahe ybatryay OarrreG _ "._ (]°' aae.ra,'w�. ❑..e....Oor_a..ed
__ I
41.Signature.Of Penn Ce tfyeg Cane Of Deady: - ' a2.Cattier(Mari Oily One) C[raer ❑Heath 05ar
RAMESHBHAI P PATEL,BY ELECTRONIC SIGNATURE _ I 0 Coaling Plrysidar ❑
43.Nam.Adders And Zip Code Of Person Certfyilg Cause Of Death: `• - e4.License dinar 45.Date Coated
RAMESHBHAI P PATEL ,685 VAIL ST. PRINCETON,IN 476'70 :� 01040266A 08232013
, i 7.'Ala
48.AddNma FYnea SCMta Prauider: 1
48.Signature of Local Heads OP+ar. v ` (s9. For Registrar Only -Dale Fins IMafDayfYeary
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE -. I I AUG 23 2013
AMENDMENT TO CERTIRCATE OF DEATH„ENTRY OR ORIGINAL) I
� _�� a6-Ia-0'1 --303 -00` . aI4 -Oa? ^
d Ferrite reaporm'bZty. Disclosure b vosmbry and there wit be no Denary Ior:Cusa.
Slate Faun 53395 ATTENTION ESTATE:The Social Searity A is being requested by this state agency n ode to
NRA-20
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