Death Certificate - Dillon, Kenneth A_7/25/2014 "' INDIANA STATE DEPARTMENT OF HEALTH 3 5 0 7 5 5
f' k,
i? j CERTIFICATE OF DEATH .
` :" Local No 000148 EDR No 000000394402 State No 031073
1.DeceIX S Legal Name(Firs.Mddle,Last) Ia. Maiden Name(If female) 2.Sex 3. Time Of Dean 4. Date Of Death(MOIYNDay/Year)
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KENNFH A DILLON MALE 04:45 PM 07/10/2014 -
Monte Days Hass Minutes 10/24/1933 POSEYVILLE, IN
9. Ever in U.S.Armed Forces? 10.If Deem Occurred In A Hmpal: 10a. (Meath Occurred Somewhere Other Than A Hospital
❑Hospice Facility ®Decedent's Home ❑Nursing H ameLongrcrm Care Facrity
®Yes 0 No ❑Unknown ❑Inpatient❑Emergency Department Outpanmt ❑Dead on A+nval 0 OPer(speciy)
11.Fatty Name(If Not InY:wadn,Grve Street and Number)
6664 WEST 400 SOUTH
12.Cay O Town,Sam.And Zip Code 13.County Of Death 14.Mantal Status• At Time Of Deem
OWENSVILLE, IN,47665 GIBSON 0 Mamed0 Maned But anieam ❑psis
❑Wicicrwed ❑Neves Mashed ❑Unkiorc
15. Surviving Spouse's Name 15a.(If W'e)Gire&Moen Last Name 16. Decedent's Usual Occupation 17. Kind Of Busnessandusty
PEGGY DILLON GARRETT MAINTENANCE MANUFACTURING
18.Residence-State nBa. County 180. City Or Town
INDIANA GIBSON OWENSVILLE
1Bc. Sweet Md Number 180. Apt No. 18e. Lp Code 181.Inside City limas?
6664 WEST 400 SOUTH 47665 0 Yes ®No
19.Decedent's Educators 20. Decedent Of Hispanic Orgn 21. Decedent's Race
•
9TH- 12TH GRADE;NO DIPLOMA NOT HISPANIC White
22.Famer's Name(First.Mode,Last) 23.Mainers Name(First Mddle,Last) 23a.Mother's Maiden Last Name
DEWEY DILLON AMY DILLON WATERS
24.Informant's Name 24a.R laddnstup To Decedent 240.Maing Addess(Street And Number,Qty,State,Zip Code)
PEGGY DILLON WIFE 6664 WEST 400 SOUTH, OWENSVILLE, IN 47665
25.Pace Of Dispasv C -
25a.Method Of Daposraon 25o.Place Of Disposaon(Name Of Cemetery.Cremamoy.Other Race) 25c.Location-City.Town.And State
®Bwal ❑Cremation Daub= Entombment - - '
na
❑Removal From State
❑Omer(Speoty): OWENSVILLE CEMETERY OWENSVILLE, IN
26.Was[awe Congaed? 27. Name And Complete Address Of Funeral Faotty 27a. Funeral Home License Number.
❑Yes 0 N COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671
27b. Sgnature Of Indiana Funeral Service Licensee: 27c.license Number(O Lcemeez
RICHARD DEAN HICKROD , BY ELECTRONIC SIGNATURE FD01012153
Cause Of Death (See Instructions And Examples)
Approximate
23.Par,I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset
Such As Cardiac Arrest,Respiratory Arrest.Or Ventricular Fibrillation Without Showing The Etiology.Do Not Aobreviate.Enter Only One Cause On To Death
A 4-.e. Add Additval lines If Necessary.
L:unediate Cause(Final Disease Or Condition Resultng In Death) A. METASTATIC MALIGNANT MELANOMA OF NECK 2 YEARS
or uua...ce...po
Sequentially List Conditions. It Any.Leading To The Cause Listed On e'
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated D.....0....ca..o..,r.ar
The Events Resulting In Death)Last C.
ow etc,..e C®u..v Mt
D.
Part II.Enter Other Sion.:rant Copeons Cooabupno to Death But NIX Resoprg In The Ukdedyvg Cause Given In Pat I 29.Was M Aaoosy Perfmned? 0 Yes 0 No
NONE 30.Were Autopsy Finding Available To Complete The Cause Of Dean? Yes ❑No
31. die Tobacco Use Combtte To Death? 32. If Female: 33. Marne Of Death:
❑Yes ❑Probably®Nd Unknown
❑emn.w.cum,P.avw 0 wy,.e.I r...ou o..3. 0 u'P,.P..Se P.y..e we-.ra o.,.aa.a ®Natural❑Homicide ❑Acddent ❑Pending Investigation
❑Nat w.r.•4 e.n Peas 43 o.,.T.i,�e.w.o-a. ❑uteri•Penn..wa.The Pat vim, ❑Suicide❑Caid Not Be De.enNned
34.Date Of Injury(M ntn/Dayiyear) 35. Time Of Injury 36. Pace Of injury(E.G.,Decedents Hare.Cansm3cmn Site.Resaurant.Wooded Area) 37. Injury Al Work?
❑Yes ❑No
38.locaton Of Injury-sate 38a. City Or Town 300. Street a Mittu er 38c. Apt.No. 38d. Zip Cade
3G Desame How Injury Occurred a O. If Traispe mavdnIryury. ..N
pa,...43,.. pP ..� Qo..ls.an
41.Sgnre.Of Person Cer`aeIg Cause Of Death: 4 I t I '
ai - _42.Cen Only One)
(Check e)
CHESTER ROBERT BURKETT, BY ELECTRONIC SIGNATURE \ L ®Ceefting Physician ❑Coroner ❑Heat,OCCer
43.Name.Address And Zip Code Of Person Ce tNi g Cause Of Deady 40, License Number 45.Dare Cart_`ed
CHESTER ROBERT BURKETT ,9200 HWY 68 P.O. BOX 550, POSEYVILLE, IN 47833 01029806A 07/14/2014
46.ACapOnal Funeral Service Provider: 47. 'AkaS:
45. Sgnature of Loral Heath O:cer. -- -49. For Registrar Only -Date Feed(MON/DayD'earr
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE JUL 14 2014
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
.•. al10-1 i-042 -) oo - Col- 3,3 if moa r
State Form 53395 ATTENTION ESTATE:The Social Secuny a is being requested by this state agency in alder to pursue responsibemy. Disclosure is voluntary and there will be no penalty for refusal.
- IVRA-20
- (7105)