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Death Certificate - Cook, Jesse Ray_7/31/2014 INDIANA STATE DEPARTMENT OF HEALTH 349 / (j5 .. ` CERTIFICATE OF DEATH -;i Local No 000159 EDR No 000000396301 state No 033685 I.DaYdes*s Lege Name(Brett Male.Lm4 la Malden Name Of%male) 2.Sas 1 Roe Of Death 4. Date Of Der (to tvVaWVeeh JESSE RAY COOK MALE 04:00 PM 07/22/2014 - Occurred In A Resent 10a. If Death Oc toed Sommer!Other ma,A Hospital ' 0 Hospice Facie 0 Decedent's Nonce 0 Rasing Imrne&ap%rhn Can Fatally 0 Yes 0 No 0 Uneven 0Ir ate4 0 Emergncy Department OupaSed 0 Dead on Asia 0 ons(SpeNM 11. Fasty New plea InsS,tat.Give Steel at ember) - 7683 EAST 550 SOUTH 12.City Or Tom,Sate.AM to Gee -11 Come Of Der w.Made Status At The Of Death 0 0 acme FRANCISCO,INN 47649 GIBSON Widowed 0 Ne 0tnem a 1S&M eng Spouses Name 15a.(If WW)Cdve Medst Last Nana Id Decedent's Usher Ocopaoh 17.Kind Of 9ranmtglmy r SHARON COOK POWELL _MACHINE OPERATOR FACTORY 18. Rmidese•State 18a Candy 18b. Gay Or Tom INDIANA _GIBSON FRANCISCO 18e Street And PAmrte 18d Apt N, . 185. 2p Cods 182 Mee City ueb7 7683 EAST 550 SOUTH • 47649 D Yes 0 N 19.Decadenra Gasmen n 20.Deadest Of tat Oben 21. Decedavh Race HIGH SCHOOL GRADUATE OR GED COMPLETED NOT HISPANIC White 22 Fathers Name(Fit MM.Lee) 21 MMnda Name(9rnl.wdate.tea) 23a Mothers Medan last Nam LLOLYD SMITH COREAN COOK _COOK 24.bdamesa Name 24a RedstonsNp To Decedent 24b.MOM Address(Street AM Nabs.City.State.$Cada) SHARON COOK WIFE _7683 EAST 550 SOUTH, FRANCISCO, IN 47649 20 Place Of Ohposidm 25a.MOM Of Dbpmtiat • 250.Place Of DM:mtlm(Name Of Cambry.Crmmmy.Over Race) 25c.Laceern-Cey.Tow,AM State 0 WWI 0 Otnad n 0 Donate 0 Emmental 0 Removal Fran Sot D Omer(Speed/ EVANSVILLE CREMATORY . EVANSVILLE, IN 2a Waa Cotner Combed? 27.Nam And Carpals Address Of Fume Fatty 27a Fuss par.Wane Meer ®vas D No LAMB BASHAM MEMORIAL CHAPEL, INC.,226 E.WASHINGTON STREET,OAKLAND CITY, IN 47660 FH83005312 270. Sigmta Of Ream F,nera Seem UOemee: 27c.license Nea(Of Loewe) _ JERRY LEE BASHAM,BY ELECTRONIC SIGNATURE 1 Manta - Cause Of Death(See Instructions And Examples) Approximate 28.Pan I.Enter The Cron d Ewa -Diseases.5Ies.Or Complications-That Duty Caned The Death.Da Nor Ender TraarW Event; Interval: ()reel 9th As Cardiac Anent Respsmry Arrest.Or Ve tIwlw FtlSedan NAmwt 9eWn9 The EDSogy.Do Not Abbreviate Enter Oney One Carne On To Death A Line. Add Addenal liras If Necessary. Immediate Cause(Final Disease Or Cand do n Restating In Death) A METASTATIC ADENOCARCINOMA OF THE PRLISTATE er YEARS a/elora • -t Sepuereiay UsI CondD n. If Any Leading To Re Cause Usted On a the A Enter The Underlying Cause((bane Or hiry Thad bldated r.nloaaow.��av The Events Resulting n Death)last C. am asp as osmium.04 D. Pal S.Ens Other But Not Resulting n The Ondereing Cause Gen n Pad l 29.Was M Poem Rearmed? 0 Yes 0 N DEMENTIA 30.Wall Autopsy Finding Avalable Ta Carpets The Case Of Der? Oyes 0 No 31. Did Tobacco Use Coterie To Dea017 32 It Fernier 33. Mama Of Death: ❑Yes ❑noway❑Ne E3 unknown 0 w maw's' " 0 nao•Maw nor 0 w masts el Paean van u e.n nor 0 Natant 0(%miles 0 Accident 0 Parana lvsm/gttn 0 al PaTal Saran a an T.v vw San Nall 0 eras Mama arm no he Yar 0 Sable CI Cam Not Be Demoted 34, Oat Of 5y(KtiwDrylrea) 35.Time Of eery 38 Place Of herd(E.G.Madera long Cmsaucdon Ste.Restaurant.Wmeed Arm) 37.5y Al ebr\l D Yes 0 N 38.Locaa,Of head-SUN 38a City Or Tom 380.Shea 8 Number 38.APL No. 300 71p Cade 39. Describe Hoer May Occurred • go,�gaw,. OP ' >,srr Dm.Pate 41.Sigmas Of Penton Cateha Came Of Death: . 42.Cattier(Cheek One per BARRETT W.DOYLE,BY ELECTRONIC SIGNATURE I 0 certifying Ryer 0 Can ,0 Heath Otter . 43.Name.Address AM 2p Code Of Perm Caayhp Caw Of Death: 44.Lkerme Nees 45. Dab Called . BARRETT W. DOYLE ,520 SOUTH MAIN ST,PRINCETON,IN 47670 07292014 45.AOIIImS Funeral Service Prates •47.Wm: 4S Slpvame al Local Norio Wow . 42. Fel Re9Htrar Only •Oate Feed(sMtdDaynrea/ .- BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE JUL 30 2014 AMENDMENT TO CER7L9CATE OF DEATH(ENTRY OR ORIGINAL) J.,:44:14. a6- D - 100 -On 1. 5/0 .0©( fSy-ett Ups ATTENTION ESTATE:The Social Security 0 b being requested by ths state agency n order to pursue respshvbie. Dermal b voluntary and them ere 1 be no peed f retina. t^ - fly051 e -