Death Certificate - Watkins, George_7/1/2013 leer, CERTIFICATE OF UtA Ili
::._ / Local No 000115 EDR No 000000329269 State No 028378
1.Decedent's Legal Name(First.ISd:e.Last) la. Maiden Name(If female) 2.Sex 3.Time Of Death 4. Date Of Death(MmeuDay(Year)
GEORGE WATKINS MALE 11:34 PM 06/17/2013
6a.Age-Yrs 6b. Under l Year 6c. Under 1 Month 6d. Under l Day 5e.Under l Hour 7. Date of Bath(Month/Day/Year) 8.&replace(City and State or Foregn Country)
87 Months Days Hours Minutes 05/08/1926. HORNERSRUN,WV
9. Ever in U.S.Armed Forces? 10.1f Death Occurred In A Hospital: 10a. If Death Occurred Sornewilere Other Than A Hospal
Hospice Fealty ❑Decedent's Home ®Nursing Homeiong-term Care Fao3ty
0 Yes ❑No ❑Unknown ❑Inpatient ❑Emergency Department Oumatem ❑Dead on Antral 0 otter(Specify)
11. Far3y Name(If Not Insttuhon,Give SYeet and Number)'
TRANSCENDENT HEALTHCARE OF OWENSVILLE, LLC
12.City Or Town,Sate,And ZJD Code 13. County Of Death 14. Manat Sates At Time Of Death
0 Mated Marred.But Separated ❑Divorcee
OWENSVILLE, IN,47665 GIBSON 0 Widowed ❑Never Married ❑Unknown
15.Surviving Spouse's Name 15a. (If Wife)G'we Maiden Last Name IS. Decedent's Usual Occupation 17. Kind Of Businessandustry
BUILDING AND
PATSY WATKINS FINNEY CONSTRUCTION CONSTRUCTION
18.Residence-State 18a. County 180.City Or Town
INDIANA GIBSON FORT BRANCH
tad. Apt.No. 18e. Zip Code 18f.Inside City Limos?
18c.SYeet And Number
0 Yes ❑No
905 NORTH HIGHWAY 41 47648
19.Decedent's Education 20.Decedent Of Hopanic Onew 2t. Decedent's Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White 23a.Mothers Maiden Last Name
22.Father's Name(First.IAddle.Last) 23.Mothers Name(Fast.Middle.Last)
MELVILLE WATKINS IDA WATKINS HUMPHREY
24.Informant's Name 24a.Rsatalsnip To Decedent - 2db.M•aang Address(Street And Nomoc,Qty.Sate,Zip Code)
SHARON MCCAULEY DAUGHTER 27044 BARRA, NOVI,MI 48374
25.Place Of Disposition
25e Method Of Dsposibon 25b.Race Of Oisposioon(Name Of Cemetery.Cremamry.Other Race) 25c.Location-City,Town.And State
❑Burial 0 Cremation ❑Doaton❑Entombment
Removal From State
❑other(Specify GOODWINE CREMATION SERVICES PALESTINE, IL
26 Was Came:Contacted? 27. Name And Complete Address Of Funeral Facility 27a. Funeral Home License Numb.
O Yes ®No STODGHILL FUNERAL HOME INC, 500 E PARK ST HWY 168, FORT BRANCH, IN 47648 FH10900013
27b.Signature Of Indiana Funeral Service Licensee: 27c.License Nianbes(Of Licenseey
ROBERT S STODGHILL t BY ELECTRONIC SIGNATURE FD01024378
Cause Of Death (See Instructions And Examples) Appronmate
28.Part I.Enter The Chain Of Events -Diseases.Injuries.Or Compecatios-That Directly Caused The Death.Do Not Enter Terminal Events Interval: O set
Such As Cardiac Arrest,Respiratory Arrest.Or Ventricular Fibrillation Wthout Snowing The Etiology_Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Additinat Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. ADENOCARCINOMA OF THE ESOPHAGUS 6 MONTHS
ae n rot A.•cs.,•v...do
B. DYSPHAGIA 2 WEEKS
Line A. lists Undr Conditions. ft Any, (Disea To The Cause Listed ed w wroc...r�..v....09
Line A. Enter The Underlying Cause(Oisease Or Injury That Initiated
The Events Resulting In Death)Last C. CEREBROVASCULAR ACCIDENT 3 YEARS
war>•••w•dw op
D. HYPERTENSION SEVERAL YEAR:
Part tl.Enter Otter Significant Conditions Cbnirrpucnd to Death But Not Resulting In The lWerlyag Case Grass In?an I 29.Was An Autopsy Per-teemed? 0 Yes 0 No
30.Were Autopsy Finding Available To Complete The Cause Of Death? 0 Yes ❑No
IRRITABLE BOWEL SYNDROME 33 Mymy Ofpeatn:
31.ed Tobacco Use Cmtnbuce To Death? 32. If Female:
O „ w ❑esrat•rr...ao.•., 0 N em ..eel errs,www•2 w„wwe 0 Natural 0 Homicide ❑Accdent 0 Penang lnvestgahm
❑vez ❑Prbad ❑NO 10 Unknown wwc .•naan•r u°o.
7e r few e.w.Dane 0 u..P.•n w•r44rw..,The Poi... ❑Suicide 0 Coed Not Be Determined
34.Date Of InNry(Mbn:NDayrvear) 35. Time Of lnNry 35. Place Of Injury(E.G..Decedent's Home.Coneuuctien Site.ResauronL Wooded Area) 37.Injury At Work?
. -. ❑Yes 0 N
3a.Location Of Injury-Sate 38a. Cry Or To.tm 36t{e=4;BCruher 33c. Apt No. 38d. Zip Code
�-�- •;-�-�..T_�.�a._ ••V• e 40.If Traispaa:nd unryry.Shaft
39.Desmee How byury Occurred ` • '..'.Y+` C'Yyt V. p,....oP..rw OP. a U°•^•^0°..P's.r1
41.Signature,Of Person Ce:fying Cause Of Death: Z 42. Ce , (Check Only One)
BRUCE CARLTON BRINK JR, BY ELECTRONIC SIGNA-TURCI A' ' 0 CerMng Physician ❑Corner ❑Heaboficer
: a 44.License Number 45.Date Cerfed
a3. Name,AdiYess And Zip Code Of Person Ceetaing Cause Of Death: �.
BRUCE CARLTON BRINK JR , 410 NORTH MAIN STREET:PRINCETON; IN 476Rr 02000610A 06/18/2013
46.Add:.mal Funeral Service Provider. • •• (^ 47. 'Mast
C♦
-1".1 * ••s"f: 49. For Registrar Only -Date Filed(Mmt.IDayfYear6
48.BRUCE BRINK JR,VIAr. -”y C-- JUN 19 2013
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE MENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
D State Forth 53395 ATTENTION ESTATE:The Social Security p is berg requested by this state agency in order to pursue responsziEty. Dsclosure is voluntary and there will be no penalty for refusal.
,k� ' RA-20
,e • N(7/05)
..-- VOID IF ALTERED OR ERASED-NOT VALID UNLESS CERTIFIED BY HEALTH DEPAR