Death Certificate - Hartley, Robet W_9/3/2014 •
r^&i."- INDIANA STATE-DEPAIR OF,•OIEALI H",y,
( Jt ' CERTIFICATE OF b-EA-
TH
t\' » �. -LocaLNo 000182 ' :.EDR.No 000000401382 - - -- `"•state No 038421' - ;
1.Decedent's Legal Name(Fist:Mgda,Lau)':. - .la.:Mahn Name gltarts) _ 2 Se 3 imea Dean„ <. tortes Dead"(N_ _ 1
ROBERT WILLIAM HARTLEY ' - : MALE- 09:35 AM 08/22/2014' ti
79 Morelli Days Haan- Abatis ? 10/05/1934- • PIKE COUNTY,•IN
9. Ever Si U.S.Armed Forces? l0.If Deem Occurred In A Hosea*: -Ma If Death Occurred SorneeMre Other Than A Hospital '' .
❑Hospice FacAty 0 DecedMS Hann Q Nuestr.Horne Longterm Care Fadray
0 Yes ❑No ❑Unknown ❑Ii-eatat❑Emergency Department CSryatent ❑Dead mPmval 0 czar(Spearyl .
11.Fa Sty Name (I1 Not lnstnja.Give Steel and Number)
611 NORTH LINCOLN STREET
12. Cey Or Town,Stab,AM Zip Code 13. Canty Of Death 14. Mantel Stead Al Time Of Dean
0 Manioc❑Mamed,But Separated ❑Divorced
SOMERVILLE, IN,47683 GIBSON ❑NMowed 0 Never Marred ❑Unknown
11 Suviwg Sparse's Name IS. (11 NYe)Give Maiden Last Name 16. Decedents Usual Occupaton 17. )&t Cl Bnnesa.tnsusby
BEVERLY KAY HARTLEY BILDERBACK DISABLED DISABLED
19. Residercs-Stars tae. County :fib. City Or Teen
INDIANA GIBSON SOMERVILLE -
Sec. Saes Ana Monter :9d. Apt No- 18e, Lp Code tea reside City Lams?
611 NORTH LINCOLN STREET 47683 0 Yes ❑No
IIII
19.Decedents Educabm 20. Decedent 01 Hispanic Ongn 21. DebedeKS Race .
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Fathers Name(First Midae,last - 23.Wears Name(Feat Mine,Last) 23e Ma is Medea last Name
HENRY HARTLEY ELSIE HARTLEY MCGILLEM
24 Informants Napa 24a.Relabcnsap To Decedent 240.Mating meets (Street AM Number,City.State.Zip Code)
- BEVERLY KAY HARTLEY WIFE 611 NORTH LINCOLN STREET, SOMERVILLE, IN 47683
I 21 Place Cf aabs.ben .
Me.Meted Of Cupostan 25e.Place Of Disposibn(Name Of Cemetery,Creme-dry,Cow Rats) 25c(oaten-City,Town.And State
O Btral ❑aamaan ❑wnabon❑Entombment •
Q Removal From State
❑Other(Specify): SOMERVILLE CEMETERY SOMERVILLE, IN
25.Was Coroner Ce tKtad? 27. Name And Complete Address Of Funeral Fa"' -27a. Final Napa license Number.
❑Yes 0 N CORN-COLVIN FUNERAL HOME, INC., 323 N. MAJN'ST. PO BOX 278,OAKLAND CITY,IN -
47660-0278 FH19400002
2T Space Of lndana Fureral Serra licensee: 27c. license N.nba(Cl Lreee): •
RICHARD D HICKROD;BY ELECTRONIC SIGNATURE FD01012153 • .
Cause Of Death (Sae InstrucCons And Examples) Approximate
25.Pan I.Enter The Qhain 01 Fventi -Diseases,Injuries,Or Complications-That Directly Caused The Dealt Do Noi Enter Termnal Events Intervat Onset`
Such As Cardiac Anent Respiratory Arrest.Or Venticuar Fibrillation Nathan Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Adddi al Lines If Necessary. ,
tnmediate Cause(Final Disease Or Cattion Resssrg In Death) A CHRONIC OBSTRUCTIVE PULMONARY DISEASE -
Nola ta,..a<...wuw
Sequent"List Conditions, If Any,Leading To The Cause Listed On B. a..,a a.r<,�vo at
•
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Laat C "
• •
a.m taws,a,..a»a or)
D.
Pan Ii Eder OTa km"cenl Con corn Dean But Nct Resdag In The Underlying Case GYM In Pant 23. Nes An Autopsy Pedamed? Q Yes 0 No
CORONARY ARTERY DISEASE - 30.there Finding Autopsy di Avadable To Complete The Cause Of Death? Q Yes ❑No
' 31. Did Tobaco0 Use CattnoUa To Dean? 32. It Female: 33.Maraca Of Des=
0 snywvrn Pier.. 0".vie u Tem a Doan 0 Not"eau:.e.n.a. lan C110010*. 0 Natal❑Horatio ❑Accident ❑Pering Investigation®Yes ❑PtadeOFY 0 No 0
Unknown
0 w rte:..u"nowt oo.nr.n w rut p.m ❑maw."a Asowe eel m.new
❑Suicide❑COW Nd Be Determined
34.Data Of Injury(Mon•fDayNear 35. Tyne Of Injury 36. Place Of Oyu}(E.G..Decedent's dome.Censou[lion Si,Resttran t Wooded Area) 37. Injury At Work?
❑Yee 0 N
33.Lccann Of Witty-Stara 38a.City Or Town 38t. Soon 3.Namcer 3& Apt.No. • 334 Zip Code ,
39.Desmbe How our!Occurred 40. II Trenspabtm Iryvy.IP�5aecc..M -
Ocesop ew oreerew 01Pernea Qt:.Rrwn
41.She.Of Person Cend)*g Case a Dealt 42 Caruso(Check Orgy One)
MICHAEL J.ALLEN, BY ELECTRONIC SIGNATURE ®Certyg tr Physiaan ❑Groner ❑Huth racer •
NM*,. 43 Ne,morels And Zip Code Of Part Certifying Cause Of Dealt - - 44. License Number 45. DaY Cart6ed
MICHAEL J.ALLEN ,3801 BELLEMEADE AVENUE, SUITE 200-A, EVANSVILLE, IN 47714 01048785A" 08/27/2014 _
468. AddbIa Funeral Service Prwger.. - 47, 'Ages:
48. Signature d local Hearn Ofacen . 49. For Registrar Only •Date Filed(MonSVDayNeer): '-
. BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE �.'AUG 28 2014
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) ,
State Form 53395 ATTENTIONE5 TATE:The SdCal Seaaity C is being req ested by INs Mate agency n arte:b0 otsske responsib&ry Disclosure is vokamry ald tare wA beta,pansy for refusal
WARNING. OF GINA DOW MEN EHAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT
TURNS FROM ell Te YELLDW WM N R BBD eRIGI DOCUMENT. --HIODENReI ON FRONT-THAT PEAR$WHEN PHOTO • I O/
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