Death Certificate - Gardner, Joyce_6/23/2014 ' , Be-Aoe-Yrs t BO:Under 1 Yeari 6c..Under 1 Month:et DnaIt/ay> :Be.Under 1 Hour, 72 Date of Byth.(M.onLYDay/Year) 'S.BirthpLatbe(City end Slate or ForeignCounty) I, i 1
9.,Ever in U S.Armed Fordes7: 10.II DeatttOoarree In A Hespitat , ,li 3,, .,:s. t -::,4•.'10a:I:Deattipccurred Sornelshere Ober Than A Hospital' „ ,r-
15a. al lAite)Gbe Maiden Last Name 3-, • T i e' -10. Decedents Usual Oocupation • I jf:Kane cc thisireanneusty: - '...
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"" .241s.Mading Address (Street And Number,City.Statk Zip Code) - : '. ' • .
25a.Method Of Disposition -, - - i, : , 250.Place Of Disposition(Name Of Cemetery,CreMadary;Other Place); 25c,Location i city.Town And State ' . • . .
. 26.Was Comner Contacted? , " 27. Name And Complete Address Of Funeral Fa,bity i.i, ,, „..',... .L's• t e c ...z, ‘.., ,,,... , . . 27a Funeral Home LicenSet.'NUM,.be. r.,
- HOLDERS FUNERAL HOME OF GIBSON COUNTY, INC:, 319 SOUTH MAIN STREET, ; ' ' • .
272 Signature Of Inciana Funeral Seneca Licensee: • ' . ; : . ' 27c License Number(Of Licensae):. ,'
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2e Part I.Enter The ChaM Of Eventi -Diseases,Injuries,Or Complications-That DireCtly Caused TTP Death:Do Not Enter Terminal Events Interval: Onset i
. Such As CarcliacAriest,Respratcry Ariest,Or Ventricular Fibrillation Wthout Snowing TheEtiology:Do Not AbIyey_late.Enter On&One Cause On ' To Death
I, Inimadiaie Cabse(Finil Disease Or Condition Reitatavg In Death) A VENTILATOR DEPENDENiT RESPIRATORY FAILURE 1 FEW WEEKS_ '
' •Sequenhatly List COndaions, 11 Any.Le•aclirla To The Cause Listed On B. ESOPHAGEAL PERFORATION`, - e....;;.,...' .4 ,
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i Part Il.Enter Otner Sionificant Conactons Conthbutme to Death Bet Not Resulting In The Underlying; Cause Shin In Part It • 29:-Was An Autopsy Performed?
‘• •,/ ' e 30..Went Att.OpSy Finding Available To Garrottes The Cause Of Deabq• ' : -
-.:' 34, Date Of Injury(montwpayiyeal „ - ,, 35, Time Of InturY 36. Place Of Inery(E G.;Decedencs Horne;Ccenatuction Ste,Resta:rant Wconled Area) 37. Injury At Won?., ''
I. 39. Descrte How hen Occurred .
:. 41: Signature, 01Person Candying Cause Ot Death:-
•.:. 43,Name.Address And Zgo Oahe Of Person Certifying Cause Of(haat 44. License Number 45. Dabs Car...2ea • .
.„•' State!on,0 533,95..ATTENTION ESTATE;The Sepal Security#is tieing requested by thii,stati'lgelict ircoicleik'Piirlue respcSiiibikti.,Diiclosure is Yoluntary arid then:twig be no penatty tor refuSal : ? ',, ei.f.
' ' WAR NINd. ORiGINALtiocUMST HAS A mui4rIdOLOFIE6 BACOR0-6 ND ON SfrEOlAg Ming-SEbt/RITY PAPER AND THE GREAT-SEAL Of TNE STATE OF IND/ANA C/N BACK THAT , .
...TURNS FROM ORANGE TO YELLOW WHEN RUBBED;ORIGINACDOCUMENT HAS HIDDEN VOID ON FRONT THAT APPEARS SVHENPHOTOODPIED.,". b....-_,•3 k-e--......iv'' -