Death Certificate - Hyneman, David Terry_11/12/2013 ,`.--` "�• �' `' ': �' 1092890
-r .: INDIANA S A . •
liPk'S?, CERTIFICATE OF DEATH
' >1 Local No 000165 EDR No 000000346747 State No 046149
1.Decedents legal Name(First Agddle.Last) Ia. Makin Name(If female) 2.Sex 3.Time Of Dean 4. Date Of Death(MxttlWayfiear)
DAVID TERRY HYNEMAN MALE 01:35 PM 10/03/2013
5. Social Scurry Number 6a.Age-Yrs 6b. Under 1 Vex 6c. Under 1 Monti-6d. Under 1 Day 6e. Under 1 Hour 7. Date of Bitf (MonttDaywear) 0.Birthplace(City and State or Foreign County)
62 Morns Days lours Mnutes
❑Hospice Facty ❑Decedents Home ❑Irstg Hate/Long-term Care Faatty
❑Yes ®No ❑Unknown ®Indecent❑Emergency Department Ouya3ent ❑Dead on Arrival ❑other(Specify)
11.Faclity Name(If Not butsjtm,Give Sleet and Number) S
GIBSON GENERAL HOSPITAL
12.Cvy Or Town.Stare.Ara Zip Code •13.County Of Death 14.Mental Stabs Al Time Of Death
0 Married Maned,But separated ❑Divorced
PRINCETON, IN, 47670 GIBSON Occupation `ndawed ❑Never Marred ❑Unknown
15.Surviving Spouse's Name 15a(If Wde)Give Maiden Last Name 16. Decedents Usual OccupaWn 17.Kind Of BusvressAndusty
LISA DIANE HYNEMAN MOUNTS COAL MINER I COAL MINING
18.Residence-State 18a.County 18E.City Or Town
INDIANA GIBSON PATOKA
18c.Street And Number • 18cl. APL No. 18e. Zp Code net. Ltoe City lots?
109 SOUTH WREN LANE I 47666 ®Yes ❑No
19. Decedents Education 20. Decedent Of Hispanic Onga 21. Decedents Race
9TH- 12TH GRADE;NO DIPLOMA NOT HISPANIC White
22.Fathers Name(First M4dde.last) 23.Motes Name(First,Mbae.Last) ' 23a.Mothers Laden last Name
DAVID F. HYNEMAN NORMA HYNEMAN I LIVERMORE
24.ln camanrs Name 24a.RaavonsNp To Decedent 24 b.Mang Address(Sleet And Number.Ciy.State.LP Code)
LISA DIANE HYNEMAN SPOUSE 109 SOUTH WREN LANE, PATOKAI IN 47666
25.Place Of DiscosMan I
25a.Method Of Dspositon 258.Race Of Dispouton(Name OI Cemetery,Crematory.Other Race) 25c.Loratpn-City.Town.And State
0 eual ❑Cremation ❑Donator❑Entombment
❑Removal From Sate
❑Other(Specify): COLUMBIA WHITE CHURCH CEMETERY PRINCETON, IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Faciery 27a. Funeral Home License Number:
0 Yes ❑No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 1 FH83005671
27b.Sgnatae Of Indiana Funeral Service Licensee: 27c. License Number(Of Licenseek
MARK R.WALTER,BY ELECTRONIC SIGNATURE FD01013010
Cause Of Death (See Instructions And Examples) Apprmdmate
28.Part L Enter The Grain Of Events -Diseases,Injunes,Or Complications-That()treaty Caused The Death.Do Not Enter Terminal Events Interval: Onset
Such As Cardiac Arrest,Respiratory Arrest.Or Ventricular Fibnllation Without Showing The Etiology.Do Not Abbreviate.Enter Orgy One Cause On To Death
A Line. Add Additinal Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. ACUTE MYOCARDIAL INFARCTION IMMED
w.ere 4.•C..t..-M
Sequertaly List COI:Cates. If Any,Leading To The Cause Listed On B.
line A. Enter The Underlying Cause(Disease Or Injury That Initiated a.tra...bR.t.om
The Events Resulting In Death)Last C.
n.do Y.Casquano at
D.
Pan II.Enter Omer Sonficant Condiiens Contibut e.to Death But Not Resulttg In The UndeMig Cause Gfvin In Part I 29. Was An Autopsy Performed yea ®No
30.Were Autopsy Findng Avattle To Complete The Cause Of Death? ❑Yes ❑No
31.Dk Tobacco Use Cotaute To Deat.? 32.If Female: 33. Manner Of Death:
❑m."watt we.,om Tao ❑".:m.6t T..ao.t ❑ee Rona.c.ITTooaro wow.2 Oar Corr:. 0 Nataal❑Homicide ❑Accident ❑Pending L:VCSaaa al
❑Yes ❑Probably❑No ®lln'mown ❑.AP'an ennvtty n on,To tel.w Soon Doe ❑uwa rv,.o.'r we-Ts.Poo 1,99 ❑Suicide Cab Not Se Determined
34. Drs Of Injury(Mon..JDayfYearl 35. Time Of Inury 35. Place Of lr{try(E.G.,Decedents Hame.Constumon Ste,Restaurant Wooded Area) 37. Injury Al Wax?
I ❑yes ❑No
38.location Of Injury-State 38a.City Or Town 368. Sleet&Number 38c.Apt No. 380. Zip Code
D -i .
39. Denote Hay Injury Dc reed 40. If Tra aporate 8yay,arofr
.ak I
41.$enrage.Of Person CeLEqug Cause Of Dealt • _ , 42.Certifier(Cheek Only One)
BARRETT W.DOYLE ,BY ELECTRONIC SIGNATURE t ❑CenMng Pny'sloan ®Coroner ❑Heath 05cer
43. Name.Address and Zip Cade Of Person Gertfying Cause bDeath: L, - 44.License Number 45. Date denied
r'
BARRETT W.DOYLE , 520 SOUTH MAIN ST, PRINCETON,IN 47670 I 10/09/2013
46.Adel-Nate Funeral Service Provider. 47. •AFaS:
I
48.Signature Local Health 05cer. 49. For Registrar Only -Dare Filed(MbtNDay(Yeak
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE r I OCT 10 2013
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
a6-04 -as -301-000• S8 s -oat,
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tr5 Sate Fom 53395 ATTENTION ESTATE:The Social Secuny a is being requested by Ids state agency if aver to pursue responsibility. Disclosure is voluntary and there will be no penalty for refusal.
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