Death Certificate - Feightner, Larry G_11/12/2014 ;Aitt- . INDIANASTATE DEP•• 'TMENTOF HEALTH;
I
I : T i ' `t_ CERTIFICATE.OF DEATH '
r f Local No 000239 - EDR.No 000000411859 .: State N6 050409
,.1.DecederKe Legal Nat-se flat Mate.Last) - le. maiden Nate(Ilfemale), 2.Se. 3.Jute Of Death 4. Ot Of Death(MaYNDaY 4.
��1D[ppp�� LARRY GENE FEIGHTNER . MALE •01.26 AM ✓ -1024/2014
l
ID.If Death Occurred In A.hosp:al. 10a. If Death Occurreo Somewhere Other Than A Hospital
❑Hospice Fea4.y ❑Deuxras Home ❑Nursig:'.onen_ong-tetm Care Fealty®Yes ❑NO ❑Unknown ❑Impaaem 0 Emergency Department Ouhaser.. Dead on Amvat Oder(Specy)
1,71• I. Fadrty Herne(If Nat Inst^�on
t ,Give Sceet a=Number)
I Herne GIBSON GENERAL HOSPITAL
f 12.Coy Or Term Sate,And Zip Cade 13.County Of ceeN 14. Mamal Salts At Tyne Of Death
0 Maimed 0 Married.&a Separated 0 Divorced
0,- PRINCETON, IN,47670 GIBBON 0 Vhdowed 0 Never Ma.-led ❑Unknown
15.S:rviwg Spouse's Name 15a. (If Wie)Grve Maiden Last Herne 15. Decedent's Usual OcoAaxn 17. Kira Of BUSircssll dos%
SEWING MACHINE SALES
,JANET W. FEIGHTNER BAKER AND SERVICE SEWING MACHINE
IE.Residence-State I lea County leo. City Or Town
Ilia INDIANA GIBSON HAZLETON
pJ lac. Sent And Number tea Apt No. 18e. Zip Code let.Inside Gay taws?
• 6509 NORTH SR 65 47640 0 Yes GI No
19. Decedents Eduradon 20. Decedent Of Hispanic Ongn 21. Decedent's Race
ggPGBACHELOR'S DEGREE(BA,AB, BS) NOT HISPANIC White
G 22.Father's Name(First Nnae,Last) 23.Mat'er's Name(First Maidle,Last) 23a.Mothers Maidenlast Name
6 SAMUEL EUGENE FEIGHTNER ALLENE MAE FEIGHTNER MCCARTY
..1 24.In.'omnanls Name 24e.Relationship To Decedent 240 mason Address (Street And Number.Gy,Sate,Zap Code)
• JANET W FEIGHTNER SPOUSE 6509 NORTH SR 65, HAZLETON, IN 47640
' I 25.Place Of Dsoosgan
25a.Meted Of Dspcsoon 250.Place Of Dspospon(Name Of Cemetery,Crematry,Oyer Place) 25c.Locaton-City,Town,And State
, 0 Bwl 0 Cremation 0 Donaton 0 Endnomem
' D Removal From State
❑Otter(Speedy): MOUNT OLIVE CEMETERY MOUNT OLYMPUS, IN
• ' 26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral FadLy 27a, Funeral Hone License Number.
0 Yes ❑No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671
' I27o.Signature Of Indira Funeral Service Licensee: 27c. License User(O'.licensee):
RICHARD DEAN HICKROD, BY ELECTRONIC SIGNATURE I ,rtFD01012153
Cause Of Death (See Instructions And Examples) Approximate
28,Pan I.Enter The Chain Of Events -Diseases,I.ryunes,Or Complications-That Directly Caused The Dent Do Not Enter Terminal Events Interval: Onset
' Such As Cardiac Arrest Resphata r Arrest,Or Ventrioular Fibrdiatgn Wrthout Showing The Etiology,Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Ad&Lral Lines If Necessary.
a Immediate Cause Disease Or Condition Restating In Death) A SUDDEN CARDIAC DEATH MINUTES
e oaep.o.r a.aa:
•
id.. Sequentially List Conditions, If Any,Leading To The Cause Listed On 8_ De a raw a•Oan••• •on
Line A Enter The Underlying Cause(Disease Or Injury That Initated
• The Events Resulting In Death)Last C.
Du mla..•wamv ore
=+1
s� D.
Vl Pan II.Enter Other Swraicant Concruons Con'nbfnd to Death Stn Not Resd:ng In The Underlying Cause Gin?In Pen I 29.Was An Autopsy Performed? Dyes 0 Ho
HYPERLIPIDEMWHYPERTENSION.PREVIOUS MYOCARDIAL INFARCT,CORONARY ARTERY DISEASE 30.Were Autopsy Prding Avadaole TC Canpfde The Cause Of Deen? Dyes ❑No
31. Old Tobacco Use Catbibde To Death? 32, 11 Female: 33. Mama Of Death:
el 0 Yes ❑Prexdy❑No tTJ Unknown
0 tee npaevemee.a v... 0 new..urn.aDme 0 ne•.oae a_n.aaexav,42cers ao-o. 0 Natwal 0 Horrciee 0 Accdent 0 Pesdvng lrnes:igation
_ D w naa.Y.a neon Gnne,.ne Mb.air.. D un,a.e...a...aees a.ewe.n, O Suicide 0 Coda Not Be Determined
1 3:. Date Of Injury(Month/Day/Year) 35. Time Of Injury 36. Pfau Of Icy 'y(EC.,Decedent's Hume,Co:s',rucdon Sae,Restaurant Wooded Area) 37.Irjvy At Work?
D Yes 0 No
(z 35.Location Of frytry-Sate 38a.City Or Tom 3e0. Strut6 u-,ber 38c.Apt.No. Sad. Zip Cox
El 35. Desa,be How Lytry Occurred 40. If Transpora t Injury,Soeat r
1
Daa..Parm De.eap Da.a.ra-.❑Mr IY.MI
V)• a1. Signature,Of Person Certytg Cause Of Death: 42 Cenfier(Coact Orly One)
'BARRETT W. DOYLE , BY ELECTRONIC SIGNATURE � _ O Cerrying Physician 0 Coroner , 0 Hern Oerer
43,Name,Address And Lp Code Of Person Cer:ytg Cause Of Death. 44. License Number 45.Date Censed
iBARRETT W. DOYLE , 520 SOUTH MAIN ST, PRINCETON, IN 47670 11/10/2014
45,Additiaul Funeral Service Provider. I a7. -aas:
4a.Signature of Local Heath Officer. I 49. For Registrar Only -Data Filed (Month/Day/Year
1 BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE •NOV 10 2014
1 I AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
S ',e:Form 53295 ATTENTION ESTATE The SocialSeo1T.y r4 is Gehl;reques ea Dy this sae agency n Order to pursue respons tidy Disclosure i;volunthry and there wtlfbe no aenatty.fxrefusal -
0t-,a ��//L I^]es 3I�.1/'a. ORIGINAL DOC .V.ENT HAS A MIRTICOI ORED BACKGROUND ON SPECIAL WHRE SECURFW PAPER AND THE GREAT SEAL OF THE STATE OF:NDW.'A ON BACK THAT^a
.. YARN NG .TURNS FROM ORANGE TO YELLOW WHEN RUBBED-ORIGINAL DOCUMENT HASHIDDEN V tD ON PRONT THAT APPEARS\'MEN PHOTO COPIED
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