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Death Certificate - Green, Virgil_8/12/2014 ,4195 4. INIJIANA J1AIC UCrnf[ImCl'I yr nLPLIn Vv 1 1 V -1 i,V. CERTIFICATE OF DEATH :,- EDR No 000000320362 State No 021148 Local No 000080 1.Decedents Legal Name(Fast P. Last) tor. Maiden Name Of female) 2.Sex 3. Tune Of Dram 4. Data Of Death(Mn?JDaylrear) VIRGIL RAY GREEN MALE 12:30 AM 04/23/2013 5. Sonar Security Number 6a. 01/14/1926 DAYLIGHT:IN 9. Ewa it U.S.Armed Faces? 10.1106521 Outlaw m A Naptat: 10a. t Death Occurred Sanewhete Other Than A Hospital 0 Hasoire Family 0 Decedents Home 0 Nursing HomeLang-wen Care Faptty 0 Yes 0 No 0 Unknown 0 Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival 0 Omer(specify) It.Facility tone(If Not Instance;Give Street and Mmeer) GOOD SAMARITAN HOME AND REHABILITATION CENTER 12.City Or Town,State.And Zip Code 13.Casty Of Death 14.Marital Steed At Terse Of Dean 0 Married 0 Marred,But Sepaxed 0 Diverted OAKLAND CITY, IN,47660 GIBSON 0 Widowed 0 Never Mimed 0 Unlnowm fS.Sunivird Spume's Name 15a.Of Wde)Give Maiden Last Name 16. Decedents Usual Occvp.ton 17.KId Of Bamesvindratry MAY M GREEN ASH CLERK MANUFACTURING IS. Residence-State 18a.County 180.City Or Tom INDIANA GIBSON OAKLAND CITY 18t.Street And Number 18d. Apt No. 18e.Zip Code 181.amide City Limits? 515 SOUTH GIBSON STREET 47660 EL Yes 0 No 19.Decedents Education 20. Decedent Of Hepatic Origin 21. Decedents Rare 8TH GRADE OR LESS NOT HISPANIC White 22.Fathers Name(Fast St adle,Last) 23.Motors Name(First Made.Last) 23a.Mothers Maiden Last Name WALTER GREEN DOLLY GREEN JOHNSON 24.Info marts Name 24a.Relationship To Decedent 240.Haig Actress(Street And Number,City,State.Zip Cade) MAY M GREEN SPOUSE 515 SOUTH GIBSON STREET,OAKLAND CITY, IN 47660 25.Place CI Dispoetian 25a.Method Of Disposition 25b.Place Of Disposition(Name Of Cemetery.Crematory,Other Place) 25c.Location-City,Town,And State 0 Baal 0 Creniamn 0 Dorian 0 EntanMhent 0 Removal From State 0 Omer(Spe cif WILLIAMS CEMETERY WINSLOW, IN 26.Was Cams Contacted? 27. Name And Complete Maass Of Funeral Faddy 27a. Fumed lime License Number. 0 Yes ®ND CORN-COLVIN FUNERAL HOME, INC., 323 N. MAIN ST. PO BOX 278, OAKLAND CITY, IN 47660-0278 FH19400002 lib.Signature Of ndana Funeral Service Licensee: 27c license Number(Of Licensee): RICHARD D HICKROD, BY ELECTRONIC SIGNATURE FD01012153 Cause Of Death (See Instructions And Examples) Approximate 28.Part I.Enter The Chan Of Events -Diseases,Injuries.Or Crmp5catiomm-That Directly Caused The Death.Do Not Enter Temhihal Events Interval: Onset Such As Carorac Arrest.Respiratory Arrest Or Venlioriar Fibrillation Without SZ.n.:y The Etiology.Do Not/.tbreviate-Enter Only One Cause On To Death A Line. Add Additinal tines II Necessary. Immediate Cause(Final Disease Or Condition Resulting In Death) A. CEREBROVASCULAR ACCIDENT aeta...r eon I WEEK . Sequentially List Conduces. If Any.Leading To The Cause Listed On B. ATRIAL FIBRILLATION a eta y.a�pn 1 MONTH Line A. Enter The Underlying Cause(Disease Or Injury That initiated The Events Resulting In Death)Last C. b.*IC.At.ra e..e Cc D. Pan U.Enter Other Siana.t and ons Ki ten^to af,But Not Resulting In The Udedyi g Came GMn In Pan I 29.Was An Autopsy Performed? ❑Yes 0 14 TYPE 2 DIABETES MELLITUS,HYPERTENSION.PERIPHERAL VASCULAR DIME ASE WITH BILATERAL ABOVE THE 30.Were Aeopsy Finding Available To Complete The Cause Of Dean? KNEE AMPUTATIONS 0 Yes 0 No 31.Did Toba[m Use Cm nbute To Dean? 32. If Fematc 33. Manna Of tea ❑Y63 ❑Ptobebry®ND Unknown ❑wPn .twad Peru.. 0 woad a Tn.ap..n 0 edFinewe ea P.Ofa w.r.a C...u de 0 NiYral 0 Ho Riot 0 Accident 0 Pen6g arsCSt2ae0n 0 n.N.r.d e4 P,yw u Deft Tv nose e.n.DM 0 u•,e,415.9wwce.,lh.•P..re. 0 Suicide 0 Could Nd Be DetenYned 34. Dal Of Injury(Malt rOayrYea) 35.Tone Of Injury 36.Place Of Irquy(ED.,Decedents Home.Consthrtion Site,Restaurant Wooded Area) 37.Inlay At Wort? 0 Yes 0 No 38. Location Of Injury-State 38a.Coy Or Town 380. Sweet 8 Number 38c.Apt.No. 38d. Zip Code 39. Describe 110.v lmhjury Occurred _ _ Dos c. m 9r❑P.Speedy: Da.rse.d.l 4,. Signature,Of Person Catfyi g Cause Of Dram: - 42.Cotter(Cheer Only One) -- TERRY GEHLHAUSEN , BY ELECTRONIC SIGNATURE - _ E1 CerSIg Physician 0 Coroner 0 He=Diem 43.Name.Andress And ZIP COde Of Penal Certifying Came Of Dealt . - - 44.ticeme Minh 45. Date Carded TERRY GEHLHAUSEN , 1020 W. MORTON, OAKLAND•CITY,IN 47660 : 02000730A 05/02/2013 46. Adddnal Funeral Saone Provider - - 47.'Alas: 48.Signature of Load Health OI.mr. .- - 49. For Registrar Only -Date Feed(Mot vDa/Yeat BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE - - MAY 03 2013 AMENDMENT.TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) air- ILA- IS-pot - 0°o . 055- 0o1 State Form 13305 ATTENTION ESTATE:The Social Security a is bring repuesed by this state agency in ceder to pursue resparsibaty. Disclosure is vduntary and mere w1Tl be no penalty for refusal. ;l4 _y IVRA-20 (7/05) -' 4 4 • 4.4 t. • , _' III I :i i.t.•_ . .s_.a , ti. a •.