Death Certificate - Nolcox, Jimmie Don_12/10/2014 l .-Y ; tIND1ANA-STAT ,DEP ItTMEAI OF.'.HEALTH. - - -
i ;CERTIFICATE:OF DEATH ,
1> ,Local.No 001,383 . ' ..EOR°No 00000021`1469`'- ' "stateNo 032925'`- �`
I:Decede It Legs l!•art. (Fre.Mjddte Yost);. 1a Ma cen Name(If -ac)-, --2.Se 3..Time Of Dean ',x .4 Dee Of Der:-(Mon.YDayt(eer)
JIMMIEDON-NOLCOX ::'''.7....;-'-'.. ' ... - ;-," : - "" 'MALE 05 30 AM ° 07/27/201'1
.: 74 Monbb ' D vs 11 t Manes , .I MT CARMEL, IL,. . . ,
9. E in U.S Armed Forces?, 10 If Dean Otemed 1 A Hospital: - - ' tma. If Death Occurred Soenewnere One(Than A Hospeal' - .
Hospice Facitty. D Deridem's"orne 0 Noising Honei Cog-term Care Faetty •,
0 Yes-0 No 0 Unknown EUroatiem 0 Emergency Debarment Duna ten 0 Deis on Anal D Oyer(soppy) -
11.:Fat yName-glNot ins:bSQ,Give S}eet and Number)
SELECT SPECIALTY:HOSPITAL-EVANSVILLE . . -
.12.:Gy onrovm Stale,And Lp Code _ • ' 13. Count/Of Death - 14.i,Macta Statu3At TlmeOl Deal_ ,
"' •. .. ' 0 Married 0 Maned,But separated 0 Divorced
EVANSVILLE;IN;47713'. .-•_... ,:_.,. „VANDERBURG-I., 0 NewMarned�'0 unknown
15. Slmiving Spouse's Name - , 15a (If VAe)Glee Maiden Last Name - •18- Decedents Usual Occupation -- - .17: Kind Of esuessiodunyt r.
- ' ' MANUFACTURING
RITA-NOLCOX _ HUGHES AUDITOR BUSINESS
-:15.-Resierde-Stte :ea. County 160. City Or Town
INDIANA GIBSON PRINCETON
lac. Stee:And Number. 181. Apt No 1Se. Zip Code 19f. Inside City Lords?
❑Yes ®No
2324NORTH OLD HWY 41 _ 47670
19. Decedents Edaeaan • - - 20. Decedent Of Hispzec Oo4n 21,•Decedents Race
SOME:COLLEGE CREDIT BUT,NOT A'- ,
DEGREE - - ' _. NOT HISPANIC IBlackor African Anie/iwn . ' . - .
22:Fatnets Name(FfT.'Nidde:Last) - ' - 23.Nomads Name(First Middle.Last) . ' 23a.Manes Maiden Last Name•
NATHANIEL NOLCOX . . - . MILDRED NOLCOX CHAVIS
24.Informant's Name - ' 24a.Relattonsrp To Descent tab.Main;Address (Street AM Number,City,State,Zip Cade) '
RITA NOLCOX • • . . • - SPOUSE 2324 NORTH OLD HWY 41, PRINCETONfIN•47670
25.Place Of Disoosibon - •
25a Method Of Disposaos• . . . - ) 25o.Race Of Disposiboo(Name Of Cemetery.Crematory.Other Place) • 25c.Locaton:Ciy,Town,And State - '
10 Sixth 0 Cremation 0 Demuth 0 Eapmbnery .
0 R ter seal Fran state
D.Otherl(Speoy): . ..• ; ' . . . -' OAK HILL CEMETERY 'PATOKA, IN_. : - . - .
'28.Was Camper Con:aced/ - 27. Name And Complete Address Of Funeral Fealty ' . 27a.•Funeral Home License Number.
❑Yes 3 N ' COLVIN FUNERACHOME INC, 425 N MAIN ST., PRINCETON, IN 47670 . - FH83005671
27o, Signature Of Indaia Funeral Service Licensee: ' - 27c. License Nisnoer(co Licensee)
MARK R.WALTER', BY ELECTRONIC-SIGNATURE IFD01013010
Cause Of Death (See Inslrucdons And Examples) Approximate
-28.Pan L Enter The Chain Of Events`-Diseases,Iryuries,Or Complications•That Directly Caused The Death.Do Not Enter Terminal Events _ _ Interval: Onset
Such As Cardiac Arrest,Respiratory Arrest'Or Verericutar Fibrillation WUwut Showing The Etiology.Do Not Abbreviate,Enter Only One Cause On - 'To Death
A'Line. Add Addtinal Lines ll Necessary. - - .
Immediate Cause(Final Disease or Condition Reiuf&sg In Death) A END STAGE HEART-FAILURE -
. .. - o..i.aa A.•ce-a......0e,
`Secbenyuaty List COndiiKeii.If Any Leading To The Caine Listed On ' B. ACUTE RENAL FAILURE ,-
Dee in to es a aa.a.nv M
Line A: Enter The Underlying Cause(D`sease Or 4ylrycThal Initiated '
The Events Resulting In Deals)Last C. ACUTE RESPIRATORY FAILURE
c....icy k,•caisson on '
D. . _ .•
Par.II.Enter Other jianilcanl Conddions Contnbttag to Death But Not Readbrg In The Undertyvg Cause Gin In Part I• 29..Was M Au:Wry Peramed7
30-,Ware Autopsy Fetug Available To Complete the Cause OI Death?. '
31.,Did Tomcod Use Ccnaibute To Des 7; 32. II Female: i 13]. Mama Ol Dea"t •
.❑Yes: 0 I'ra0a1Y❑Np:®Un:rwwn 0,.,town ace......., 0..taw u Tne 0105 C 0 a-e5'eit.ea.wT.n vain C ow. D;ti :®Want 0 Hoi:.iode 0 ACCdent 0 Pvid:.l.^vestgalion
_ 0.w wife.u n.Pw a own,"i-e-.teen- 0 Lie ."sn.r.'ewv+,en tote 051dode 0 Caid Not Be Detemtircd ,
3<. Date Of Injury(ManpWryHea) •35.-Time 01Injury 36. Place Of Iryvy(E.G.Decedent's Home,Consoiton Site,Restaurant Wooded Area) 37. Injury At Wont?
.. I ' 0 Yes '•0 No
38.:LooationOf Inryry'Slate - 38a. City Or Town 36b Street&Number ]BC. Apt No 360. Zip Caere
It 39. Deso.be Now bury Occ sec 40 II T ransom mi Injury;5 �y.
. DP.•..w.ar D^• th U'•n .'.Obenav�l
At,Santana,Of Person Cer_y1M Cause Of Death:, . "' 42'Cat 5er(Check Only One)•.
VIJAY K $HASIN ;BY ELECTRONIC SIGNATURE 0 Certifying Physician 0 Canine; : ,.D Hear Ocscer 2 t '
I
43..Name,Address And Zip Code Of Person Cer fyug Cause Of Derti - m Limns..Number 45. Date Cer_5ed
VIJAY K BHASIN /1312 PROFESSIONAL.BLVD.;SUITE 200, EVANSVILLE, IN 47714 . . / 01057474A - - '07/29/2011 -
I0 Adti.ionai F awake Prosede - I n Alta , I-
a8 $yamre o(Locel HetlpnO ceT - a9 F Re; ln Only Dab Fled (M ,eWDryeYea)
I
RAYMOND VV. NICHOLSON,.JR VIA ELECTRONIC SIGNATURE - - - JUL 29 2011' z
_ . x _ , -,AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) F
i• L
a " . t.
.§:a:o.Fom5339S, ATTENEON ESTATE The Scoot Seamy`S is beina`equestedby this state agony n order to pia sue responsibility Disclosure/s a,'alcater'y and the a we be no pony for reflsal. '
. %RI A'0G11),I P■. 0RPGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHrrE SECURITY PAP WAND THE GREAT SEAL OF TAE STATEAF'INDIANA ON BACK HA .