Death Certificate - Blakley, Mark S_6/9/2014 cp- 3` 3�t` 2 INDIANA STATE DEPARTMENT OF HEALTH
K...46: `_� CERTIFICATE OF DEATH
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Local No 000200 EDR No 000000386213 State No 022814
1.Decedents Legal Name(First Middle,Last) la.Maiden Name Of female) 2.Sex 3. Time Of Death 4. Date Of Dean(MonWDaytteat) '
MARK S BLAKLEY - MALE 12:30 PM 05/20/2014
10.1f Death Oconee In A Hospitat 10a II Death Occurred Somewhere Other Than A Hospital
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0 Hosplie Sty ❑Decedent's Man ❑Nusiq Hamtapbrtn Care Fealty®Yes ❑No ❑Unknown ❑Inpatient❑Eaaeaky Department Outpatient ❑Dead on Anval ®one:(So ddy)
OTHER
11. Facility Name Of Not Instariak Give Steen and Numbs'
219 PINE STREET
12.Cry Or Tort Slate,And Zip Code 13.Canes Of Death 14.Mental Status At Time Of Death ,.
0 attwd]Married,er pra t Divorcee
VINCENNES, IN,47591 KNOX Wa C] eve Married 0 U
15. Swvheg Spouse's Name 15a. Of W1fe)Give Maiden Last Name 18. Decedent's Usual Occupaion 17. Kind Of Busnessentl soy
CATHY BLAKLEY CAVINS CONDUCTOR RAILROAD
18. Residence-Stae 18a County 180. City Or Tam
INDIANA GIBSON PRINCETON
IBC Street And Number lad. Apt No. 18e. Zip Coda 181 Inside City limits?
1474 NORTH OLD US HY 41 - 47670 ❑Yes ❑No
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19.Decedents Education 20. Decedent Of Hispanic Onpn 21. Decedent;Rare
SOME COLLEGE CREDIT, BUT NOT A
DEGREE NOT HISPANIC White
22.Father's Name(First Middle,Last) 23.Mothers Name(First Midair/,Last) 23a.Mothers Maiden Last Name
LOWELL BLAKLEY SHARON BLAKLEY GRIDER
24.Informants Name 24a.Relationship To Decedent 24b.Mailing Address(Street And Nwnber,City,State,Zip Code)
CATHY BLAKLEY WIFE 1474 NORTH OLD US HWY 41, PRINCETON, IN 47670
' 25.Place Of Dispostion
' 25a.Method Of Disposison 250.Place Of Disposition(Name OI Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State
❑Biral 0 Crena= ❑Donation❑Entombment
❑Removal From State •
❑Other(Specify): EVANSVILLE CREMATORY EVANSVILLE, IN
26.Was Coroner Contacted? 22, Name And Complete Address Of Funeral Facility 27a. Funeral Home License Number. I
0 Yes 0 No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671
27b. Sgne:re Of Indiana Funeral Service licensee: 27c. License thanker(Of licensee):
MARK R.WALTER, BY ELECTRONIC SIGNATURE FD01013010
Cause Of Death (See Instructions And Examples) Approximate
28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset
i Such As Cardiac Arrest,Respiratory Arrest.Or Ventricular Fibrillation Wrhout Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Lie. Add Addition Lines If Necessary.
Immediate Cause(Final Disease Or Concklin,Resulting In Death) A. EXSANGUINATION
!raw"."a.■w.e 00
Sequentially List Corldtims, If Any,Leading To The Cause Listed On B. SELF INFLICTED GUNSHOT
Line A. Enter The Underlying Cause(Disease Or y That Nitrated 0.'brwa"c°"°ere co
The Events Resulting In Death)Last C
. oraty YMae eeeryai
0.
Pat II.Enter Other Sio:Gant Con;tions Coniibutaxi to Dean But Not ResNUng In The Undelyig Cause Glen In Pan I 29.Was An Autopsy Perfarned7 ❑Yes ®No
30. Mare Autopsy Funding Available To Complete The Cause Of Death? o Yes I]No
31.Did Tobacco Use Contribute To Deaths 32.II Female: 33. Mane Of Death:
❑wn. er.vwra rev 0"WI u Tr..of o.."' ]ru w.pw.u w.Prw M 42Orp 01dm, 0 Natural ]Homicide ❑Accident ❑Pending Investigation Yes ❑Pnobaby 0 N ❑Unknown
0 w Payers u vra.+o err.T.lrid drat own ❑uua.,r ParenAl,T.Puy vat. 0 Suicide❑Could Not Be Determined
34.Dab Of teem?(lemtvDayiYear) 35. Time Of Injury 36. Rare Of Injury(EG..Decedent's Home.Cansmxsion Site,Restaurant Wooded Area) 37. Irytsy At Work?
0520/2014 - 12:30 PM MOTHERS RESC D Yes 0 No
38.Location Of Mow-Slat 38a. City Or Town 380. Street 8 blunter 38c. Apt No. 38d. Zip Code •
INDIANA VINCENNES 219 NORTH PINE STREET NORTH 000 47591-00
39.Desrmbe How Inlay Occurred 40. II Transpalatbn lnlwy, duly:
DEW 0"-L.IM1M^x Qwtsr m'
SELF INFLICTED GUNSHOT
41.Sq atwe.Of Person Certifying Cause Of Death: 42. Certifier(Check Only One)
DONALD M. HALTER, BY ELECTRONIC SIGNATURE ❑Ceniyirg Physician 0 Coroner ❑Heath Officer
• 43.Nero,Address And Zip Code Of Person Certifying Cane Of Death:
u. License Number 45. Data Certified
DONALD M. HALTER ,2375 SOUTH OLD DECKER ROAD,VINCENNES, IN 47591 05/22/2014
48.Additional Funeral Service Provider. 47. •Akas:
M8.Signature of Local Heath Officer. 49. For Registrar Only -Data Fded(MohNDay(Year): '
RALPH JACQMAIN,VIA ELECTRONIC SIGNATURE MAY 22 2014
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
r/6-11-01 - loo-003 . 1 (0-oat .
State Form 53395 ATTENTION ESTATE:The Social Secunty#is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary and there will be no penalty for refusaL
-----."‘... ° - SA. 1 MAY 2 7 2014 0 .
Health Officer Dated
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This is a certified Copy of an Original Document. I hereby certify that , •
this copy is an exact reproduction of the Certificate of Death for the
person named therein as it now appears in the permanent records of the
Knox County Health Department, Vincennes, Indiana. Not valid unless
stamped with official raised seal.
