Death Certificate - Dixon, Albert_10/22/2013 .
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ja-:.� ?'� _5 'INDIANA'STATE:DEPARTMENT OF,HEALTH I .
4 3, at' CERTIFICATE OF•DEAITH • i.'
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\ ... •Local No'000213 .: • EDR No.0000.00t96532 . r'state No 018853.
..':1.Decedents Legal Name(First;Midde,Alt)• r C ta..Maiden Name Or female) . 2-:Sea I3. Tene 010,01 4 Dab Of Den,•(Mo lsiDaynYrl••
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ALBERT DIXON. ' , <-' '' MALE t 05:15 AM 04/26/2011
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97 mown,. ( oeya.. (:Han•' "'NOT l..
e.'Ever n U.S:Armed Fdps7 :to.a Dear Oconee In A Hasped: . -. 10a,II been Occurred Somewhere Other
No Than A Heaptal
�� - 0 Hdslace Fadry '0 Dedamts Homo/ 01NIn+q HCmYLbg4eml Cars Fealty
�O.Yes ®No"❑Unknown ❑trpaee,Y❑EmIXpelcy paparimeru otrM+:lw 0 oe.d°rim."' ❑oow(spear F •
Ii..Facility Name.01 Nat N9su1Ol Give Street and Number).J '•A 7 ' - -
• WILLOWiMANOR;NURSINGIHOME r' - -
12.CAyCr Torn.Male.Are,Zip Cole - e 13.Comity Of Death. i' . IA.Mama)SlausAttane Ol Dun
/ - ,0 uanw O'Martaa But SeNaed'0°Merced
VINCENNES,IN,47591 ..--. KNOX' I: •.2LVl sed O Ne`e(Man"d- 0 Unknown_•
15.,Sumniry Spouse's Name. • 15a. pt IlWererve Madan Last Name. ♦; 16. Decedents Us al Ocaa tcn 17.Kano Or Buvess1MUVy .•
. . `-� FARMERS •I • AGRICULTURE
r tea.Cdy,OrTam 1
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,-f8.ReWarca-Stm • tea. Camry ♦ I;♦•
INDIANA . KNOX•• - ` • . - VINCENNES
Mu;Street And Number • Ill. Ant-No. lee Leg Code ISr.snide Gay lento
I•' . 1321 WILLOW ST. ., . r 47591'S II Yes 0-No
•19.,DIXedenfs Entaeon 20. Decedent Of Hj,Pamc Onpn' 21.Decedents Race '` ..
' • HIGH'SCHOOL GRADUATE ORIGED' • . I.
COMPLETED .- • NOT.IHISPANIC . . , White
22.Fames Name(First M,dde.LnV.. 23.Mothers Name(First.Made,Last). 23a.manors Mae, Last Herne
THEODORE DIXON • ANN•DIXON . , COLLINS
2e Intdmats Name 24a.Reb•.mstip To Decedent 24o,Memo Address.(Street And Ntmber.Qty.Sipe,Zip Code)
• JERRY DIXON SON 1712 OLD WHEATLANDROAD,VINCENNES,IN 47591
25.Rau Or Gsposilun
25a Method Of Gspostsen 250.Rac e Of GspoYbn(Name CI Cemetery,Crenubry.Mar Race) . .25c.1.r ab-.t•Qty:Town.And Stale
anal❑aavadn❑Dayton❑Entombment
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0 Removal Fran State
0 Omer(SpeoryT HAZLETON COMMUNITY CEMETERY HAZLETON. IN I'
28 Vas Conner Careens? 27.Name Pod Complete Address Of Finer*Foamy
1 27a Fure M Lame Number.
0 Yes. 0 No COLVIN•FUNERAL HOME INC,425 N MAIN ST.,.PRINCETON,114,47670 . FH83005671
.270.,Slgnaua Ol trtara Fibs Sen-ca Lemmae:, NUM a(Of llcetuee)
MARK♦R.WALTER., BY ELECTRONIC SIGNATURE IFD27r 0 titans 1O13010
Cause Of Death (See Instructions And Examples) l Apprmhnate
; 28.Part I.Enter The Crum Of Events'-Diseases:Ir(uries.Or Complications-That Directly.Caused,The Death.Do Not En:er,Terminat Events 1 - 'Interval Onset
Such As Ceaac Arrest,Respratory Arrest.Or,Veni ntlar.FienItatiCo VMUpul Showing The Etiology.Do Not Abtreviate.Enter Only One Cause On To Death
, • A Line.•Md Atlaaal Lees II Necessary,
MmeaateCause(Falai Disease Or CDnd.lion Resulting IODeath) A. STROKE 2WEEKS .
au min-m A c.,..e.,...on
B. CEREBROVASCULAR DISEASE • MONTHS'
Sequentially nt Late a Oons;,e Any.Le Leading To The Cause Listed On p,..lot es a Ca ss,.CA 1
Line A. Enter The Underlyimg Cause(Disease Or Mary That Initiated I
The Events Restive In Death)Last 'C. t
O t .
Pale.Eases Otyssreirt roptpm Co a bue'aso Death But Not ReSuOn2 N The UNe,lykg Cause Ginn In Pall 29,Was An Aubosy Peram/7 0 Yes .0 No
30. Were AUopsy Fins°AVeaade To Cape,.The Cane Of Oath? 0 Yes,0'No,
DEMENTIA.HYPERTENSION,CARDIOMYOPATHY 33. Mannar CU Mm:
31.DC Tobamo Use Casette To Death? 32. II Female.
0,.,...rr,w....e v... 0 e..n.s C r,,,e can* 0•....e...u».wn me,•.e ten a mw. .®'Naeral 0 Homi?de 0 Accident 0 Paonp invest aeon
❑.Yet ❑Probe*0 No ❑UlWnwn _. U Ae.r..a.ns.u n.e.e Cm,"I.,r..•seen ten. 0 o,..-ee..m,..„e,.n...e r,., 0 S'.ode 0 Cote Not Be Oeamusd
' 3c.Date CI May(MCM9ayfea) 35.Ton CY Imlay 38, Race Of trytay(E.G.Deceeents Home.Cmanae,n Ste;Resatt Atoded Area) 37.loamy Al Was/
- 0 Yes 0 No
38.Loobn Of lrlery-Stab 38a. City Or Tenn -38b. Street&Master 1St.Ave.No. sad Zip Code
I
q�SeNty)
39.OesmW How Lyuyom.led ❑ Iln`�:pr:.�'Ll "^•poe.aa.wl
'4t Spnwae.Ol Pe cnCweynp Cause Ol Dealt ,42.Catteer'(Check Only Ore)
CHARLES.E.HENDRIX JR.,,BYeELECTRONIC SIGNATURE O Ceerymp Physician. 0 Coronae 0 Hert Oseer
43. Name;Adores And Zio Cole Or Person Ceraytg Cause OI Death H. License Number 45.Dab Certi`Ad
CHARLES E HENDRIXJR. ,406 N.1ST STREET; KNOX, IN 47591 01030371A 04/29/2011' •
I a7, 'Akas:
48.AddObnal Furel e, Sena Provider. I
_ • 149. For Registrar Only -Date Red(MolBVDayeYear):
RALWahine'CQMAIN,VIA ELECTRONIC SIGNATURE • . � APR• 9'2011
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY,OR ORIGINAL) 1
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State Fate 53395 ATTENTION ESTATE:.The Social Security a is ben;reaxsed by this stale agency in order Io pursue respansibdty•Disclosure is;voMttery and tee will be no penalty to refusal
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1.J A ,� , MAY 0.5 2011•
•.ifealth Officer Dated .
This is a cert:fic..d Copy-of an Original Document. I hereby.certify that
, this copy.is an exact reproduction of the.Certificate ofttDeath'for the
person.named.therein as it now appears:in.the permanent records of the
Knox-County Health Department, y'incennes;.Indiana.'Not valid-unless-
tampdwith; ofcial`raiseseal.
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