Death Certificate - Arburn, Jerry W_1/3/2013 „z. ,:...ill�fo�b �i�c aeaRu ' t'I1f. 896422•A
t CERTIFICATE OF DEATH
Local No 000181 EDR No 000000282295 State No 044666
1.Decedent's Legal Name(First.Mlddie,Last) la.Malden Name(If female) 2.Sex 3. Tore Of Death 4. Date Of Death(MmndLDayh'ea)
JERRY W ARBURN MALE 02:55 PM 09/28/2012
10.If Death Occurred In A Hospital: 10a If Death Occurred Somewhere Other Than A Hospital
❑Hospice Fealty ❑Decedents Home 0 Nursing HoneLag-tem Care Farifty
❑Yea 0 No ❑Unknown ❑Inpatient❑Emergency Department Obl ate= ❑Dead on MT"' ❑Other(Specify)
11.Fealty Name(If Not nsntpn,Glee Street and Number)
RIVEROAKS HEALTH CAMPUS
12.City Or Town,State.And Lb Code 13.County Of Death 14. Mama Status At rime Of Death
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4 ®Maned❑Married.But Separated ❑Warted
PRINCETON, IN,47670 GIBSON ❑Widowed ❑Never Married ❑Unknown
15. Surviving Spouse's Name 15a. Of Wte)Gtve Malden Last Name 16. Decedents Usual Oaagatah • 17. Kind Of BusnessAndta:y
MARY BETTY ARBURN PAULEY FARMER AGRICULTURE
18.Residence-State tea. County lab. City Or Town
INDIANA GIBSON PRINCETON •
18c. Street And Number 18d. Apt.No. ' 18e. Zap Code Iaf.Inside City Limas?
2353 EAST 250 SOUTH 47870 ❑Yes 0 No
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19.Decedents Eau:aeon 20.Decedent Of Hepanic Origin 21. Decedent's Race
SOME COLLEGE CREDIT, BUT NOT A
DEGREE NOT HISPANIC White
22.Fathers Name(First Mtdpe.Last) 23.Mother's Name(First.Middle,Last) 23a.Mothers Maiden Last Name
WILLIAM HOWARD ARBURN RUTH ARBURN KOHLMEYER
24.Infamanl'e Name 24a.R tada iship To Decedent 24b.Matting Address(Street And Number,City.State Zip Code)
MARY BETTY ARBURN WIFE 2353 EAST 250 SOUTH, PRINCETON, IN 47670
25.Mace Of Drspaerica
25a Method Of Dsposison 25b.Place Of Dispcsibon(Name Of Cemetery,Crematory,Other Place) 25c.Locabal-City,Town,And State
0 Bunt ❑Creriaion ❑Denton❑Enmrnbment
❑Removal From State
❑other(Scepf)k MAPLE HILL CEMETERY PRINCETON, IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Fadlty 27a. Funeral Hare License Number
❑Yes 0 No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671
27b. Sanaa/re Of Indiana Funeral Sere Licensee: 27c.License Number(Of Licensee
RICHARD DEAN HICKROD, BY ELECTRONIC SIGNATURE FD01012153
Cause Of Death (See Instructions And Examples) Approximate
23.Pan I.Enter The(Tai Of Events -Diseases,Igunes.Or Cenphcauau-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset
Such As Cardiac Arrest,Respiratory west Or Ventricular Fibrillation Without Showtg The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Add.tinal Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. PANCREATIC CANCER 1 YEAR
tin CO,In.cawwww44 04
Sequentially List Conditions, If Any.Leading To The Cause Listed On B'
Na le(Or
Line A. Enter The Unsay That Unsaying Cause(Disease Or Injury at Initiated l ..l.e_o�w art
The Events Resulting In Death)Last C.
. an.10.41 Omegas.04
D.
Pat IL Enter Othasrfiic nt Conditions Conlibutno to Death But Not Restitng In The Underlying Cause Gain In Pan I • 29. Was An Avspsy Perfumed? ❑Yes ®No
30. Were Autopsy Fldng Available To Compete The Cause Of Death? ❑Yes ❑No
31. Did Tobacco Use Contbute To Death? 32. If Female: 33. Manner Of Death:
❑ ❑PrpbaWy❑ 0 ❑NpjP .-vwa'"`•°m° ❑P+w+M Tel..amen ❑uen.w,NA Pmcnwit en.tom Oro. ®Natural❑Hmtlode ❑Accident ❑Penang Investgedon
Yes Na No Unknown
0"°P„ow4 en,+ve.a Cs”Tot,or a.e.o..n ❑uww4w..wvwn.,a.e..rr. ❑Suicide❑Coda Na Be Dearunined
34.Dace Of Injury(M ntIDayf Yea) 35.Time Of N)ury 38. Place Of InOry(E.G.,Decedents Hox.Ca:svucdon Site.Restaaant Wooded Area) 37.trylsy At Wok?
❑Yes ❑No
38.Locator Of Injury-State 38a.City Or Town 38b. Street 8 Number 38c.Apt No. 38d. Zip Code
39.Describe How Injury Occurred O If Traisoala❑tury.peofr ❑«w 4>Pa1
°aas Lyce u
41. Sgnaure.Of Person Certifying Cause Of Death: 42.Cutter(Check Only One)
JON M HALL, BY ELECTRONIC SIGNATURE Et Certifying Physician ❑Corona ❑Heath Offerer
43.Name.Address And Zip Code Of Person Centro Cause Of Death: 44. License Number 45. Data Cabbed
JON M HALL , 4015 GATEWAY BLVD.STE.3000, NEWBURGH, IN 47630 01050887A 10/10/2012
46. Add:eOnal Funeral Service Provider 47. 'Akas:
48.Signature d Local Heath Officer. 49. For Registrar Only -Daa Feed(Montl/Dayfteak
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE OCT 11 2012
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
State Form 53395 ATTENTION ESTATE:The Social Security t is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary and there will be no penalty for refusal.
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V010 IF ALTERED OR ERASEOINOTNALIO:UNLESS CERTIFIE BY_HEALTH:OE�~�PARTMENT