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Death Certificate - Royal, Chester D_6/17/2014
,a yr INDIANASTATEDEPA MENT OFHEALTH ;` CERTIFICATE OF DEATH s'- ,` ' , Local,No 000843 •EDR No 000000381442 .. state No;019143 n 41OCcadenteLega Namet(Fesl Middlelast)-,, ' ,1 ^ la:Nation Name(Itleme).; - 2.Se '3.Jade Ot Dean 4. Date Of Reath(Mon:NDayry r) . HESTER DAVID ROYAL,: - ` r -,` 1 - .' "MALE :.. 04:00 AM 04121/20141 110 11 Deaf:Occurred t A Hospital' loo If De,?Occurred Somewhere Omer Than A Hospital y❑Yes (]No 0 Unknown m Emergency ❑�� „�•al ®hosgca Faairy ❑DeceeeMS Herne ❑Nursing Hpme&ong-term Care Faotiry ❑Inpate ❑ ergency Department Ou atem ❑Odier(SOeoY) 111. Faccty Name (It Not Instl:an,Give Street and Number) 'DEACONESS HOSPICE CARE CENTER 'F 12. City Or Town,State,Arid Zip Code 13. Cony Of Death 14.Marital Status At Time Of Death 0 Maned❑Marcel,But Separated ❑Doomed VANSVILLE, IN,47747 VANDERBURGH ❑stowed ❑Never Mamed ❑Unt n :.15. Suv,wq Spouse's Name 15a. (IIVdte)Grve Maiden Last Name 16. Decedents Usual Occupation 11. Kind Of Busleesstndussy 1 ANICE F'ROYAL MILLER - , WAREHOUSEMAN INDUSTRIAL STORAGE ?1S. Residence-State 13a County 160 Gty Or Tom - 'NDIANA GIBSON PRINCETON 13c.Soee'Ard Number I 161 Apt No 'Be. Zip Code 1St. Inside Dry Umutsi 15 WEST MILL STREET 47670 0 Yes ❑No 19. Decedents Education 20. Decedent Of Hispanic On9n 21. Decedents Race ti j:TH GRADE OR LESS NOT HISPANIC White :22.Fathers Name(First.M1dd:e,last) 23.Mousers Name(First,Middle,Last) 23a Mothers Maiden last Name :-OY M ROYAL LOUISE ROYAL GASSER +24 Irn.rmarl's Name 24a.Rela'tonsyp To Decedent 240 Ma&ng Address (Sueel And Number,Cdy.State,Zip Code) ANICE ROYAL WIFE 915 WEST MILL STREET, PRINCETON, IN 47670 25.Place Ol DSoosedh ' r 25a.Memod 01 Dsposaon 25b.Place Of Dlsposlbdn(Name Of Cemetery.Crematory,Omer Place) 25c.Location-Coy,Town,And State ©Baia ❑Cremation ❑Donation❑Entombment ❑Removal From State ❑Dane(Speay): OWENSVILLE CEMETERY OWENSVILLE, IN 126.Was Corona Contacted, 21.Name And Complete Address Of Funeral Fealty 27a Funeral Horne license Number. ❑Yes El No DOYLE FUNERAL HOME, 520 S MAIN ST, PRINCETON, IN 47670 FH10400010 270. Signature Of Indiana Funeral Service licensee: 27c. License Number(C4 Licensee). :ARRETT W. DOYLE . BY ELECTRONIC SIGNATURE FD29500009 t Cause Of Death (See Instructions And Examples) Approximate n Su.Pan I.Enter ia The Chain Of Events - st,Or a'Nunes,Or n Vtitiass-Tnat ng The Caused The Not Ab re Do Not Enter Tent'OnEvents To Deat Onset Sum As Cardiac Arrest,Rs If Necessary. Or Ventricular Flvigatidn N11Mtn S.howig The Etiology.Do Yol AOtresiate.Enter Only One Cause On Te Dea:n A Line. Add Mdihnal Lees If Necessary. Immediate Cause(Final Disease Or Condition Resulting In Death) A METASTATIC SOUAMOUS CELL CARCINOMA YEARS t W,is P.x,e Cavw.m W : Sequentiafy list:t Centro:cm, 1:Any,Leading To The Cause listed On B W,ula 4 AC ...v.,e pt Line A Enter The Underlying C.use(E4.c se Or Injury That Initiated The Events Resulting In Dcs;,)last C a.I.a...v.„po j D 1 Part II.Enter Omer Rarni'sntCond3iuns':Ptmutno to dean 9u,Rot Resulting In The Underlying Cause Gun In Pan I - 29. Was An Autopsy Performed? 0 Yes El No - E01LItt.FRAIL 30. Were Autopsy Find g Availeole To Complete The Cause Of Dean? ❑ B ?` Yes ❑No "31. Da Tobacco Us:Ci not se To Dead 32.If Fendue. 33. Manner Of Death. 0tea tit.are Vann Pat 10.0 ❑P,.,.nu i.e.or oaan ❑Nae,•sa'e.e.A,a.rev,t,c n Pro ounn ®Natural❑Homiode ❑Accident ❑Pending Imesbga'vm -3❑Yes ❑Probab;t No ❑UnFrcwn III.. anoan Ts n reap Bete.Pere ❑tb.,,.Pe Pie>wew.a The Pane.. ❑SUcide❑COo Not Be Detemuned 34, Date Of Injury(MorJFrytYeerl 3S "Time Of Injury M 36. Place Of lr•{try(E G.,Decedent's Home,Conauucton Ste,Restaurant'Noce-ea Area) 37.Itjpry At Word? f ❑Yes ❑No •'38. Location Of Iryu r y-Sta '&a. Dry Or Town 3S0'Steel&Number 33c. Apt No. add Zip Code 39. Descise how Injury Occurred 40. it Traispanati n L'yuy,5 y ❑P+n.KSe.ar ❑P....T1 lfeea a❑oa.ls..al !let Seara:ute,Of Person C.:21prd Cause Of Dean' 42. Cert her(Check ONy One) -jI OUGLAS JAYE HATLER, BY ELECTRONIC SIGNATURE G Cettyig Pnysioan ❑Coroner ❑HeanOSmr •43. Name,Address And Zip Code Cl Person Cat-trying Cause Of Death 44. License Number 45 Date Ce2`ed -iOUGLAS JAYE HATLER ,4498 FIRST AVENUE, EVANSVILLE, IN 47710 01039937A 04/28/2014 46. Addiaw Funeral Service Pr:vider 47. •A'av R. • ' q , . 343. Signature of Local Heaut O:`or. 49. For Registrar Only -Date Filed (.MenthDayr:ear) =,-OBERT KENNETH SPEAR,VIA ELECTRONIC SIGNATURE i -- - . . APR 30 2014 AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL); a� 0 ao�t-ooa , 8 T . i ' ' tale Form 53395 ATTENTION ESTATE:The Social Se_unry ais being requested by Ohs state agency in'orderto pursue responsib&ty Disdcsure Is voluntary endthere vw(be no penny for fe.sal. a - il//L p N I- - , ORI,GINAL DOCU VEM HAS A MULTICOLORED BACKGROUND ON SbEC(5L WHIT!SECURITY PAeEERAND THE GREAT SEAL OF THE STATE-OF INDIANA ON BACK THAT' ■1Mfll`I ,Y\.7•..TURNSFROAIORAN•E T•YELLOW WHEN RUBBED-ORIGINAL DOCUMENTHAS HIDDEN VOID•_ FRO THAT APPEARS WHE PH.TO .-ED,_ 2- .