Death Certificate - Scott, Hazel L_2/24/2014 %""e4\ INDIANAb 1AIt UtrAM IMtN I UFMtALIN .LUJCUUJ
e* }` CERTIFICATE OF DEATH
`` n Local No 000210 EDR No 000000356768 State No 055284
1.Decedents Legal Name(First Male,Last) la.Maiden Name(If female) 2.Sex 3. Time Of Dean 4. Date Of Death(Mort/Day."(ear)
HAZEL LEE SCOTT a) GAMBILL FEMALE 03:25 AM 12/03/2013
. 10.If Dear Occurred In A Hospital: 10a.If Death Occurred Somewhere Omer Than A Hospital
0 Hospice Facility ❑Decedents Home ®Nursing HanelLong-tern Care Fealty
Q Yes ®No Q Unknown. 0 Inpatient Q Emergency Department Outpasent 0 Dead on Arrival Q Oren(5 ,.y)
11. Facility Name(If Na Insot:ton,Give Sleet and Number)
GIBSON GENERAL HOSPITAL-SNF
12.City Or Town,State,And Zip Cede 13.Covey Of Death 14.Mantel Stews At Tex Of Dem
®Maned 0 Marred.But Separated 0 Diver--ed
PRINCETON,IN.47670 GIBSON Q vroowd Q Never Married Q Unknown
15.Surviving Spouse's Name 15a. (If Wde)Give Maiden Last Nate 16. Decedents Usual Occupation 17. Kind Of Businessandusby
THERNE SCOTT HOMEMAKER HOMEMAKER
IS.Residence-State 18a.County 180. City Or loan
INDIANA GIBSON FRANCISCO
15c. Sleet And Number ltd. Apt No. 18e.Z41 Code 181. IrsideOy Limits?
4644 EAST STATE 64 ROAD 47649 0 Yes ®No
19. Decedents Education 20. Decedent Of Hispanic Ongus 21. Decedents Race
UNKNOWN NOT HISPANIC White
22.Facets Name(First Mdde.Last) 23.Mothers Name(Fest Mddle,Lass) 23a.Motets Maiden Last Name
IRVIN GROVER GAMBILL LILLIE M GAMBILL FISHER
24.Irbrmants Name 24a.Relationship To Decedent 245.Mang Ao&'ess(Street And Nanber.Cry.State,Zip Code)
THERNE SCOTT HUSBAND 4644 EAST STATE 64 ROAD, FRANCISCO,IN 47649
75.Place 01 Disposition
25a.Method 01 Dsposiian 25o.Race Of Disposition(Name Of Cemetery,Crematory.Other Place) 25c.Location-City,Town,And State
0 Burial 0 Crema;on 0 Donation 0 Entombment
0 Removal From State
0 Omer(Speedy): COLUMBIA WHITE CHURCH CEMETERY PRINCETON. IN
26.Was Cocoon Contacted? 27.Name Ar.0 Complete Address Of F,aieral Faafty 27a.Fared'Hone license Number.
Q Yes 0 No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 IFH8300567 i
270. Syrayre Of Indiana Funeral Service Licensee: 27c.License Number(Of LicenseeF -
RICHARD DEAN HICKROD, BY ELECTRONIC SIGNATURE FD01012153
Cause Of Death (See Instructions And Examples) Approximate
28.Part I.Enter The Chain Of Events -Diseases,blunts,Or Complications-That Direct),Caused The Death.Do Not Enter Terminal Events Interval: Onset
Such As Cardiac Arrest Respiratory Arrest,Or Ventricular Fibrillation Without Snowing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Add4inal Lines If Necessary.
Immediate Cause(Final Disease Or Condition Result mg In Death) A. ACUTE CONGESTIVE HEART FAILURE 48 HOURS
N.boa t..(ywy.a 07
S ueriia List Conditions. If Any.Leading To The Cause Listed On B. CHRONIC CONGESTIVE HEART FAILURE _ TWO YEARS
eCi gy y g Ice..uIP 4.reua..�om
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last C. HYPERTENSIVE HEART DISEASE MANY YEARS
Ns*Mt A.A Cwuy.w00
D.
Part II.Enter Other andfc ant Condoons Con,nbuting to Death But Not Resulting In The Udalyvg Cause Gnin In Pan I 29.Was As Autopsy Performed? Q Yes Q No
30.Were Autopsy Finding Avaaade To Compete The Cause Of Death?
CHRONIC ATRIAL FIBRILLATION.HYPERLIPIDEMLA.HYPERTHYROIDISM,FIBROMYALGIA.THROMBOCYTOPENIA 0 Yes 0 No
31.Did TrCacoo Use Contribute To Death? 32.It Female: 33.Maurer Of Dean:
0...n.>.wwe,.Naas*, 0 F.r.Svire.«o.. Q whir.&e.n.a...wow is Din a o... Q Natal 0 Homicide 0 Accident 0 Pending Investigation
❑Yes ❑Probably®vial ❑Unenorm 0.,n.,,.n s.n.:.w a bin To re,Bob.O..e • 0 unto..e.nnentWe.rt....... 0 Suicide Q Could Not Be Determined
34.Data Of Injury(MonWDayrrear) 35. Time Of Injury 36. Pace Of Infuay(E.G.,Decedents Home,Cdnsuuction Site,Restaurant Wooded Area) 37. Injury At Work?
Q Yes Q No
38.Lmatibn Of Injury-State 36a. Cry Or Town 38b. Sven,i2.dM.er Sac. Apt No. 38d. Zip Code
39.Desobe How Injury Oconee 40. If Transporabol lyry.$iedfy
Qt...nh..e. Qu.u.s.LJP°vrt Qa..M«h1
41.Signature,Of Person Cerlykg Cause Of Death: 42.Cer.Ser(Check Only One)
WILLIAM R.WELLS ,BY ELECTRONIC SIGNATURE ®CerUyirg Physician Q Coroner 0 Hewn oM et
43.Name,Address And ZM Code Of Person Ceit-tying Cause Of Dam: -_ _---� 44.License NwnSer 45. Date Ceitd
WILLIAM R.WELLS ,510 NORTH MAIN STREET, PRINCETON, IN 47670 01017790A 12/04/2013
46.Additional Funeral Service Provider. a7.-Alias:
48.Signature of Local Health Olhar. 49. For Registrar Only -Date Filed(MonNOayrYearp
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE DEC 05 2013
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
:86-a- 13 -300 -tab- 64a - oo4
• state 295 ATTENTION ESTATE:The Social Seamy a is being requested by this state agency N ceder to pursue responsibility. Disclosure is voluntary and there we be no gamey for refusal.
' (7/05) 1
VOID IF ALTERMOR ERASED-NOT VALID UNLESS CERTIFIED BY-HEALTH DEPARTMENT'