Death Certificate - Arnold, Lucille_10/26/2013 ISIS AN OFFICIAtXOP 'OF�RECORD OF IEATH ORIGINAL.00PY.UN F LE Al INDIANA STATE E PA'TMENTa itlEALT ".)
1 1 - C
-+c INDIANA-STATE-DEPARTMENT-OF-HEALTH 5 3 4083
1 CERTIFICATE OF DEATH
" `% Local No 000061 EDR No 000000193455 State No 015825
I.Deexrls Legal Name(First Abode,Last) :a. Maiden Name(If female) 2.Sex 3. Tone Of Dean 4. Date 01 Dear'(M_triDayNear)
LUCILLE ARNOLD HOLDERBAUGH I FEMALE 05:35 AM 04/08/2011
10.1'.Jean Occurred n A Hwpfal: 10a. L'Dear Occurred Somewhere Otter T:an A:Hospial
0 Hospice Fealty D Decedent's Home 0 Nursing Hotttelwg-tern Care FamLty
0 Yes 0 No 0 U.-:known Olnprent 0 Emergency DepartmentOuyasent D Dead on Arrival 0 otter(SOecy)
II.Fealty Name(If Not Insttitw,Give Smeet and Number)
RIVEROAKS HEALTH CAMPUS
12.Ccy Or Town.Star.And Zap Code 13.Camy Of Death 14. Mantel Status At Time Of Dean
0 Mamed O Mamed.But Separates 0 Divorced
PRINCETON, IN,47670 GIBSON 0 Widowed 0 Never Married 0 Unknown
15.SOmwg Spouse's Name 15a.(If VAe)Give Maiden Last Name 16. Decedents Usual Occupation 17. Kind Of BusnessMeusoy
ROBERT ARNOLD RETIRED STORE CLERK RETAIL SUPPL STORE
18.Residence-State 18a. County 1E6. Cry Or Tavn
INDIANA GIBSON OAKLAND CITY
' 18c. Sceet Ana Number 1130. Apt N0. 113e. ZIP Coos 181 I.steCcy Limos?
631 SHERMAN ST.STREET 47660 ®Yes 0 No
19.Decedents Education 20. Decedent Of hispanic Ongn 21.Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White 1
22.Fames Name(First.MEae,last) 23.Movers Name(First ■adle.Lao 23a.MDTefs Mader.Last Name
HARRY HOLDERBAUGH TINA HOLDERBAUGH BOWMAN
24.Lam..-.atS Name 24a..R&aoonsNp Tc Decedent 246.Maing Aoa'ess(Street And Number.City.State,Zip Code)
ROBERT ARNOLD HUSBAND 631 SHERMAN ST. STREET.OAKLAND CITY, IN 47660
25.Place Of asppsiaon I
25a Memo Of Disposom 25b.Place Of Disposim(Name Of Cemetery.Crematory,Otter Place) 25c.Location-City,Town,And State
0 aural 0 Cremation D Dooraton 0 Entombment
0 Removal From State
D Otner(Swa)t MONTGOMERY CEMETERY OAKLAND CITY, IN
26.Was Coroner Contacted? 27. Name Ana Complete Actress Of Funeral Farley 27a. Funeral Horne license Number
❑Yea 0 No LAMB BASHAM MEMORIAL CHAPEL, INC., 226 E.WASHINGTON STREET, OAKLAND CITY,
IN 47660 FH83005312
27o. Sgr.atue Of Indiana Funeral Service Licensee: 27c.License Number(Ct Ucenseet
JERRY LEE BASHAM , BY ELECTRONIC SIGNATURE FD01016589
Cause CH Death (See Instructions And Examples) Approximate
2E.Pan I.Enter The Chain Of Events -Diseases.Lyunes,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset
Sum As Cardiac Arrest,Respiratory Arrest.Or VeanaAar Fibrifaaan Without Shawn i Inc EUdogy.Do Not Aboreviate.Enter Only One Cause On To Death
A Line. Add Additlnal lines If Necessary.
L:mediate Cause(Final Disease Or Condition Resulting In Death) A. RENAL CELL CANCER RIGHT KIDNEY UNKNOWN
t.wr0,,.A rd...on on
Secuerkialy List Conditions. If Any,Leading To The Cause Listed On e. later,,,c.„te`
---
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last C.
DieIte Au A Ccanoare Dr,
D.
Pan a.Enter One,Situ. 't Condsons Conubutino tc Jean Bart Not Resdprg In The'XCerlytrg Cause Chin In Part I 29.was An Autopsy Performed?
❑Yes 0 No
ISCHEMIC HEART DISEASES.HYPERTENSION.OLD AGE 30.Were Autopsy F'dnS AVa]ade To Connors The Cause Of Dewar? 0 Yes 0 No
131.ad ipoac00 Use Can-route To Death? 32. If Female: 133. Manner Of Der.:
0 we e,_ewe.,Pau Yoe 0%Teae Te.orr,.e 0 wrnev.-.a..=es,.,rwe.,42 and oro.e. 0 Natiral 0 Homicide 0 Accident 0 Penang Investigation
0 Yes 0 Probably 0 No ED Unknown
Ow>.vr.a a...P. ..'u a...; ,,..teed.Piet 0 twaoe a=rean wen m.peeve., 10Suicide O Cacao Nm Be Determined
34.Date Of Injury(MontJDay0Year) 35.True Of Injury 36. Place Of Injury(E.G.,Decedent's Horne.Constriction Sr=.Resaurant W000ed Area) 37. injury Al Wort?
D yes O No
38.Lxzron Of Injury-State 3Ba. City Or Town 380. Street&Number 3Ec. Apt.No. 38d. Zip Code
39.Desrme How Injury Occurred 40. If Transom'w.L'.h'y.Soecy
0a't..id..-.w 0,..0. 0.astrit,Doe.tsar)
41.41. Signature,01 Person Gen'ying Cause Of Death: 42. Certifier(Check Only One)
RAMESHBHAI P PATEL, BY ELECTRONIC SIGNATURE 0 Cer.Sing Physician 0 Coroner 0 HeattOacerr
43.Name,Address Anc Lc Cade Of Person Cerbfyug Cause Of Dean: 44.License N--moer 45. Data Cer.Seo
RAMESHBHAI P PATEL , 685 VAIL ST., PRINCETON, IN 47670 01040266A 04/11/2011
46.Addumal Funeral Service Proroer: 47. A+as:
' 45.Signature of Loral Teat:rcer. 49. For Registrar Only •Date Filed(MwttDaylYeary
BRUCE BRINK JR.VIA ELECTRONIC SIGNATURE I APR 11 2011
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) I
State Fo,•m 53395 ATTENTION ESTATE:The Social Secuhty a is being reouestec by this state agency in order to pursue responsibiSty. Disclosure is voluntary and mere will be no penalty for refusal.
NRA-20