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Death Certificate - Warren, Richard W_12/19/2014 , . . .... .. . . . „ . .. c"r-r9,41:**--(;;;;':"1.(4i::rir.11'si?;:tTn.":"0.g...--:.v!INDIANAISTATiEDEPiikTIVIENTR:WillEALI H':,P ;71-/",tity......1 :1(.., Z if i,.., tr.:7. •o:„, .1 IS.C.SSAI,;',7.4,,7'-.--s„?.,l(n,:f*:t.7.-"LV?:..2.'i.:--S L.-7,CERTIRCAtEt•OF,215EATFOz;RE§LIBMITh= f:', ' ' '''• .4.,'rc..; ‘.....'!=1,'-'• jV,.. e. .,...:91"..;• 0;.;jillfri.i'll.ri?1',1" 1..1.: re : . .1 ItY " ri-ini..":11itg: fKl ;Ari??1:-'; ''.. ; ...: L •:::-. ;.4.::-. ': >4: ;:::.-7,,, '".EticiliNc4.002501;z:'4 .... "s-EDR..Nor000000415643z--:, -,,I,-.. ..:siateti4S;.052247::s....-- :1_,Dececarts LegalName(Fesuldidate„Lasty))-- '',--- ,.. •I.: ,....-- t;:,.";maide”fartrI(II frate):::,:tt; ,' 5,1,,,..,.I 2.Seut,:,, u „,3, Tare of Death). pv;.4 DatepperehquottleDayt-ret7; ' t .. t..,. - ' .,' '',.....„ 4-) ..:`; -::„. ,,t , . 'I.,,:, ,( ''ItC. '"' ' t .. .,t,' 7 :, i--"•••• - .. .:,•••••-.. • ;:,,(, ,,e•:•••, -.::. , ,,,, ,,,•••",. RlHARD.CA/AYNE WARIkENn "-..'. • .* .-.• -.: "'• " 't Sit' •1:-..“'", :'-..\:, -i ..”'"‘‘, .:t MAL E1'. --‘08:46 KM -.;' . S-r-:.- ..e:c1:1/18/2014. i. 80;• .e.. 10,;ths •, -; loan Nan - ' 'MPI‘des I,' •: ‘. ,. '06/13/193,€ FORT BRANCH, IN - - : • Armed Forces?, 10.d Death Occurred In A Honda: 710a It Death Occurred Somewhere Other Tnent Hospital . , • , , . . • ; '‘'-';'; 0 Hue*.tat/. 0 teCeern Home .0 letrisits2 Hone/Long-terrn Care Faolry ' O.,Yes 01No'O.Unknown 0.1rpanent 0 Emergency Clepanment Outhetant 0 Deaddh Amy''' 0 Othet(SPidolY)' ,". . • ' ' ' . ' ' it.Faddy Name(If Not Inv:tram Give Steel and Number) 1708WEST BRUMFIELD AVENUE 12.City Or Town.SureAra Zip Code ' 13.County Of Death .14. Mantel Stars At Time Of Death . ' • 0 Married 0 Manied;But Separimett 0 Divorced , . • PRINCETON,IN;47676. • , . ,'' ',- e GIBSON ' 0,Wdoeed 0 Never Marred. 0 Unithown 15.SurdHrg Spouses Name 15.s Of INVEIGH,Maiden Last Name - I6.-.Decedents Usual Occupanon 17. Kind Of BusaessAnclustry JANA JANE WARREN JONES • MAINTENANCE SCHOOL 18. Residerce t State laa.County - ,ills. City Or Town INDIANA GIBSON PRINCETON •., Inc Street And Number 1 1 ' 180 Apt No. lee.Zip Code 47670., VII.Irate,City tents? 1708 WEST.BRUMFIELD AVENUE , 0 YeS 0 No 16 Decedents Educaboo . . 20. Decedent Of Hispanic Ongtn "21.Decedents Race .... ••' . - • , • 8TH GRADE OR-LESS- NOT-HISPANIC "white • a Fathers Name(First Mita.Last) . 23.Matters Name Vint Micelle,Last) 23a.MoMer's Maiden Last Name - . • . FRANK WARREN . ZELLA WARREN . PEEK 24.Informant's Name- , .24a.RelattchShip To Decedent ..' 240,Mang Address (Street And Number.City.State.ZIP Code) • .. . . ,JANA'J WARREN - ' WEE . .. -.•• - ,1708 WESTBRUMFIELDAVENUE; PRINCETON;-IN 47670 . . - - . _ . - -. 25.Placa Of DISPOSIOCO 25a Metiod OlDiSpaltal 25t,Race Of Disposibon(Name Of Cemetery.Crematory.Other Race) i 25c.Locason-City,Town.And State ,Optrial 0Creme:en 0 Deruiton 0 Erecenernem . . . • • 0 Romani From State 0 Oiler(00ecity):. • • .. . . MAUMEE CEMETERY • JOHNSON, IN 26.Was Cooler Comecon? , 27. Name Ana Complete Address Of Funeral Fruity , i 27a.;Funeral Horne license(finer ., Y 13 No HOLDERS FUNERAL.HOME"OF GIBSON'COUNTY, INC:, 319 SOUTH MAIN STREET, . . -. es E0 OWENSVILLE,•IN.47665 • FH89000021 .275. Signatse Of Indiana Fulani Service Licensee: • " . 27c. license Number(Of Licensee). . FtANDALL.K DIKE., BY ELECTRONIC SIGNATURE . . .... - . . : FD01010177 Cause Of Death(See Instructions And Examples).' .. . . Approximate ar:1.,Enter The Chain Of Events -Diseases;Injuries,Or cOmplications=That Directly Caused The Death.Do Not Enter Terminal&tents Ittervat Onset Stith As CardiadArrest,Fli3SPeetCry Arrest'Or VerPriodar Fibrdlation Without Showing The Etiology.Do Not Ablutiviate)Enter Only One Case On To Death ... A Lide, Add Addtinal tiles II Necessary. Iminediale Cause(Final Diseasebr Condition Restitiog In Death) A. ADENOCARCINOMA LUNG ' • . 3 MONTHS " . loe tt forms cememorm OS . ' .. • EMPHYSEMA ..4 5 YEARS , •.SequenUally List Contliticrts.;If Any.Leading To The Cause Listed On ?nein Ai a oinnoionn Off IS A. Enter The Underlying Cause(Disease Or Inttry That Initiated The Events Resulting h Death)Last C. c•-•.to......cc-c.a.-04 , . . D. ' • . pistil Erne(01110111 Bus Not Rewriting In The Undenyerg Cause Gnin In Part I 29.was An Abloas7 Pertained? a Yes a . . • . " . 30...INere Autopty Fleeing Available To Complete The Cause Of DeaM7 0 Yes 0 No :.NONE . 31.DO Tooscon Use Con.thbtae To Death? 32.If Female: . 3.3.-Manner 01 Dealt 0 ell mese.Amen.Yu, 0"'Me*to he•Or D•rh 0 Noe Prorms.MS 0.npnrs'nye 42 Oen tonne 01 Haan'0 Homicide '0 Accident 0 Penctng InveSP2IPOn 0 Y, 0 P r o b a b l y 0 No:0 1.1 0 1,e m 2 . 0„0,0„,„.......e......t a Din 71 no?peen Dun 0 irm.'";°;""tm”"pee w . 0 Sukkle 0 Cab Not Be()Offline° -34. Dare Of Injury(McSear) 35. Tire Of Injury. • 36..Place Of InPirY(E.G..Decedents HometCceseucece See Rest Wooded Area)•. 37.Mtn Al Wort? . " 0 Yes Quo . . .. . . . , 38. Location Pt Injury•State . . 38.3, Clay Or Town ,380.•Street 6 Number • 38c.Apt No. ,380. Zip Code • • . I'36'Descnbe How InPrrY Occulted /I• - t ,. ' • . , . 40. If Tr-sneeze-art Injuy, ecify: Oesynomeer OPeoionow UPennn 0°.1.1se.en ' I 41.Signature..Of Person Cerwyrg Cause Of Death: , 42.Cer55er(Cdecrt Orly One) ‘,I CHESTER ROBERT>BURKETT;BY.ELECTRONIC SIGNATURE - - I'S coroyin;Physician ' 0 Coroner ,0 Heath 05cer 41 Name-Address And Zip Code Of Person Certlytng Cause Of Death: I . . . , • . 44. License Number CHESTER ROBERT BURKETT•,9200 HVVY 68 :O 'P . BOX 550 POSEYVILLE. IN 47633 ,- • - 01029806A - . ' 45. Dale Catted 11/20/2014 . ._ . ,. 47. Alas . ie.Signature of„Uxal Ha=Ofbcep--.: ." , t ' - , .. , -149.1.For Registrar Only -Date Feed BRUCE BRINK JR;.VIA'ELECTRONIC SIGNATURE ' :.•• a :"•.NOV 21 2014 , z z i 't t : . 'AMENDMENT.TO.CERTIFICATE ORDE18114(ENTRY,OR ORIGINAL) % • , . ;.,..::-.•,..:-:"1:-.:. ;-., ",,, , ..,... ,---. -... • ....z.3:, .:: 3 .:: / 's `o. -.: - ".o.""j..."..-•:.. .- -..,,r.-: ..z., I.- . .• Z. •• •..,' ; r, '-.:'., -• ; ; 4,. 'Ire;- I.:r•':.- ,•-,.•::: . ::: ....a-•:-:;;•.- • ::?..•:••:;, ,1---::. :i:: a a, 1,?. - ;,t2,::::! &%::iirit:;1;-.4i1- 16,a-::::r-:?...! ! ; .f. .-.• :•-•"•:;.-tf_fc-:..?-a-•:;',-_, „.0-'-..- '-h„,..),..-:',7 i a."7.; -. %,"•Statefi4I52 e?,3e5tATTEFTSON ESTATE:jibe5061.Sepeisyse Ills tecteestegpy trus,stautlegoucyladrderitoPutteremtaibBty;tatS.F.10,1,rel!..rofurlfacYJsrldt,eleTiTI:.”‘"N9.. .tatt..s!).t.::::(..) ' P'iWARNIG .ler•-A . • • N3;OFSGINIAL•6090MEkT!SA.S.48U1.TICOLOREISBACKGRONNI:i081SPE6ihtiq-OkE.SECI>IYAA461"StNCOISE GREAT.id:Airo&ft4E .i-Ai*.i:i 91,aiA14,,,oniBACKAiaTc it, 4 ANS. -00•RANGET•tELLOWWHEN RUBBE010FliGi NAC DOCUMENT HAS AIDDEKtVcilD a N FRONT:THATAPPEARS WAEN:PHOTO COPIED-K;C:Itir2):::.-II7tr,t2:1::: !!;,:ci--4-230.- 7.--:`' rt.,. - :::::`-:-.1:1•• : '7,2 :-4,:,•11.r.:-..- ' t:1---2 eli:".% TATE OF INDIANA ft..3 El:;.1 !--5.1.3 Cf. '''ta ft,cv-if11)4-7,-;"