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Death Certificate - Whitten, James R_7/3/2014 "j q' / INDIANA STATE DEPARTMENT OF.HEALTH ` 4 !i_ CERTIFICATE OF DEATH]• Local No 001216 EDR No 000000f391348 stateNoa027860>". - O )} 'De eae Is I Name'(Fyr Ar e,Las:) 3a. Maher Name (I:'emelt)- 25ea 3 -Tone Of Demp @-Date Of Der.(A,"JDayhear)•I 4! 1Ij W JAMES ROBERT HITTEN A MALE 1055'AM ; 06/22/2014 16:If Dear Occurred In A Hosoilal: 16a. If Dean OH-cured Somewhere Crier Iran A Hospital Yes ❑N- ©Hospice Factry ❑Decedents Home ❑Nursing home$mTterm Care Fadtty 11 0 ❑unknown ❑Inpatent 0 Emergency Dep2.mentOuMatert ❑Deadon AIrwat ❑Omer(specGA) m 411 Feat/Name (If Not lnstrdn,Give Sreet and Number) X'CHARLIER HOSPICE CENTER ');,12.Cy Or TOwn,Sate,And Zip Code 13.Cototy O'Death 14. Mental Status At Time Of Dears 1i_ t Marred❑Marred,But Seoamted ❑Divorced 'EVANSVILLE, IN,47713 VANDERBURGH ❑Wddwec 0 Neverizmed ❑Unknown 15. Slrrttg Spouse's Name 15a. (I1VYe)Give Maiden Last Name 16. Decedents Usual Occupation 17. Kind Of BusioessAndustry it ;PEGGY WHITTEN HOOVER TOOL AND DIE TOOL AND DIE '115 P.esibence-State lea Cray tee. City Or Town IIINDIANA GIBSON PATOKA t let. SCee:And Number lad Apt No. tee. Zip Code 181. lr,side City tints, 1 108 SOUTH WEST STREET 47666 Yes ❑No 19. Decedents Education 20. Deaden:Of Hispa-ic Ongin 21. Decedents Race HIGH SCHOOL GRADUATE OR GED .COMPLETED NOT HISPANIC White 22.Fa::era Name(First,Midde,Last) 23,Matters Name(First,Middle,Last) 23a Mothers Maiden Last Name LAMES COMMADORE WHITTEN AUTHELIA WHITTEN SLINKER ii 24.Insnants Name 24a.Relaassnp To Decedent 240 Mal'i9 Address (Sven And Hinter.Cry,State.Zip Code)Ce) PEGGY WRITTEN WIFE 108 SOUTH WEST STREET, PATOKA. IN 47666 25.Place OI Disposi.on - I 25a Mead Of DSpcsoon 255.Place Of Dtspositon(.Name Of Cemetery.Crematory,Omer%ace) 25c.location-City,Town,And State ❑Ducal .Cremation ❑Ccnaoon❑Entombment ❑Remmai From Sate ❑Omer (Specify): • MT OLIVE CEMETERY MOUNT OLYMPUS, IN 26.V:as Coroner Contacted', 27. Name And Complete Address Of Ftmeral Faosy 27a. Funeral Home DCenae Number ❑Yes p No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671 Signa:re Of Indiana Funeral Service Licensee: 27c License N• ..der(Of Licensee): JOHN W WELLS , BY ELECTRONIC SIGNATURE IF D01009940 Cause Of Death (See Instructions And Examples) Approximate 29.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused Tne Death.Do Not Enter Terminal Events - Interval: Onset Such As Cardiac Arrest,Resctraary Arrest,Or Vererwar Fibrillation Wthout Showing Tne Etiology.Do Not Abbreviate.Enter Only One Cause On To Dean .A Line. Add Addeinal Lines If Necessary. Immediate Cause(Final,Disease Or Condition Restlasg Ir.Deem) A END STAGE RENAL DISEASE 1 YEAR pp a.to to s.•Ca,ea.ee,on Sequentialy List Cond,tiens, C Any,Leading To The Cause Listed On B. e Line A. Enter The Underlying Cause(Disease Or Injury'That Initiated pnnlab.uvai,reM The Events Resulting In Death)Last C. Da ie so s..caeesa,v D. 051 a.Enter Omer Significant Coregyrs Scn:nti:_no to Death Ste Not Resdsng In The Underlying Cause Glom In Pant 29. Wys Ar.Autopsy Pedamed? ❑yes (v]No '%Pere Sumo'?Fv-ng Avatanie to Ccmpfete Ths Cause O:Dorn? CUTE M'N:ooUseC INFARCTION osour Ti0N _ I ❑Yes ❑Ito II 31. Dm Toon:co Use CCa-Sate To Death? 32. !I Female 33. Larne:Of Death. i❑Yes ❑ProbaNy D' N: ❑U .m.vn I ❑v.:n.T evm.Pate... ❑ter..Al ire a Deal T cut 0 Natural❑Hotom de ❑At09em ❑Pendng Investgabon ID .r.n siaa. ..0 a..T.I H.mt.ant.. s pwv • ❑Seioce❑Cala Not Be Determined 34. Date Cl lryury(,'CUEING 3yr,ear)nt 35. Tura Ct Injury: 36. PI OI`In ( 0 c H rxn Ste,.Resaurant Wooded Area) 37. LyueAt\tors? {N - a�s. ❑Yes ❑No n'32. '-ocationOf Inyal..Sate ?fa Dt•or Town 3ED. Bunter)ly(:',-de: 33c Apt No. 350. Zip Code 1 I JUC 2 2014 I i 39. De scope How lntry il ..:e - a> <9III Transper.::m burr, eoy: I s7/'/JI°�{>/,. ❑ ❑a.unY'OP....'❑arl5-'flu l',41. Signature. O1 Person Cer..'yuy Cause f as[aatn G I BSs 42. Cer:.Ser IDhecs,Orq One) PATRICK C. FLAMION t BY ELECTRONIC SIGNATURE ON COUNTY AUDITi e�y'aw Pnysiaac ❑eaprer .❑Hearn Or+ar a43. Name,Address And Zip Goa Ol Person Cery,ng Cause CM Dee._ 44. License Name% 45.Date Certied If iPATRICK C. FLAMION . 801 ST. MARYS DRIVE# 110 EAST. EVANSVILLE, IN 47714 01027520A 06/23/2014 46. Aod:onal Funeral Senice Provider. 47. id • t 4e. Sig-._'.re of Local Hea::CM:Er. 4's. For Registrar Only -Date Feed(Mann°DayNear)t 1ROBERT KENNETH SPEAR,VIA ELECTRONIC SIGNATURE : I - - JUN 24 2014 . - 1 - 5 % AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)- l.- 1 e2( ia o$-la3 boa sir aaa s ;. a� o4'as i��q��� Tb� o��oa�f�SS is'1.e' nano : s .e e�. .0 ep Coro a WE? p� out Y j r I ..ate Form 53399 'ATTENTION E50RIG1N'AE.DOCUALEFr( AMULIIWLDln=DYEiZL,KUHOaTlica Pcr1AM-1ifErSVG3RiiYyPAr4tRAS.45e;i b.af THESTArieSI EtarciN BACK THAT' --.WARIYLNG..TDRNS.FROM ORANGE TO YELLOW WHEN RUBBED.ORIGINAL-DOCUMENT HAS HIDDEN VOID ON FRONT THAT/APPEARS\VeEN PHOTO CO PIED: ^' .v ... .a - u a. « - �i>-�v.ad