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Ma 'O Manor.Da Sepanen 0 Dre;rten K EVANSVILLE.'IN:47714 VANDERBURGH OV41oat! O NOW Maned•O mnoen '.
". 15.Sntw9 Seooies Name 15a g1•.t1tGre Maaen Last Urea 1e.Gecedeas Usual ocape:cn 17.-Kind O Snenss4M:sey . -,
r HENRY L KIESEL OWNER • . SHOE MART fi
S. 10.Residence.Sae lee Coalty Ito.City Or Tenn
A: INDIANA GIBSON FORT BRANCH
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t Yes O NO 1 ,13_WEST'RED BANKROAD. - 47648 ;;�
a\ 13.Decedean ECSancn - . 20.Decedent Ol lispa-ec O:on .21.Decedents Race Yf
HIGH SCHOOL GRADUATE OR GED •
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COMPLETED -1. NOT HISPANIC White
n:Frats Herne(Fast M.a t,las) P_M:MS Nana(Fast ALC6a.Last) 230 McIwrs Msoen Lail flame:
. LYNN ARLINGTON HARVEY- NELLIE HARVEY t (POSHARD
2a.Ir}tcnms Name 74a Raswreo To Dndao ale.!/sang ALe;ess(S:•eel Ara N.te.Cory.S=e.Lp Cos_? ' ,I
a JUDITH BRAZIER - ` DAUGHTER •• 10150 VICKERY LANE,SHAWNEETOWN:IL 62984 .
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05*M:Cd CI:.tapea+an r.'.250 Rote Of W WSibn(Harm CI Cemetery,Cniri1cr.Other Plate): 25c Leacat--Cry.iwm.AM Slate
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rc O mt.:isoe&T): ▪ - EVANSVILLE CREMATORY - EVANSVILLE,.IN-
O 9 Was C Vac Contacted? 27:N34110 AM Ctarple a ALrma Cl Rnsl Faet•y a Funeral H01110 License Nutter..
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W - . STnteo: • OK FAMILY FUNERAL HOME. 1330£.4TH STREET, MOUNT VERNO Rooter(Of 47620 F1410800015
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cc "a S'clatre G wane Enid Senxe liaMSee: .. - - '• 27c License Rooter(Of!remes):
W WILLIAM B.STENDEBACK,BY ELECTRONIC SIGNATURE • I FD20800038 - - . �� 'e
1••• Cause Of Death (See Instructions And Examples) - • • pnpm.isa•e
Q- 2e.Pa-.I:Ente:.Tre Ceen 01 Event!-Diseases.Im rss.Or Co pIA.3am,-Tai Daects-Cameo The Deus.Do Nei Er er Teisnitsl Events IrRr:m Onseu- '
LL Sum!As Cara Arrest Respiratory Arrest;Or Vertu:MW FcrOlatioo YA:nou 51greyg rho Eiceogy.Do Not A_`brevlate.Entor Orly One Cause On To Dear.
A Lie. Ad_A.::s'.01 LMs U Necessary. '
0 L:-mute Cxlse(Fra!('slaw Or Concl4An Resl•q La Death) A CEREDROVASCULAR ACCIDENT - DAYS '
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yam( SeA-C-r1La:CorCvss;If Caus Leading Ta The Cause Listed On . :1w,m As A a,,,ana05 y�
's7 "t.a A'-Etter The Underti e;Cause(Disease Or Y.pry That Whaled ,
4e Events Res ling La Den)Last -• - - 1•i C. LEFT HIP FRACTURE •y _ . . . . .. w.ma.. ,circa -• - D.' FALL . . . )
pr.lt Eme C:Xr$.T+fcrt Condom COnt0ct* to!Deem ern Not Restdx91n Ire UndenyY9 Cause Gnsn In Pon y 29.Was An ANwp•y Performed? OYes t]Ng
,Ary��, - b.'_.Na Autopsy Fetap Aedatle To Cec' orb The Cause Cl Death? a/
31.DaiCaalo Use Corrma10 Denl; 32. ;Fence: - - i .
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r 3a.Da*Cl L�.y(Mat-vayIYear) 35 .T.e a N,vy, 30.Place Of bj.ay IEG.0/coaxes Hoye.Cmstruccn Se:R taunt)Stoat]Areas 37,I.ytey At Mee? - I 1
C.I - 10262013 - .04:00 AM RIVER POINTS ASSISTED LIVING - Yen 0 N I 39
U.'Laran Of1vry•Shies 335 Cey Cf.royal - - 3E3 Sreet A?".--nter Sea-..pt.Nt t 351 Ze Code
INDIANA- - ' EVANSVILLE . - 3001 GALAXY;DRIVE - - • 47715•
.De H ca}O]area e0,II T a spa '-n Very,SOeo f
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W I FALL FROM STANDING POSITION TO GROUND . • . - _ - ;
1 41.Sc•ce Ut Perm:Certtscy Cause DI Deem - e2.'Came(Cnect Orly One) -
IANNIE E.GROVES:BY ELECTRONIC SIGNATURE 0 cart/pry Pnfskam 0 Coroner . 0 He=Oi2ex -
( u43 fla:e.ACrns av'to cat Ol Penal Car+yvq Corse CI Dent.
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ANNIE E.GROVES':201 S.MORTON AVENUE, EVANSVILLE,IN 47713 NONE - - 12/192013
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ISTENDEBACK FAMILYFUNERAL HOME CARMI IL- - • - -
e5.:5:mc:tl lartl ales 0."a:. .. ' e3. For Registrar Only"Data FUea(`fx-'Oayn'et):
RAYMOND W.NICHOLSON.:JR.:VIA ELECTRONIC SIGNATURE ' :DEC 26 2013:
- - - -AMENDMENTTO CERTIFICATE OF DEATH OR . - • _ i; - ..p
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1SaterFOrm.,3 e5 ATTENTION ESTATE The ScootSec.cyaIs toes;remesedbydasslawagt�ne a 1dptsus espan Witt' Dsoosu reisSOLna ryendtheteaa!ownoponalyfOretvsaL �T+1 �.4
%.WARNING-+nF V F DOCUMENT
MORANGE TOYEMIOW WHEN ;y ORIGINAC0000CENTVHA3 HIDDEN •I13 NFR D THAT APPTEAR V,14-EN PH TO a:IND)A?AO'=Ki9-r41
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