Death Certificate - McGregor, John A_10/22/2014 .' �\i -�a.4 s. �� a n.. v t ,G • :I . �T (�-�._ ri l -ix. \ i .'t` -. fir- `W.ai- ( R:-0
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_ye D A A a Y TH; - -
_ ; 'CERTIFICATE OF DEATH
•
. Laf al No 000483 EDR No.000000403896 State No`04110.0
1:Oecaoenh Legal Name(First Aeddla,last)'. - It Maiden Name (If female) 2.Sex 3.lime Of beset 4.,Dap Of Deat,(MontwDa )
JOHN A MCGREGOR ' 'MALE .- 041.31 PM . : 09/08/2014
84 Months Dan. " Fours" Minutes
Hospital
D.HOSpke Facility 0 Decedents Home 0 Nursing HomHlon3'Uam Care Faulty " - .
0 Yes 0 N 0 Unknown 0 npatent 0 Emergency Depatnent Oupasent 0 Dead en .'rMal. 0 Other
I I.Fac3Ry Name(II Not Inst4uton.Give Street and Number)
- DEACONESS GATEWAY
%R.CM Or Town,State.AndZip Code 13. County Of Death 14. Marital Status At Tine Of Death
0 Married 0 Married.But Separate 0 Divorced
.. NEWBURGH;IN, 47630 •. WARRICK .0"1°°".e° O Never'Awned Unknown
. - . ,..
15. Sunivng Spouses Name 15a. (If Wde)Give Maiden Last Name 16.Decedent's Usual Occupaton 17. NndOlflusnessMQutry
• JANE MCGREGOR WINLAND COAL MINER - MINING - . - : •
It Resience-State 18a.County - 180. Gay Or Town " .
INDIANA .. GIBSON OAKLAND CITY .
. 19c. Street And Number tad.Apt No. lee. Zip Code 1W. nude Day limits?
❑Yes ❑No
10539.EAST 350 SOUTH- 47660
" 19.Decedent's Educatr. 20.Decedent Of Hispanic Oren - 21. Decedent's Race •
1
9TH-12TH GRADE;NO DIPLOMA NOT HISPANIC White . -
22.Fathers Name(First kiddie.last) - - - - 23.Mother's Name(Fest Mdole:Last) 23a.Mother's Maiden Last Name
ELVA MCGREGOR • HAZEL MCGREGOR • . WITHRO ,
24.ntdmants Name 24a.R Wtarshp To Decedent - 24b.Madng Address(Steel And Numbs,City,State,Zip Cade) '
JANE MCGREGOR WIFE " . 10539 EAST 350 SOUTH,OAKLAND CITY, IN 47660
2s:Place a Disposloon
15a.Method Of Dsposinon. ' 25b.Plate Of Deposition(Name Of Cemetery.Crematory,Other Plece) 25c.locat.,-City,Twin.And State
0 Burial 0 Cremation 0 Donato.,0 Entombment -
0 Removal From State • - -
D Otter(SOecfyk SPURGEON CEMETERY SPURGEON, IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Fad'aty • .. n
27a. Funeral Hoe License Number.
®ores ❑No - CORN-COLVIN FUNERAL HOME, INC., 323 N. MAIN St. PO BOX 278, OAKLAND CITY, IN
47660-0278 FH19400002 .
27o.Signature Of Indiana Funeral Service Licensee: 27c.License Wrier(Of Licenseep: ••
MARK R WALTER, BY ELECTRONIC SIGNATURE FD01013010 .
Cause Of Death (See Instructions And Examples) . Approdmate
28.Pan I.Enter The.Ceram 01 Events -Diseases,Injuries.Or Complications-That Dtedy Caused The Death.Do Not Enter Terminal Events - Interval:Onset
Such As Cardiac nest Respiratory Arrest Or Ventricular Fibrillation Without ShovAng The Etiology.Do Not Abbr.Nate_Enter Only One Cause On. To Death
'A Line. Add Addldul Lines H Necessary. .
Immediate Cause(Final Disease Or Condlion Resuld g In Death) A. ACUTE MYOCARDIAL INFARCTION . 1 HOUR
N.e(1 a,.C............pit
Sequentially Liu Ccndidors,.lf Any.Leading To The Cause Listed On B' pe.p..Ar.,w,.ea
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated .
The Events Resulting In Death)Last C. . -
b,..la..Ace-ea-.on
• D. . . -
Part IL Enter Other • - - t•De. But Not Resulting In The Underlying Cause GNin In Part I 29.Was An Autopsy PMrmed? D Yes 0 No
-
. . 30,Were Autopsy Finding Avalede To Compete The Cause Of Death? IJ Yes 0 No
31. Did Tobacco Use Contribute To Dead)? 32. N Female: . 33.Manner Of Deasy:
0N.P,.rm4wmP.a.4. 0n..w.un..rpr, 0 Nei w.weLe.aewe..wow,42DmvDia, 0 Natural 0tlornldde 0Accidere 0PendunInvesigaton
0 Yes 0 PmWdy0No ❑tlnkrhvwn 0.t'pawl eeere:ee a pen r.1n s' "D... 0 u...i.e,wew..wen 1.P.e r.. 0 Suicide O Could Not Be Determined
34. Date Of Injury(MonVAaytYear) 35.Time Of injury 3e. Place Of Injury(E.G.,Decedents Flan.Construeon Si*,Restaurant Wooded Area) 37. Injury AMA?
" D Yes 0 No
33.Location Of Injury-State 38a.City Or Tam_ 380. Street&Number 36c. Apt Ft. 380.Zip Code
39. Describe How Injury Occurred : 40. If Transportation Injury..�peddfyy.
Duw. -°- Cr., U'•^^s, Dc.-ar.drt
. at Signature.Of Person Gait-trying Cause Of Death: - 42. Canfur(Check Only One)
JAMES HENRY GOSZKOWSKI, BY ELECTRONIC SIGNATURE 0 CeAFAngPhysklan 0 Coroner 0 Heath OlSon
43" Name,Address And Zip Code Of Person Certfytg Case Of Death: 44. License Number 45.-Date Crtfied
JAMES HENRY GOSZKOWSKI , 700 WILLOW ST, STE 202,VINCENNES,.IN 47591 01037052A 09/15/2014
•46. Additional Funeral Sella Provider, , Q"'Akan:
49 Signature of Local HeaIT ORGY: a9. Fw Registry bay -Dace Fate(MermWayO'er}
' RICKYB YEAGER,VIA"ELECTRONICSIGNATURE : : r, : - • . SEP 152014 - . .
` - „AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)), ; ; - " - " .. " -
State Foam 53395 ATTENTION ESTATE.The Social Security 0 is being requested by Js;state agency in ordr ld paste rmyonnNbly Dsdpsdre ta voluntary and there wig as no penanq fa refusal _
-` l.m a.,mery ,u,urrc een m3nV e.oee nun rife roeft Cr., ere rue cTeTt.ne'safari(lh Ref.mit'