Death Certificate - Williams, Vera J_6/24/2014 ISSIISTAN OFFI A I'1,.. IIt i 1 (. _ '1 • • . ) --I , I- .1 - ; , ,.;:,
/ 4\ INDIA • i • . - , l i 1078727
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� - CERTIFICATE OF DEATH
4 Local No 000124 EDR No 000000389483 2.Sex State No 026475 laYnear)DeaM nes ` le. Maiden Name(If lank)I.Canines Lea Name(Ara.Wide,Last)
VERA JUNE WILLIAMS CLARK FEMALE 12:50 PM 06/10/2014
Months Days Nan ^mutes -. -- 06/12/1928 MT CARMEL, IL
9. Ever in U.S.Aimed Faces? IOU Dean OCVare0 in A Hmgtst 10a. tt Death Occurred Sonewaere Omer Than A Faced
0 Hospice Fa )ty 0 Decade is Herne 0 Nursnp HmwlmPteml Care Facl tN
❑Yrs 0 No ❑Unknown 0 Iroa6er,t ❑Emepenq Deoaonent Ovatiabera ❑Dud m Artiva 0 Oster(s icy) N -F -
11.Faaty Name(tt Not nstttbdr\Give Street aid Number) -_v w
RIVEROAKS HEALTH CAMPUS I ' - . N
12 Cry Or Town.Stex.An Zip Code 13.Canty Of Death _ - 14.Matta Stare At Tone Of Dean
.a_-; Zt 0 Maned 0 Married.B Seated 0ONdmac
PRINCETON,IN,47670 GIBSON / F_ 0W°a'v°d 0Nen Maned 0Unknown
15.Stimmirg Spouse's Name 15a,Of Wde)Gee Maiden Last Name " 16. DecMmts Usual Occupation 17. KM Of BesnesvIndusty
• G ABSTRACT TITLE
JOHN WILLIAMS SECRETARY COMPANY
18.Rename-State 18a.Canny 18b.City Or Tan
INDIANA GIBSON PRINCETON
,SS Apt No. Itt. it Cate 181. trade City Leah?
301,a< resent And Number
WEST GLENDALE STREET
47670 0 Yes 0 No
19,
19.pecedeasEWw:+on 20. Decedent Of Hispanic Oran 21. Oeuden[S Race
HIGH SCHOOL GRADUATE OR GED HISPANIC White NOT HISPA
COMPLETED 23.Mother's Mame(Fist Mule.Last) 23a.Moses Maiden Last Nine
az.Falters Name(First Male.Last)
LLOYD CLARK MABEL CLARK EVERS
24.Informants Name 24a.RSaamstvp To Decedent 240.Mailing Andras(Street And Number.City.State,Zen Cade)
JOHN WILLIAMS HUSBAND 301 WEST GLENDALE STREET, PRINCETON, IN 47670
25.Place Of Diroceaa,
25a.Net Of Deascat 250.Plate Of Dispaleon(Name Of Ceme:ay.Cternetay,Other Place) 25c.Lmaeen-Coy.Town,And Sate
0 Bahl 0 Gentian 0 Donation 0 Entombment
0 Removal From State
0 Omer(Spedyr COLUMBIA WHITE CHURCH CEMETERY PRINCETON, IN
26.Was Cormier Contacted? 27. Name And Complete Address 01 Funeral Fadely 27a. Funeral Home License Number.
0 Yes 0 No COLVIN FUNERAL HOME INC,425 N MAIN ST.,PRINCETON, IN 47670 FH83005671
27D.Signature Of Indiana Rang Service Licensee: 27C License N,dee(Of Naeaeet
MARK R.WALTER, BY ELECTRONIC SIGNATURE FD01013010
Cause Of Death(See Instructions And Examples) Appronrnate
28.Port 1.Enter The Chain Of Events -Diseases.Mama.Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset
Such As Cardac Artesia Respiratory Arrest Or Ventricular Fibiiatian Without Showing The Etiology.Do Not ADDredate.Enter Onty One Carne On To Death
' A Line. Add Ad6Dnal lines tt Necessary.
A. TYPE II DIABETES WITH NEUROLOGICAL MANIFESTATIONS SEVERAL YEARS
munediete Cause(Final Disease Or Condition Reuling In Death) eta era..n on
SEVERAL
B. TRANSIENT CEREBRAL ISCHEMIA MONTHS
Line A.D Enter List a Underlying au, If Cause Leading To The Cause Listed ed On Da w,o a.rase..m
A. Enter The ng In Death)Cause(Disease Or Injury That Initiated SEVERAL YEARS
The Events Resulting In Death)Last C. HYPERTENSION ow tie 44A cowwwcs 01
D. CONGESTIVE HEART FAILURE SEVERAL YEARS
Pat U.Enter Omer 5 But Na Rattan;In The Underlying Cane GMn In Part 1 29.Was An Autrey P%Mmed? 0Ya 0 NO
30.Were Autopsy Fswq Available To Complete The Cause Of Dean? 0 yes 0 No
HYPOTHYROIDISM 33. Manner Of oaan:
31.Old inane Use Cdntribtrte To bum? 32.d Ferrate: 0 Namrn 0 i iJCide 0 Accident 0 Penciaa Imetgadon
0 NO n-0,..we.,rrr.w ❑r,q-star..scam 0 Na✓iw4e.rwa.a.w..,.a o-rao-.w
0 Yes ❑Probably 0 No ❑Unknown 0 ra P.a.*.as Pin-.y ears Te l r San an 0 tarr•nw+Vin eta r.a mew 0 Suidde 0 Clan Na Be Determined
34.Date Of Injury(MnwDeylar) 35.Time Of tan 36. Place Of navy(EG..Decedents Home,Casauctron Site,Resaraanl Wooded Area) 37.Injury At Work?
❑yes 0 No
]ea. Cry Or Ton 386. Street 8 Natter 38c-Apt No. 36e,ZC Code
3A Ld�ar 0llryroy-StSa
39.Oeealpe Ha"Many Occurred ffmF/
41.Spndrt,Of Person CarHymg Case Of Death: 42.Cattier(Check Only erne) f.Ormer 0 death OOm
BRUCE CARLTON BRINK JR. BY ELECTRONIC SIGNATURE I 0 certy69P"rsdan
44.License Number 45. Date Canted
ai Name.Address Ana Zip codem Person Certy+a caseaoath:
BRUCE CARLTON BRINK JR ,410 NORTH MAIN STREET,PRINCETON, iN 47670 02000610A 06/13/2014
47.'Akin:
aB AOO6ipna Funeral c
Service Render re wden
4B Sipneose of Local Hetet Officer 14E. For Registrar Only -Date Filed(MmaJDayNeaF
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE I JUN 16 2014
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
aG 12 D1 - /D1 - 003. ab4-0af
State Form 53395/ ATTENTION ESTATE:The Social Seamy a s being requested Dy Pis state agency in order to pursue respasibily. Disclosure is voluntary and there will be no penalty for refusal.
(7)05) r EVOIO IF ALTERED ORERASEDxNOT VALID UNLESS 6ERTIFIED BY HEALTH➢EPARTME'NT;