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Death Certificate - Hall Charles E_8/25/2014 llnitrualgr•TIB•541-4Tinace.572.-.141."•.-71/7,176•31V.Tif..1•71-•3ites-Blacti.-617.-111."11 - .8.11.:110VA.-tt-P7a..ti-.7-•-•54.".").6.1 ..B.131-":14.4.i.- 41.7•.-Pir';.i.-4131117.1t0,ti.,,Y37.17-at • .•.7.4.,(,1-47-4.);>41'(:(2:"."," ::"..79'it'r5;;:1";-..;-7 Y. ;1' I • 4 • i •• I (D • .7 - ' o • 4 eAttH 4(71 .":-,-:)., ;E; i-•...,i. s:-•,,,••,-1,:,-----------,---....-•---•••--- •••••••--i •....• . :: • •••••••••t•-.)•2liir.f•-:4-, :!■ •11,1;;;:.--...tiry." ----;< i ! •.1-1,-,---,-... -:::•• •••• t -t,y t.-4-tt ''. - t .•-•,, I „}-:: :. .• .4.,,CERTIFICATEOF:DEkrit. • ',,. -; '.:,,. ! -,-..;„....„...=;.-;..,,,,- 1,,t1 ,:."3.,..r..7,,_.,.; • .•:, -,1 ,..11 ,..- -,-...., • •=-;....al-e.- :,re:ir?.?;;;Slis.;:r.,,iri.,..3,. . • 3 3 >, ; ';,...:: -f3=::11::'•;":5;=& ', :•./ C• •'''' tielb 1.1 i s ) •.' . . ;31;ttilib(iijij: "9s8-9;12:". I i :* - • P ftfa016'5sf. J;;- h V• ,Zi. ) t.`'-- -Lacat No • i .: -: ."' i 'k '-'777EDR7No " c •:-..,-;•,7" I:, LStatiiNalf : - 7;7 .7•;,,-.,f-f:5,tr ,:. 79.-(4a1.:4' -, 1.Oecedents Legal Name7(Firsuleddle,Last)..,,e• .7,-. -: •. .. .t .7.-9 ,.---" .....:. :::. -t..t'sr.....'”:, ?",: , 7:'...(,,... ,^4-,. VOievn•V2 ., • ,x,- F Sea ,,-BTne O f.o,r ),',.( ,4.,93.,5!?.:"4:. .04.:50.i:UP V..,..;-”.w;..:.:.f • - - " f „ -„ , -- " vtg „ , „ -, f „ - , , „r- : , CHARLEB EDAARDHAL! % i .. -.:. . _ &:..:. ,;•- . 'MALE 7-7( 7,--N0500 PM.5: ;7,7' 7,08/07/2014Y‘,....,:, .z..,.•-. • 5. Social Secunty Number 6a.Age•Yrs i So.yncler,I Yea BetUnder 1 Month Ed Under.,Day Se.(Under 1 Heir 7. Date of Binn(MandVI)ayffear) 6.BLit:place(City a20 State or Foreign Costly) .' ; 847 i :. hficaras• '. A". Days g. '''. i :How, ' .:.. 3 ,krede, ‘3 : ''., --, 11/b1/1929••• ..tAON El_i-01•1,,IN ..! •I :Z i. i . : y 9.:Ever in u.S.Armed Faces?,. 10.tf Deal Occurred In AHospitat -.. - „it ( ( 9, - 10a. If Death Occurred Somewhere Otner Than A Hospital ,.• 1, .-74 1, 1-9.4' „? .1 ',, n 1 ,i• - 0yes 0 trap 0 uncn'own 0.inpanent,0 Emergericy DeparAeyt Outoriant 0 De•rioriAmysi a otne(speaiy) , 7 -.' ' . , ". :>. ! it Facilay Name(ff Not tristascn.Give Sate and Numtdr) : %. 1 ' r` T ;.- ; : 5635 EAST SR 64. : • , . : Y•7. -:. f: ; z '.. c i ,; 7 12.Crty Or Tam,State,And ap Ccde ( ; ' . . : • a: - 13.CountyOf Peril ' : ; . • • 14.Manta Stews At Time Of Deam• • . ' . . • . . , , _., ..( • , - - • 1 ' t - ' . -'7 a .:',‘. ..! 4. _(1 ' - ' ' :' • 1 ' ' 'tal toariied ID Namedi 8u1Sepated 0 Divorced .( , ,. , • . . • FRANCISCO,,1N.7.47649 . - . :.; -:. 27•::::. ..Th7-:;;;,. GIBSON. ' ....' .•- ..-,,•• D Widowed p Never Named 0 Unknown. . • 15-1314Y•F•Spouses Nat,. - • '" i • : , 15a.(If Wde)Give Maiden Last Name : ( . i6;-Decedents UsualOccupraon • ; 17..Kind 01 Business/Incsoy • . '' 1 ' ' - ' ' * ' ••' BUSINESS OWNER\ - ; ; ;1 • . f. ' -7- DOROTHY HALL • LINNE I : c7.. 5 ; : : : ; " : OPERATOR .-. . %, 1 FOOD SERVICE. - - ; ;; -"' •c- •- INDIANA FRANCISCO' . . , • " - 7' " '7 . 18s Sven And Number . . . , • t • ' ■ 5635 EAST SR 64 , , . . C 0 Ye< 0 No:7 : , < : : . - i 7. - : 47649 : 19. Decedents EducaDon ; i 20.Decedent of Hispanic Origin t: ,7 a. •2I. Dececlent's Race - . HIGH SCHOOL GRADUATE OR GED . . • / .,., -, - . ,... . ' COMPLETED '7 :-. • 7-'. '7• • -- •••, , .. - , ..... • • : 22.Faneas Name(First,Madle.Lamb - • - ' . ' ' :" • -- ' 23.Mores Name(Fast Made.Lau) . , . • EDWARD L HALL' . , . • : ; ;'. --. .; NELLIEjRHALL::. : . . 77 7 :: -7. GATES ".. , • -; . , • 24a.R•abonship To Decedent (•„ 240.Mang Address(Street And Number,City.State,Tip Cone) '• d .4 . • t . i„, ., • . A . ..... . - DOROTHY HALL- • • SPOUSE-7.. z-- --. - '' 5635 EAST'SR 64FFRANGISCO, IN•47 649,7:- .... . .•- i 7•..,. -- •.7. ; - ?Se Medic:40f Disposition t ' 9, • t 25o.Place Of Disposition(Name Of Cemetery.Crematory,Other 111ace)F 25c.Lacs:ton(City,Town.And State ,:( 7; P :: ; • -: • ' 9. z . • 0 Buiai 0 Cremation 0 ck3natal 0 Entombment . ' ' • 0 Removal From State 77 .'" . 4 ` : 1 • 0 Ozer(SPeodyk .. ' .. . • FRANCISCO CEMETERY',.. . . .. ,. .t.'. FRANCISCO, IN ' '. -",• ' - : " -- 25.was Coroner Contacted? • - , , ( 4„ .... : 4 . • - , ..,t , . ,y • , • , . ' 13 Yes 0 No , • COLVIN FUNERAL HOME INC 425 N MAIN ST,-, PRINCETON, IN'.47670. • -, 7 ;-•-, '; ; FH83005671 270. Signaare Of Indana Funeral Service Licensee: . ...- .! S. -.: c.. • 21c.License Number(Of Licensee - , . • MARK R.WALTER,BY ELECTRONIC SIGNATURE...I 7i• , 7: --,....:7- / i - 7 .7. ',. ' R301013010 - -. -7- < ' . ,.CauseOf Death,(Soo Instructions•And Examples) , • . ' • ' Approxiinate, ,. 2E.Pan I.Enter The Chain Of Fvent‘':Diseases,Injuries.Or Coinpfecaticit?,That Directly Caused The Death.Do Not Enter,Terininal Events , . ' ' - 7- interval; Onset ".... Such As Cardiac Arrest Respiratory Arrest Or Veraitutar Filonaation Without Snowing The Etiology.Do Not AbWeviate.Enter Only One Cause Oh ', Aisne. • ImiAd d And:P eal Lin eis s If Ni cessaryditi sti .., t k. -•,. t,. •';,' medate Geist(Fnal Deae Or.Con Rehng n Der1) A AOUTklENiY FAILURE. • ' , - ' 2 Y. EE115'' - . . ' - " - 6-11.R2.,NjeR.ECU.RIRENT CYSTITIS ‘.0......,,o,A.;. . cc; . . . a. ; .• 3 YEARS i. &Vieth,*List Coactlions:If My,Leading To The Cause Listed On , B. Line A. Enter The Underlying Cause(Disease Or Injury That Initiated • 1 ,,I" ' ',. " ', , . , .... ., . • .- The Events Resulting Id Death)last C. . Da aiou•coviv.,••••449- : . • - . • : ; , • % • i : a r i . - • . • 4 Pal II.Enter Ozer 561 ..6&231603CrolblattAiblatinn BLit Not Restating In The Underlying Cause GIvinfn Part I. 29.Was An Autopsy Perfomed? - • • Y . - ' - 0 es 0 No- • CLOSED HEAD INJURY RESULTING IN DEMENTIA .- - . ,- ., •-• •.., s.. z „. 30./Were Autopsy Findirg Ayalable To Corrstra The Case Of Death 0(yes: 0"1:,1,:;-",, • .. _ , , :.-- . ' . 31.Did Tctacco Use Catitute To Deets?, • 32. If Female: - : •_. :.? i( :, 'a, • , (:, ( ,,"; ,•' t 33. Manner Erf Deem:" r ',' c ' •.. ‘1.L z i ( \ 4( CI..”...........PP..... 0 P.9...."...9.4... 1:1;7b<..<4;<6;ne.aiam,....2o.”:otue 0 Natural b ijOemicicie 0 ACciaent 0 Penang Invest:gem O Tei 0 Prai/aMY 0 No b unk,,,,,,, . < . . - 0.f...a.....i....,,...,-.,„-,....D..th 0 17,4,....,4 Pori4u44Wein lie PoU r..,. , 0 Suicide 0 Coia a N'ot Be Deteirni?Led 3 -. 3 74.DaSOf Injury(McneVDayfYear) • 35.Tyne Of injury. '-:; 36.•Piece Of Injury(E.G.,Decedents Horne.Construction Site.Restaurant Wooded Areal ... 3?„Inetry At Work? . „ . . ••,,.[]Yes•• 0 No 38.Location Of Injury-State : i 38a.City Or Tom ..: --... ', 7 ( ' 38b.•Street '8 Nimiber : • - : . . .':- '• . : • . . . . . . . . . '3e Describe Mow Injury Occurred ' 4e If Transportabon Injury.axcify. t .,.• . 09...9......OP...... PP....09...19P.P. '... .. .-... -.. . .....? i , , . 41.Signature.Of Person Ceutlying Cause Of Deadt, ,„ ..... ' ..5 1 '.' . C.. i' ': .... 42.CertSes(Check Orly One) ; I • . - 7:.1 " •-= '' TERRY GEHLHAUSEN ,-BY ELECTRONIC SIGNATURE' ; 71•!,_ r. --c, I.:. c -. ..•. ..7 0 Cernillg PhiSidaa , 0 Cokned• a 0 Hein Oracer.-_ :- •- , . 43.Nara,Address And Zip Code Of Person Cerofyina Cause Of Dead!: --' " '' .''' ' `:' ' ; t . ; ,. ; , 1 . • ' r TERRY GEHLHAUSEN .1020 W.MORTON, OAKLAND CITY.IN 476601 . c - . . : 02000730A-. - -. , .. 08/14/ 014. .7 : . <6.Alaby,aFuncral Service provider 7.--:..•:: ''. 43.Sc 1elvice of Local Heath Omer':F 7- "?..„ :(; - . - ," .47" "--', -,.. a a•" -',..;„ -, ; I -; r.,,a ... •••• •ilB..For RegIstrarOnty,-Draldea(144•91911:1ayivearZ,... -,,,,,a, p „„-•ss _ • . .. - . . . . 1 ' BRUCE•BRINK JR;NIA ELECTRONIC SIGNATURE ; -c•:77,c.72: ii it .,3 n .3 '...: .: i '11 , 1 -t'AUG 142014 "7-:. -:I f, i % '7.. 7 • < ,... < ., 77. j E.s :.7 z .7,7 ; ,-, 77. i : , AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR OFUGINAL) ; 4 Z -( r C (t. :( S't 4 a a.5 t I -' -- 7'1'4 -; C• 1 I ''',-''' e it -' ,i 7•••• '''," (‘ rti r',.-,'5.; ', .5.- z5 t: tz...! .$7 i i '5,....c :5 5'1 -'" r ,:. ';,...,•% !%- -••; 4„,,„/ .: 4 ' ' f; c9S.,,Fl;34 Ct. ioD' OM - . -., ; -- ti t i - ,•, •••,:, •••• i i; - .: ; ..„ , 1. -,.• ....... - -,- - --•-•• .,•• -•• • F, •r• ::.i -t. r.:-. -- i ., •••:-.- •,•-: i i , .k, t• i ..f..z •t .,•. k4. 3 ..'.- ,,. . • ,.." - , S. - ;, .. w .-•, .i. •g- ,.;• :. C., `,- - •• :C...Z :'. "..; . -,' :-,. •;--. I, •-.. c.‘ . t• -,•.' -t.- ' '.•': ] .:- i - .N. State Fogn 53335. ATTENTION ESTATE:The SoCial SeCurity#5 being requested hi the state agency in orderto nersinfreseonsibiiity.i•Dysclosere is yolbriceiy;and there yrillTircrcinejfetitylcaphiseUrLit.:Tliitr.. 'WARNING. ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECJAi•Age SEU/STY PApER.AND THE 6Rblit Sei6:(31,ii-ig 4tiritakiNiiiig*gnimak.1'El/it,:tif:,3, • TURNS FROM ORANGE TO YEU-OW WHEN RUBBED.ORIGINALDOCUMENT.HAS HIDDEN.VOID ON FRONTTHAT APPEAR' S WFIENT6-10TO COPIED.r.rt"ti•---11.P.--"d'n-b•Yr-driClt;