Death Certificate - Beadles, Hilda J_1/9/2014 a.Ras' . a �..w."� ~yam INDIANA STATE DEPARTMENT OF HEALTH _. 8 0 2 2 4 7
•.,--, CERTIFICATE OF DEATH
s,
"' Local No 000060 EDR No 000000348288 state No 047335
1.Deedenas Legal Name(First.Mwd'e.lass
I
la. Maiden Name(IIfe female) 2.Se. 3T.-.e00Deerr a, Date aDeath(Mon'IrDay)Yea,)
HILDA J BEADLES t. BUSH FEMALE I 1 05:30 PM 10/11/2013
Ever n U.S.Armed Fortes? W.II Death Occurred In A Hospital: t0a It Death Occurzpd Somewhere Darer iron A Hospi:at
0 Hospice;actin; 0 Decedents Home p' Nursvg Horne/Long-term Care Facily
❑Yes E No 0 Unknown ❑Inpatient ❑Emergent.;Deoartmem Grtpalent ❑Dead on Armzi 0 aver(Speciy) I
II.Faciry Name(II Nor Irsbwao,Give Street and Numoer)
AMBER MANOR CARE CENTER.1, I
12.Gy Or Town State,!M Zip Code ._. - ._ 13.Cooly;a Death 14.Mental Status At Tine Of Dear.
0 PETERSBURG. IN.47567 PIKE 9 Married
dowed Married.0 everl Separated ❑Divorced
9 1\SdovRd ❑Never Mame'_ 0 Unknown
15. Surviving Spouses Nan* 1St(II Wie)GNe Maiden Las:Name IS. Decedents Usual O nma:nn 17. Kind Of Busi es.1r'esLry
HOMEMAKER I OWN HOME
I4.Redixrce-Slate 'raid. County +2d.GyOr Tmm
INDIANA IGIBSON OAKLAND CITY
15c.Steer And Numcer 1?0. Apt No. 12e. Zip Code +51.Inside City limits?
124 NORTH 1150 ROAD EAST I 47660 D Yes O No
19.Decedents Edecahon 20. Decedent OI Hispanic()nom 21. Decedent's Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Facers Name(Fist'Aloe.Last) 23.Mothers Marne(First.Middle.Last) 23a.Mothers Maiden Last Name
JODA BUSH BIDDIE BUSH BARNS
24.1c2om.art's Name 24a.Relauoisrip To pettier/ 244.Maing Atoms(Street AM MrToer,Qty.State.�Cone)
DANNY BEADLES SON 1743 EAST PRIVATE ROAD NORTH. PETERSBURG, IN 47567
25.Place Cl Disposition I
2:2.Method Of Dispesmon 250.Place a Disposi4on(Name a Cemetery.Crematory.Finer Race) 25c.Locaion-Gay,Tcvm.AM Stare
G Burial 0 Cremation 0 Donaton 0 Entombment
p Removal From State
D Ozer(Specify): BEADLES CEMETERY WINSLOW, IN
2E.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility I 27a. Funeral Home Licerme Numcer.
❑Yes p No O.D. HARRIS&SONS FUNERAL HOME, 705 E.WALNUT, PETERSBURG, IN 4-7567 FH83005524
270-Signature Of Intlara Ftneral Senice Licensee: 27c.License A'rttber(Cl Lace see):
LOWRY COOPER, BY ELECTRONIC SIGNATURE FD01004398
Cause a Death (See Instructions And Examples) Approximate
29.Pad I.Enter The Chain a Events -Diseases,Injuries.Or Comp+rations-That Oi:ecy Caused The Death.Do Not Enter Terminal Events L'trereel: Onset
Such As Cardiac Arrest.Respiratory Arrest.Or Ven:hcgar Fibrillation Wthout Snowing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. And Addstinal Lines It Necessary.
Immediate Cause(Final Disease Or Condaion Resreang In Death) A. GENERALIZED ARTERIOSCLEROSIS iY/ENTY YEARS
a•.mot.,cexa.e.ece Y.
Sequentially List Conditions. If Any,Leading To The Cause Listed On S. NATURAL CAUSES a
Line A Enter The Underlying Cause(Disease Or Injury Tnat Initialed ae mud aAth�..,w
Tne Events Resuttng In Death)Last C.
Due m rid M A Cousaa ce ar
D.
Pan II.Enter OthersicnirYarI CanCars GMGburrinC It Deer,.Our N7I RestAg In The LhkerNtng Cause Ginn In Part 29. Was AnANOCSy Perormed?I 0 Yes No
HYPERTENSION DEPRESSION 30. Were 4uaosy F-G:g Avalalle To Complete The Caused Den?,? pves 0 No
31.De Tooaroo Use Canmbsae To Dean? 32. If Female: ( 33. Manner a Death:
p.et=.o•...ace e..aw p RaTe.t.r r.,x y been D r.. ,er.a ea ate,..wee.:Cary Of cot p. Nate al 0 Homicide 0 Accident 0 PeoE g L.estige:en
p Yes 0 Protaty G No 0 tln:nomu
0 1.1 e•ern.Satter.n ova to a 3.a.ta.n 0tin_C.,..trw.e-, . 0 Sici1 c
e p Color Not Be Determined
34.Date Of Injury(MonthDeyYearl 35. Time a Vyury 3E. Race a Iryury(E.G..Decedent s Home.Gansuar.Site.Restaurant Woucle0 Area) 37.t'lury At Work?
0 Yes 0 No
32. Location a Ir11ury-State 3Ea. City Or Town 350. Street 5 Number 32c. Apt.No. 32d. Zen Code
139. Describe How Irury O.cueed 'g. 11 Trzrspce a:an lnryry s enN:
pc....c-v..w OP. '�a,>.....pm.,.�_,.
L Signature. Of Person Candying Cause a Dea V.: I 42. Center(Check Only One)
!HONESTO K FENOL, BY ELECTRONIC SIGNATURE 9 Geryvn Pnyskian 0 Groner ,p Heads[Nicer
e3.Name.address AM?r.Code a Person Cer yi'g Cause Oi Deann: I teensy N; .ter 45.Dais Ce.::iao
HONESTO K FENOL , 611 MAIN STREET, PETERSBURG, IN 47567 01028253A 10/14/2013
so.Amoral Funeral Sconce Provider. I <I Aeas.
S alure of Local Heath atKer: 45. For Registrar Only -Date Flee%Mont/Day/Year):
HONESTO K FENOL, VIA ELECTRONIC SIGNATURE I OCT 17 2013
I AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) I
I
State Fonn 53395_ATTENTION ESTATE:The Social Seamy xis being requested by this state agency in order to Pursue responsibly. Disclosure is voluntary and there veil be no penalty for refusal
v r05 _ _ �}•__
..-e • i-e73 r5•)>L T t:1-: •J i.E �s. '.1 I.fp ciY:n he -iy3t'i7 1 .L-aeon- ::Ciiitisr