Death Certificate - Hicks, John C_11/3/2014 -:n..e`. I •IANA SI ESEPIRTMENTOF HEAL 10 9 2 9 3 5
•x .. CERTIFICATE OF DEATH - RESUBMIT
Local No 000176 EDR No 000000349983 r State No 048665
I.pecedenYS Legal Name(Furs:,Middle,Last) la. Maiden Name (If female) 2.Sea 3. Time Of Death 4. Dalem beam(Month/Day/Year)
JOHN C HICKS MALE 02:53 PM 10/24/2013
Hospital
0 Hospice Fasiry 0 Decedent's Home ❑Nursing Hanellon¢@rm Care Fealty
0 Yes 0 No 0 Unknown 0 Inpateot 0 Emergency Department Ouyateot 0 Dead on Mnvat 0 Other(Speedy)
11. Fatty Name(If Not Ins:Wadn.Give Street and Number) -
505 NORTH WEST STREET
12.Oy Or Tom.State,And LC Code 13.County Of Death 14. Marital Satus At Time Ofoeam
0 Marred 0 Named.But Separated 0 Diverted
PRINCETON, IN,47670 GIBSON 0 Widowed 0 Newer Mamed 0 Unknown
15. Surviving Spouse's Name 15a:(If LYde)Ghe Maden Last Name 16. Decedents Usual Octudaion 17. Kind Of Business/Industry
CONSTANCE J HICKS STEVENS LAWYER LAW
18. Residence-State 18a.County Ito. City Or Town
INDIANA GIBSON PRINCETON
18c.Street And Number . 180. Apt No. t5e. Zip Code 1Sf. Inside City Limits?
505 NORTH WEST STREET 47670 ®Yes ❑No
19.Decedents Eoucaton 20- Decedent OI Hispanic Ongi. 21. Decedent's Race
DOCTORATE(PHD,EDD),
PROFESSIONAL(MD,DDS,DVM,LLB,JD)NOT HISPANIC White
22.Father's Name(First Mode.Last) 23.Mothers Name(Test Midde.Last) 23a.Mothers Millen Last Name
JAMES M HICKS MADALYN HICKS SAVAGE
24.Inbrtnanrs Name 24a.Rela:cosrap I0 Decedent 243.stating Address(Street And Nunar.City.State.Zip Code)
CONSTANCE J HICKS WIFE 505 NORTH WEST STREET, PRINCETON, IN 47670
25.Place Of Disposition
25a.Meta Of Discoston 25o.Place Of Dieposi00n (Name Of Cemetery.Crematory.Other Place) 25c.Ldcaaon•City.Tom.And State •
0 Bunal 0 Cremation 0 Donaton 0 Entombment
0 Removal From State
0 Other(Spearyp EVANSVILLE CREMATORY EVANSVILLE. IN
26.Was Canner Contaaed? 27. Name And Complete Address Of Funeral Facility 27a. Fungal Hone License Number
0 Yes 0 No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671
27o. Senasre Of Indiana Funeral Service Licensee: 27c. License Number(Of Licensee):
JOHN W WELLS, BY ELECTRONIC SIGNATURE FD01009940
Cause Of Death (See Instructions And Examples) Approximate
28.Part I.Enter The Clain Of Events -Diseases,Injunes.Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval:Onset
Such As Cardiac Attest,Respiratory Arrest.Or Ventricular Fiorifation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Ado Additinal Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting Li Death) A. CHRONIC KIDNEY DISEASE YEARS
.el o • . . Do
Sequenbaly List Conditas, If Any Leading To The Cause Listed On B. PERIPHERAL VASCULAR DISEASE e..un...ern.on YEARS-
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last C.
D.
Pan B.Enter Other Sgntcl.tCnnduccs Contributing to Death 84:Not Resultng In The Underlying Cause Giwl In Pant 29. Was An AutepsY Performed? 0 Yes 0 No
CONGESTIVE HEART FAILURE.HYPERTENS ION.ANEMIA 30.Were Autopsy Ending Available To Complete The Cause Of Deem? 0 Yes 0 No
31. Ds Todaaoo Use Ca:theu•e To Death? 32. If Female: 33. Marne Of Death:
0 Yes ❑Probably❑No ❑UnMam 0 4p mr.d wee Ps.r... 0 wens it 70.0 aces. 0 N.n.tr..a e+n.>.nwoe 42 pm a rm 0 Nattral 0 Homicide 0 Acodent 0 Fending Investigation
0 1.1 ieeP.p.u43D.,In1...ea..D.., 0 t.n.woa Pero.ateThe P..V.., 0 Suicide 0 Could Not BeDetemined
34.Date Of Injury(M novOay(Year) 35 Time Of Injury 136. Place Of Injury(E.G.,Decedents Hone,Construction Ste,Restaurant Wooded Area) 37.troy At Work?
OYes ID No
38.Locathn Oflrlay-Star 38a.City Or Town --- 3ep. Street.4 Number 33c. Mt No. 38d. Zo Cede
39.Describe How Inlay Occurred 40. If Transoortatan Lyurc.S y
0Dombos.t, 9P..
.. . [.'......e[.'......e Ode.rs• .l
•
41.Strange.Of"ersdn Certryvg Cause Of Oeadx - 42. Center(Check Only One)
RAMESHBHAI P PATEL, BY ELECTRONIC SIGNATURE 0 Cer_yinq Physician 0 earner 0 Heath 015cer
43.Name,Address And Lp Code Of Person Cemfying Cause Of Death: 44.License Number 45.On Cer..`..e0
RAMESHBHAI P PATEL , 685 VAIL ST., PRINCETON, IN 47670 01040266A 10/24/2013
46.Aoomtonal Funeral Service Provider 47' Aku:
48.Signature of!oral Health OfEcer. -- 49. For Registrar Only •Date Filed(MontNDayeleart
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE NOV 01 2013
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
49:1025 2013 24:CONNIE HICKS
I5-ME CONNIE IfFIrsb CONNIE
IS-Middle.
24:CONNIE HICKS
I5-Middle
49:10252013 -
State Form 53395 ATTENTION ESTATE:The Social Sew .y a is being requested oy this state agency in orde,to pursue r esporsibty. Disclosure is voluntary and there will ere no penalty for refusal.
IVRA-20
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