Death Certificate - Belcher, Thelma_8/25/2014 /..i-tip • -�• 'R..V.:.: ",`.p.:'.J'-.46.=�F r.�:."i:`.alR.�
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'�It I ` CERTIFICATE'OF DEATH s
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-` � `LOCaI•N&000422' \ EDR No 000000400030 State N0-03695,4c,.,,,-
I:Deed ir.i el Flame(Fes62Adde,•Las)- 2,,,,*---' ... ..fa Matden Name(If fanCe) :- !'' 2:$m. 3.Tr.eb1Deadt 4'Dab ODeae, -).
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THELMA•J BELCHER > SCALES.`'. : '"`•• 'FEMALE x.01:03 AM :`. a 08/15/2014
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- -.90 tt '.' -Dells', :Pass.:. , itt 11/02/1923 :, OAKLAND CITY, IN• '> J
0.+O'e.r M-.U$An.M:d.•F.n- sJ? 10„de_'e.m.`O.a X10.,0.s A' .t v'wMt - _<: -;'':;y 0 t0a noise-racily.tt De8l r Omm ed O SG Decedent's Fleprmie M A D FI B NOS g F.txrotagaem Can-Faay
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0 NO.0 Unknwn ®bw6enl 0 Emrpav Demonem.oumo6w.0 Dead I Mutt 0 od..(sPen+r),'' I. ?at
II. Feeley Name ftt Na bnat and Give Saes and Numbed r •t. DEACONESS GATEWAY: : - - `
12.C4YOr TOae.Stale.And Do Code - 11 County Of Dem fa.Ilaitls Sfa6a At ThMpDem
minicab)ime Pie separated(0 Onedied` NENBURGH;IN,47630. - WARRICK ;O wdOld. 0'r..tine-O
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li Savf.,np SpouaeY Name. .. IS.fXPAN/Dna Makin Lat Name :, . 1e Decedents news Oaupalo0 17. Kind Of a• ' •"-a••^y' ....
, - • PRODUCTION ' MANUFACTURING::
It Residexe-S1m, Ida Camry ., Ca CAy Or Tax,
• INDIANA •,,: -- GIBSON • " PRINCETON.
18c Sacs AM Wnbe tad..Apt.NO. lee:Zip Code•- - IS trade Cityai ?
,O Yes 0No
417 SOUTH PRINCE STREET - _ - -- -- - - -, 47670 -`
19.•DewOenra Edrraapn i: - 20.Decadent OI FTdpedc pgs. 21. Dced.nfl Rae. - -
" 8TH GRADE`OR-LESS'. .: . ' NOT HISPANIC' ' . White ."? . ,
22.Fmers Name(Fist Mi)]1a last) - _ x'21 Modrfe Nm(RaL r-<ddle.lat) _ 23a.MMbfa eYMm Laic Nm / `
`', HOWARD'SCALES- - EDNA'SCALES -.- , MILLER .
24.btlamWItsWtM , ,24a.RdadonSNp To Decor I 24a Msae Andrea(SFest MO Mn .Cary,$tale.TV Cadet..
- JANE'MASON--, '_: • - ' DAUGHTER.' . • 505-MEADOWLARK-DRIVE,PRINCETON,^IN 47670 -.
, `21 Rxe Ol OSpmem -
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. ❑ Metdgd Of Dme5lsm ehm• , .
250.Pte Of Cs a (mane Of Cemetery.Cremep 1.O .P .). 25c.Locates-Cry.Ten.And Srab,
i 0 Baia0 Cemai 0 Donci.0 En «t
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0 ome($seam ... - ADKINSON.CHAPEL CEMETERY OATSVILLE, IN ./ - -
` 25.Was Coroner Contacted?,- - • , 27.Nm AM Compete Address Of Funeral Panay .. -" 275:Funt'W Fbrn Uttnee Ftdrnaer.
:O.Yes ®.NO ~- COLVIN FUNERAL HOME•INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671. :
2ta,�SgtoDVS 0l bdrar,.Fasal Savke Lkanee:; - _ _ 1I 27s License Number(Of Licensee a,
' MARK R.WALTER BY-ELECTRONIC SIGNATURE,- .' - - - )FD01013010 a ' •.- .. . •
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Cause Of Death (See InsDDaians And Examples)' AppaalWe.:,%
28.Pat I ENa Tiw 4 ftf Of Eventi n Angst,Or spades.O(COm&fixes-Tat Direhey Caked The Oath.De Na Fnite Only One Ewit - r sdsvai.O set -.
Such As Cardiac AnesL fiapratoey Anal,d Vedhiadar Fdrieadw b t.ad SMwnp The Etidopy.Do Na AOGeNate.Enter Only O Caine On.` - :T0 Death;
A Line.Add Adddnal Lind ff Necessary. - - - - -
Immediate Cause(Fiat'Disease Or Ca10dta1 f4es,tsrlq In Death) A. fUl741NANT CLOSfRiDAIM OIFFHILE COOTS AND SEPSIS - - -
/ Sequentaly List Catliban a My.Leading To The Calve Listed On . 6.
line A. Enter The lseedyhg Case(Disease Or bleary That Initiated -
:The Evert ResWWg In Death)Last" "- • t .
G ooero s.4C.lee a{
D.
Pen II.Enter Other SunScant CaMems Conaa e. a Dea01 as Na Resitting In The Underlying Cause Ghia In Pan I 29.Was M Amos),Pelame07 0 Yea `'Z No .. •. •
•' - . 30.Were Autlpey Facing Avaaata TO Car's.The Case Of Deana_..0
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33. DE Totemo Lisa Carotids To DeadR 32. if Farms:
4 ' - . ;0..).0‘e�•wwne v_ 0e,.ewrt..ao_,+.D:.A.-.u..e.4.1e.1apw CI C;441 ,O.Naarai'nilorldde O*mare 0Pecicgsvises.:bn•
O2p„IPPrNMyDH000ntdam S 0w.wwau.wr...no.w7.i,_s:r:o.e. 0a.,4e._■eve The r_ : 0 Ste,OCodd Not a,Daim*ed .
7,:DMgsiury(NamYDay1'ea) 35.Tyne Ot1a ay 3e Place Of Nary(E.G.,Decedents NaM.Canauraon See.Pasta Wooded Araa)_ 37.Iran At Work? ...,...
' ' ' ..... -\ �- ❑Yes: 0NO
35-Lame Of b4ry-Sae Sea.Co en y Or Tam - .36x.Sae&Norther riMaat�adSea AOL NOr -38d. Dp Cede
39 Deaa{eeNw!t sy lXWnm : ... .. - nva... Lh.=•Eg=r. 0d,,c#La
41.SIpM•re.Of Penca CeMysp Cane Of Dearth:, - a2.CeraM(Cletli Oey One)- ' .
- BASSAM•YOUSEF,BY ELECTRONIC SIGNATURE- - - ' ' 0 Caddys0�aa 0 C`aaer ` 0"f err `
41 Nth.Address And ZiCode Of person Cenlytg Cane Of Deadt - 44.LY:erae fAVnMx 4S'DYa CerC6M
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-' BASSAM.YOUSEF.',600 MARYSTREET, EVANSVILLE, IN 47747.. . - 01042166Au' -- < 08/19/2014
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- `i5'$Ipntae aLaW Nea'ii Olecec.\+aJ ' /.. f-., 4p Fa RegIat OnIY -? t Faro(lMWDa)Meap. ; ! •
I. RICKY'S YEAGER,VIA ELECTRONIC SIGNATURE -- AUG;192014 . i t.
= y - .. ... .. .. . . . '. _ + . . - :AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGNAL) C . ( . .
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