Death Certificate - Cobb, Dennis M_10/30/2013 : . , _,c - 535015
_' lam` CERTIFICATE OF DEATH
1, .,�.1 i
`� Local No 000074 EDR No 000000196789 State No 019034
1.Decedents Legal Name (First Middle.last) la. Maiden Name (If female) 2.Sex 3. Time Of Death 4. Date Of Death(Mont:May/Year)
DENNIS M COBB MALE 05:30 AM 04/27/2011
68 Months Days Hours Minutes 06/10/1942 I HARRISBURG, IL
9. Ever in U.S.Armes Forces? 10.If Death Occurred in A ncspital: lea. If Death Occurred Somewhere Other Than A Hospital
0 Hospice Facility 0 Decedents Home 0 Nursing Home/Long-term Care Faatty
❑Yes 0 N 0 Un4nowr. ❑Inpatient (]Emergency OePai',ment Oubapenl 0 Dead on Naval 0 Other(Specify) I NEIGHBORS HOME
II.Fatty Name(If No 4scthton,Give Street and Number)
7366 S DIVISION ST.
12.City Or Town,State,AM tic Code 13.County Of Death 14. Marital Status At Time Of Death
0 Maned 0 Married.But Separated 0 Divorced
OAKLAND CITY, IN,47660 GIBSON 0 Widowed 0 Never Waned 0 Unknown
15.Surviving Spouse's Name 15a. (If Wfe)Grve Maiden Last Name 16. Decedents Usual i OccupaPon 17. Kind Of Business/Industry
JANET COBB STUCKEY OWNEROPERATOR TRUCKING
16.Residence-State Ida. County 16b.City Or Town
INDIANA GIBSON OAKLAND CITY
18c.Street And Number 'Bd. Apt No the. Zip Code 101.Inside City Limits?
7384 S DIVISION ST. _ 47660 ®Yes 0 No
19.Decedents Education 20. Decedent Of Hispanic Origin 21. Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Fathers Name(First.Middle,Last) 21 Mothers Name(First,Middle.Last) 23a.!others Maiden Last Name
JAMES V COBB PANSY PAULINE COBB MILLER
24.Informant's Name 2da.Relationship To Decedent 2db_MUitg Address(Street And Number.City.State.Lit Code)
I
JANET COBB WIFE 7384 S DIVISION ST.,OAKLAND CITY, IN 47660
25.Place Of Disposition I
25a Method Of Disposition 25o.Place Of Disposition(Name Of Cemetery,Crematory.Other Place) 25c.Locaton-City.Town.And State
el Burial 0 Cremation 0 Donaaon 0 Entombment
D Removal From State
0 Omer(Specify): ALBRIGHT CEMETERY MACKEY, IN
26.Was Corona Contacted? 27. Name And Complete Address Of Funeral Facility I 27a. Funeral Hone License Number:
try Yes ❑No CORN-COLVIN FUNERAL HOME, INC., 323 N. MAIN ST. PO BOX 278, OAKLAND CITY, IN
47660-0278 I 'FH19400002
27b. Signature Of Undone Funeral Service Licensee: 27c.License Number(Of Licensee):
MARK R WALTER, BY ELECTRONIC SIGNATURE FD01013010
Cause Of Death (See Instructions And Examples) Approximate
28.Part L Enter The Chain Of Events -Diseases.Injunes,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval:Onset
Such As Cardiac Arrest.Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter OrJy One Cause On To Death
A Line. Add Additinal Lines H Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. CARDIAC ARRYTHMIA
a..to iii re...w.v.an
Sequentially List Cond.:ons. If Arty,Leading To The Cause Listed On B. CARDIOPULMONARY FAILURE a.mo.,.wa..:...w
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last C. EMPHYSEMA _
p.m to..,.c...s ..dn
D. _
Part U.Enter Omer SgnitcantConc.0wns Centnbu-rd to Death But Not Resultng In The U.rderyug Cause Gann In Part I 29.Was An Autopsy PerfameOI D Yes 0 No
30. Were Autopsy Finding Available To Complete The Cause Of Death? Yes (]No
CARDIAC ARRYTHMIA.CARDIOPULMONARY FAILURE.EMPHYSEMA
31.Did Tooacoo Use Contho,:e To Death? 32.If Fnaa�ewe.vmir.. .r�i,i r..a;w.. 33. Maurer Of Death:
®Yes ❑Probably❑No (]Un:ntwm 0.bi 0 A , D NA e,er.euenant Win..co.,.oro.m 0 Natural 0 Homicide 0 Accident 0 Pendng Investigation
❑.u>.ere-t•aa,.e.e o o.,,T,i,..e.m..Du. 0 u.:s.eG.T.4we..n....v.- 0 Suirle 0 Could Not Be Dexmanee
34.bate Of Injury(MonrMDay/Year) 35. Time Of easy 36. Place Of Injury(E.G.,Decedent's Home,Cosou00on See,Restaurant Wooded Area) 37.Injury At Wok?
I0 yes 0 No
38.location Of Injury-State 38a City Or Team 380. Street 8Number I 38c. Apt.No. 38d.Zip Cade
39.Descnbe How Injury Occurred 40. If Transportation InFury.Soeofr
I •
41.Signature.Of Person Cerying Cause Of Death I 42.Center(Check Only One)
KEITH COOPER, BY ELECTRONIC SIGNATURE 0 Cen.fying Physician 0 Coroner D Heath Mow
43.Name,Adoess And Zip Code Of Person Cen.fying Cause Cl Death: 44 License Nurnoer 45 Dam CarPed
KEITH COOPER , 1401 SOUTH GREEN RIVER RD, EVANSVILLE, IN 47715 02002219A 05/02/2011
46.Add W.al Funeral Serum Prosider. 4f.'Aias:
49. Signature of Local Heaim Moen 149. For Registrar Only -Date Filed(MmrmayfYeaR
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE I- MAY 02 2011
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) I
ab_a1)-1 y-300 - 000.00b-00a
- State Fpm 53395 ATTENTION ESTATE:The Social Sewrry a is being requested by this state agency In order to pursue responsibility. Disclosure is vol unary and there will be no penalty for refusal.
VRA-20
(7/05)
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