Death Certificate - Lloyd, Linda M_6/18/2014 e 9:11-' INDIANA STATE DEPARTMENT OF HEALT' 10 7 8 7 0 4
}S* C ERTIFICATE OF DEATH
Local No 000121 EDR No 000000389082 State No 026334
1.Decedents legal Name(Fast,Mode,Last) 1a. Malden Name(If female) 2.Sex 3. Time Of Den 4. Date Of Den(r.+onrmaynear)
LINDA M LLOYD COOMER FEMALE 04:50 PM 06/08/2014
63 ems Days Haas lajutes - - PRINCETON, IN
9. Eve in U.S.Armed Forces? 10.11 Deasy Occurred In A Hospital: 10a. If Dean Occurred Somewhere Otter Than A Hospital
0 Hospice Fatty ®Decedents Hane D Nursing Hanelt ng-ter n Care Factty
0 Yes 0 NO 0 Unknown 0 npaient 0 Emergency Department Outpatient 0 Dead on Annual 0 Other(Seemly)
11. Frity Name(If Not Insttuton.Give Street and Number)
108 NORTH 7TH STREET
12. Cory Or Town.Star,And Zip Code 13.County Of Den 14. Mentor Status At Time Of Dear
PRINCETON, IN, 47670 GIBSON
0 Maned ID nmrx e&n rued . Divorced
❑Wowed D Never Manna D Unknown
15. Suviwg Spouse's Name 15a.(If Wde)Give Maiden Last Name 16. Decedents Usual Occupation 17. Kind Of Buaisesstndinty
COAL MINER MINING
18. Residence-State Tea. County ISO. City Or Town
INDIANA GIBSON PRINCETON
18c.Street And Number IBd. Apt No. lee. Lp Code 181.Inside City Limits?
108 NORTH 7TH STREET 47670 0 Yes D No
19. Decedents Educator 20. Decedent IN Hispanic Origin 21. Decedents Race
SOME COLLEGE CREDIT,BUT NOT A
DEGREE NOT HISPANIC White
22.Flt's Name(First Meddle.Last) 23.Maser's Name(Fest.PAddle,Last) 23a.Mother's Maiden Last Name
GEORGE E COOMER ANNA L COOMER BEARD
24.Inbmants Name 24e.Relationship To Decedent 24b.Maio g Address(Street And Number.City,State,Lp Code)
BENTLEY LLOYD SON 108 NORTH 7TH STREET,PRINCETON, IN 47670
25.Place Of Dispassion
25a.Meg]Of Dispas on 25o.Place Of Dispossion(Name Of Cemetery.Crematry.Omer Place) 256 Loca'am-Coy,Town,And State
0 Burial 0 Cremation D Donation 0 Entombment
0 Removal From State
D ode(Spec,fyk HIGHT CHAPEL CEMETERY PRINCETON, IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Fealty 27a. Funeral Horne license Number
D Yes 0 No COLVIN FUNERAL HOME INC.425 N MAIN ST., PRINCETON, IN 47670 FH83005671
270. Signature Of Indiana Funeral Sernce Licensee: 27c.license Number(Of Licenaeey
MARK R.WALTER, BY ELECTRONIC SIGNATURE FD01013010
Cause Of Death (See Instructions And Examples) Approximate
28.Part I.Enter The Chain Of Events -Diseases.Irquries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset
Such As Cardiac Arrest.Respiratory Arrest.Or Ventricular Fibnllation Wthout Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Additirul Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. RESPIRATORY FAILURE d..touam.w..,.m 1WK
Sequentially List Condi;ians, If My.Leading To The Cause Listed On B.
Line A, Enter The Underlying Cause(Disease Or Injury That Initiated ii.wln..x om
The Events Resulting In Death)last C,
on.to An•v..w.v on
D.
Pan U.Ens Other;ga5cantCpdrims Contsbu'Yg to Den But Not Resulting In The Underlying Cause GMn In Pan I 29.Was NI Autopsy Performed?
0 Yes 0 No
INFIAMMED PULMONARY FIBROSIS 30.Were Autopsy Fining AvaCondo e To Condo nine Cause Of Den?
❑Yes 0 No
31. Did Tanacoo Use Contribute To Den? 32. If Female: 33.Manner Of Den:
®"saw.,Ward 0 ww.a AT Tom Of D.e 0 eau own ea w.:14•we.41 o..a ea, 0 Naaral 0 No de 0 Accident D Pinang Investigation
D Yes ❑Probate),0 No 0 Unknown
D,.. n B.ww..a Don To,row axe..D..e, D uars,I r..o.nws.o r.. r.. 0 Suicide 0 Could Not Be Determined
34. Dam Of njury(MnndvDay/Year) 35. Time Of Injury 36. Place Of Injury(E.G.,Decedents Home.Construction Site.Restaurant Wooded Area) 37.Injury At Work?
D Yes 0 N
3B.Location Of Injury-State 38a. City Or Town 380. Smtd Nludter 386 Aix No. 38d. Zip Code
.
39. Oesbbe How Injury Occurred /
, 40.If TranspaIaom Injury,5 fy.
_j :� Da ._ 06,- 0v*A464,,own
41. Sgnaure. Of Person Cen]yig Cause Of Death: 42.Cat 5r(Cr"Only One)
JERRY L LIKE ,BY ELECTRONIC SIGNATURE 0 Cenrrlrg Physician ❑canner
0 Heath015os
43.Name,Address And Zip Code Of Person Cetlying Cause Of Death: , 44.License Number 45.Date Caned
JERRY L LIKE , 110 W. SYCAMORE ST, ELBERFELD, IN 47613 02000254A 06/12/2014
46.Additional Funeral Service Provider. 47. 'Naas:
48.Signature of Local Heats OSCer. 49. For Registrar Only •Dam Fged(MmWDayrYeaR
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE JUN 13 2014
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
d(0 , 11 _ 9,- ).03 -000 . 1-11(0- Da 8
i C State Form_ 53395 ATTENTION ESTATE:The Social Secvrry a is being requested by this state agency in order to pursue responsibility. Dadosure is voluntary and there will be no penalty for refusal
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