Death Certificate - Pollock, Jackie K_5/5/2014 °d 4 Vl V
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>� INDIANA STATE DEPARTMENT OF HEALTH
ate, ) CERTIFICATE OF DEATH
` ,.� Local No 002156 EDR No 000000290834 State No 051351
1.Decedent's Legal Mn(Fest Middle,last) to Maiden Name N female) ' 2.Sea 3.Time Of Death 4. Data Q Dean(11uCYDa1•IYea)
JACKIE K POLLOCK MALE 06:55 AM 11/20/2012
68 Mate Days limn Minutes PRINCETON, IN
9 Ever is U.S.Armed Fares! 10.If Death Omared In A Hospital -10a If Death Occurred Sarewtre 00r Than A Hospital ----
0 Hospice Feeley 0 Decedets Home 0 Musing HandLaglerm Care Fealty
0 Yes 0 No 0 Unknown O wpasat 0 Emergency Department Q,peneea 0 Deed on Antyal 0 otma( )
11. Fairy Name(N Na nsiY5at Give Street as Number) -
VNA CHARLIER HOSPICE CENTER
12.City Cr Taw,Sole,And Zp Code 13.Caamly Of Dean 14.MASS Soma Al Tune Of Dells
0 Man edE Madera,Si Separated 0 Disacea
EVANSVILLE, IN,47714 - VANDERBURGH 0 v. aid 0 Never Marled 0 Unknown
15.arriving Spouse's Name 15a.Of 1 te)Cive Malden Last Name le. Decedents Usbl Ompmm 17. Kea Of Blmmblquby
QUINITH POLLOCK SMITH ENGINEER RAILROAD
18. Revdmce-State 18a Coma 16b.City Or Town
INDIANA GIBSON PRINCETON
laic Street AM Number lid_ Apt No. 13e. Zip Code 1St.beide City links!
354 SOUTH 180 EAST 47670 0 Yes O No
19.DecedeersEclicaton 120. Decedent Of ttpaic Qqn 121. Decedets Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED I NOT HISPANIC !White
22 Father's Name(Fist Mide.Last) 23.MoRe1s Narne(Fest,Mole,last) Zia Mother's Madam IS Mane
JOSEPH WILLIAM ERNEST POLLOCK MILDRED POLLOCK POWELL
24.Idmmnarts Name 24a Relationship To Decadent 24b.Malmo Address(Street And Miter,City.Star,OP Coda)
QUINITH POLLOCK WIFE 354 SOUTH 180 EAST, PRINCETON, IN 47670
25.Place Of Dispateen
25a Method Of Disproof, 25h.Place Q Disposition(Name Of Cemetery.Cram ey,Other Place) 25c Imam-Cty.Town.AM Sae
O Bea O Cnemaian O Damian 0 Entombment
0 Removal Fain State
O Ana(Speedy): MAPLE HILL CEMETERY PRINCETON, IN
28.Was Came Contested? 27. Name AM Complete Metes Of Funeral Faulty 27e Funeral Mane tisane Number:
O Yes 0 No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON,IN 47670 FH83005671
275 Sasbae Of borate Fined Service Licensee- I 27c license Mann(Q Lranee):
MARK R.WALTER, BY ELECTRONIC SIGNATURE FD01013010
Cause Of Death (See btstructab And Examples) Approximate
28.Pal L Enter The Chain Of Events -Diseases.Intuits Or Complications-Thal Dteaty Caused The Death.Do Not Eater Terminal Everts Ftsrat Onset
Su:h As Cardiac Arrest Respiratory Arms,Or VedriMa Farllatim Wthott Snaveq The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Addtilel Lies C Necessary.
bmm=eQ¢te Case(Final Disease Or Contain Resulting In Death) A. METASTATIC BLADDER CANCER 7 PEEKS
m..p As re..eee at
Sequertay List Cmdays, ItAny.Leading To The Case Listed On B_ aej MAr-..v...04
Line A. Enter The Underlying Case(Disease Or In as)*That Initiated
The Events Reeling In Death)Last C.
tau for •ACarPmc4
D.
Pat II.Enter 06w Cmddias CamLtnm b Dean BV Not Rustling In The Unlayng Care Glen In Pan I 29.Was An Autopsy Perfumed?
❑Yes 0 No
NONE 30. Were AlLbpsy Fabric me
Amenable To Garcia The Came Of Death? 0 Yes 0No
31.Did Tobemo Use CaeWE To Death? Si It Fenae: 33.Manua Of Demt -- -- -
❑yes ❑Probably 12)No ❑Criamovm 0 w e.i.ava.he vat O"ace At T..am 0 aAn.reA $Pieria van a ate a Dealt 0 Naiad 0 Hcrtcde 0/leaden 0 Paarq kwesflpalon
O-Pi'e-t es nausea o.rere1Ho eras Sea O Lama inane.stem lahever 05.-ide0 Cold Not Be Determined
34.Data Of Injury(Mw dvtayfYea) 35.Toe d Injury 36• Race Of ipay(E.G..Decedents Home,Cmsttmm Se.Resbuao,Wooded Area) . 37. Iryuy At Yb5.7
0 Yes O No
38.1Caton Of lnluy-State 38a. City Or Tarn 38b. Street&Number 38c-Apt_No. 38d Zip Code
39.Desalt*lye.Inlay Occurred 40. Il Ttai ttamin:Y fy
Qpm..ai.m 0 w hew pa..Mdd
41.Signature.Of Person Certifying Corse Of Death 42.Canoe(Check Orly Ore)
PATRICK C.FLAMION,BY ELECTRONIC SIGNATURE 0 Certifying Physician 0 Cedar 0 Heath O#cer
43. Name.Adders AM Zip
N ,801 ST. MARYS DRIVE#110 EAST, EVANSVILLE,IN 47714 01027520A 11/20/2012
48.Adlterral Fatal Soria Provider. 47. •Alma
at Siagtanae d Lail HeAtn Officer_ 49. For Registrar Only-Ilene Fied QAmSrDgerneay'
RAYMOND W. NICHOLSON,JR.,VIA ELECTRONIC SIGNATURE NOV 21 2012
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
a6 _ 1 a-0 So0 -0D3. W? 2 -oat?
State Farm 53395 ATTENTION ESTATE:The Social Security 0 is being requested by this stale agency is ceder to pusie respassbelly. Disclose-re is voiatay and there we be no penalty for refusal.
MR y-_0