Death Certificate - McClellan, Edna_7/10/2014 °3"y INDIANA STATE DEPARTMENT OF HEALTH 10 7 8 885
4 '�-j`t' CERTIFICATE OF DEATH
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' Local No 000019 EDR No 000000365160 State No 003548
I.Decedent's Legal Name(Fast Mgdle.Last) la. Maiden Name(If femaae) 2.See 3. Time Of Death 4. Date Of Death(Month/Day/Year)
EDNA MC CLELLAN KNIGHT FEMALE 10:18 AM 01/17/2014
90 Months Days Hours ,Vnutes
Hospital
0 Hospice Fealty 0 Decedents Hone 0 Nursing Hane&agtern Care Fealty
0 Yes 0 No 0 Unknown 0 Inpavent 0 Emergency Depart-rem Outhaea 0 Dead on Amval 0 Omer(Speedy)
11.Facility Name Of Not Yistt:m1.Give Stets and Number)
WATERS OF PRINCETON,THE
12. City Or Term,State.And Zip Code 13.County Of Death 14. Mental Scats At Time Of Dear,
0 Marred 0 Marred.But Separated 0 Divorced
PRINCETON, IN, 47670 GIBSON 0 Widowed 0 Never"named 0 Unknown
15.SuMeng Spouses Name 15a. (If 1We)GNe Maiden Last Name 16. Decedents Usual Oavpabon 17. Kind Of Businesaancusny
LIBRARIAN PUBLIC SERVICE
18.Residence-State lEa. County lib_City Or Town
INDIANA GIBSON PRINCETON
lat. Sent And Number 184. Apt No_ 18e. Zp Code 185 1.--side Cty Lads?
207 JOHNSON AVENUE 47670 0 Yes 0 No
19. Decedents Education 20.Decedent Of Hispanic Ongt 21. Decedents Race
SOME COLLEGE CREDIT, BUT NOT A
DEGREE NOT HISPANIC White
V.Fathers Name(First.Meade.Last) 23.Mockers Name(First Made.Last) 23a.Mother's Maiden Last Nate
EUGENE KNIGHT ANNA KNIGHT STEWART
24.Informant's Name 24a.Relatarship To Decedent 240,Mailing Adeess(Street And Minder.City,State.Zip Code)
MITCH MC CLELLAN SON 815 SOUTH STOUT STREET, PRINCETON, IN 47670
25.Place Of Disposition
25a.Method Of Dispositon 250.Place Of Disposition(Name Of Cemetery.Crematory,Other Place) 25c.Locaton-City.Town.And State
0 Benal 0 Cremation 0 Doraton 0 Entombment
0 Removal From State
O Other(Speedy): COLUMBIA WHITE CHURCH CEMETERY PRINCETON, IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Faciby 27a. Funeral Hate license Number.
❑Yes 0 No DOYLE FUNERAL HOME,520 S MAIN ST, PRINCETON, IN 47670 FH10400010
270. Signature Of Indara Funeral Service Licensee: 27c. License Number(Of Licensee):
BARRETT W.DOYLE ,BY ELECTRONIC SIGNATURE FD29500009
Cause Of Death (See Instructions And Examples)
Ater al: On
Su.hart I.Enter The stain sp Of story -Diseases.r Ventricular Itrynes, ib Or Cation Without- lnos ng The Caused The Not Abbreviate.re Do Not Enter Enter T r One Cause Interval: Onset
Such . Add Cardiac Arrest. es If Respiratory dry. Or Ven'uiaAar FiMllatim W mwt Snowv:g The Etidogy.Do Not ADbeviate.Enter ONy One Cause On To Death
A tine. Adtl Atldiiinal Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. ACUTE GASTROINTESTINAL BLEED 2 WEEKS
Sequentially List Conditions. It Any,Leading To The Cause Listed On B. ALZHEIMERS DEMENTIA 10
Da ea...
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated rr.M
The Events Resulting In Death)Last C.
Owe to A.A Camara 05
D.
Pat II.Enter Omer Sgntcant Condoms Con;nbutino to Death But Na Resdang In The anent g Cause GMn In Part I 29.Was An Autopsy Perfumed?
❑Yes 0 No
PNEUMONIA
30.Were Atrousy Fetng Avaddde To Complete The Caine Of Death? 0 Yes 0 No
31.D d Tobacco Use Conthoute To Death? 32. If Female: 33. Mama Of Death:
0 rawwl..w.ne=wa v.., 0 Prwra.,.urww Of p•.e 0 as nw•.a eewwo-.,wed,.7 Tenor..e. 0 Natural 0 Homicide 0 Accident 0 Pendrg lnvesdgaton
0 Yes 0 Probably 0 No 0 Unknown
O as 8r.,,•6.e.88Twa1..4 Der.To 1 -e.b.0.mm ❑u.,-..nommers,.,T. ❑Sable 0 Could Not Be Determined
34. Dam Of Injury(Month/Day/Year) 35. Time Of Injury 36. Place Of Injury(E.G..Decedents Hone,Conduction Site.Restaurant Wooded Area) 37. Irqury At Work?
0 Yes 0 No
38.Locator Of lryury-State 33a, Cry Or Term 38b. Street 8 Number 38c, Apt.No. 38g. Zip Code
L
39.Demme How Injury Occurred - 40. II T e.m.s e.Injury,5 M
Qpiwd Qa.vw.i. Le°ear, 0 prvlSarlY1
a1.Signature. Of Person Ceriying Cause Of Death: 42. Lender(Check Ord!One)
MICHELLE L.SNYDER. BY ELECTRONIC SIGNATURE 0 CeMyirg Physician 0 Coroner 0 Hears Officer
43.Name,Address And Zip Code Of Person Cet Eying Cause Of Deep.,, 44. License Number 45. Dad Cerc°..ed
MICHELLE L.SNYDER , 1808 SHERMAN DRIVE, PRINCETON. IN-47670 02001984A 01/24/2014
46. Addtonal Funeral Service Provider 47. 'Alas:
48.Signature of Local Hearth Officer. 49. For Registrar Only -Date Filed(MonEJDaylYeark
BRUCE BRINK JR, VIA ELECTRONIC SIGNATURE JAN 27 2014
AMNDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
(9 G- /Or -O8-ao3 -001.911 -0a?
State Form HA 353395 ATTENTION ESTATE:The Social Secury=is oe:ng requested by this state agency in order to pursue responsibility. Disclosure is voluntary arid there will be no penalty for refusal.
V ATTENTION
. (7105) .