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Death Certificate - Wilson, Jerry E_1/9/2015
- - - f ,....r4.7>;,,,,:',,'1,-'.. h ---:,:\-... ti L' iNplAsi&SI-AltfigO:k.riutENtipf:i'LltAt.til.::!c:,;‘,,,,----..1, ::::: .:/;,--;ciit.• ir -•., :. -f-tek‘gy , #.4 - -,.: # # : -;CERTIFICATE:OEDEATH" ..- •.-- ;1 "...,-4'1 1.r. •-c:- r ', • '`' •• • :Z. : ' ' ' lit. .; ;%• 1 f. , 2 1 :"..,. "; I i:-; I,. ;.: .:i --7:,$ - -..1 ; C,.1 Tr ; : . , --,: :. : • 1- -- i ',. . f , 1 -:, ,,, ' \.,..., ' , • ; f i „\C:Cali,-.:9',. Local No 002505 ...' i \, ‘EbreNo 000000423001', ..----4: ''-‘. ' - 10601.33\-,•\-- ; ' , , State No .. . I Decedent's Legal Name(Feat,MJedle,Last)•.•::::- .„,------ ;;;i.•;- lectilaidep Name(II!ems),'-'" ,ij„ ;e•:2 Sec."..(. '3 Time Of Death-"-; ;A.Date Of Death(AcedilDay1Year);: .jERRif EUGEN'LL'VVILLSON ?. '‘.. I'd t i: ii* / '.", ,:r., ;;I. i -, -:,.1 t: ( \MkE :., ..= 06:36'AM ..:..;' fl1/26/2014) - Forces? -, loll Death Ocarred Le A Hospital .,- .,, „' -,,, .10a. If DeaMpcturred Somewhere Otherinan A Hospital- ,- -0 Yes 0 No 0 Urinown. 0 Irtoent 0 hmainen6,DePa rant owoate4'0 Dead er:AnTrai . 4 91e ' ! r s"' -'"" ' '. • " . : ' - r : . . . : 0 0r(Speedy) , // -•. - ,.. ,:• . - 11. Fateay Name(U Not Institution,Give Seeet and Number) • ' , • ;; .. `,! r: F --- ;„, -. : . . .. , - . ., ;DEACONESS HOSPITAL INC , ' , ; . 1 i i '. .! ; i ; 4 -.4- : ' i; : : • • . 12. CAty Or Twin,.State,And Zm Case , . . ,, 14.Mamal Stems At Time Of Death ' • ti ar• . .: ,-, •• ' . , 0 Matned 0 Manied.But Separated 0 Divorced • • EVANSVILLE, IN 47747 : . .. ••, ;": f•" ! '-., VANDERBURGH t"--. :-.‘ 0 Weaned - 0 Never blamer, -0 Unknown i.15. Survivirg Spouse's Name;., , , I5a. (If WIfe)Gne Maiden Last Name ::: A :: ' , 18.,Decelenrs Usual Occupation- . - 17.:Kind Of BusinessAndustry , z' ,- ' ', ' • • . . CAROLYN WILSON • • • . COX 1 :. : : tr : '..3 :- 3 3. 3 .-_ MANAGER-SUPERVISOR.- ' COUNTY GOVERNMENT c• If Residence,State . tea. County . . . . . ,INDIANA - - ' GIBSON -. . ,., .. PRINCETON.. . ' I et.'Snot And Number : . h - . ..: : ;, ., -• -. led. Apt No 18e.Zip Code 151 Inside Cdy Limits? : . ' • '• *. ; ; " ' . . .. -107 SOUTH KENSINGTON DRIVE • : .„ ,. : ; ' ._ , ? .47670 El YeS 0 No . • 20. Decedent Of Hispanic Ongin - •• :. 21. Decedent's Race / : • • HIGH SCHOOL GRADUATE OR GED ..,,v 'COMPLETED . . . • .• . . , 22.Eaglet's Name(Fast made.Last) t • . • ', 73„:MometsName(First mode.Lasql , - , :- 23a.Mother's Maide-n Last Nene . • . • , ALBERT WILSON . . - • •-, - , . • MABLE WILSON ',.. i ;.: . I ,' • UNKNOWN . .. •24.Informants Name ' • '. ' 2.4a.Relationship To Decedent • 29 Maine Address (Street And Number.Cay.State.Zip Code) • • ' , .. • • . CAROLYN WILSON WIFE , ,. ''," . 107 SOUTH'KENSINbTON DRIVE, FiRINCETON,IN 47670 . 0 . ‘. ‘., ::.2splac.ibloilbosz'on : ,--.; :.- -.. ,,. - - . -, - . 25a.Method 94 Disposittn ' 250.Place Of Disposicon(Name Of Cemetery.Crernary,Other Rape) 25c.Locator,-City,Town,And State o Banal 0 Cremation 0 Dinbton 0 Entombment . z - . • , ; „ • . 0 Removal From Stble 0 bow(Specify): . . EVANSVILLECREMATORY' -.;.-' ....'-.•-••'... EVANSVILLE;.I N ' •,.. '• ,, .. . . . . 26.Was Caterer Contacted? • 27. Name PM Complete Address 01 Faecal ..v Th.33,.. -% ,,: 3,.. ..--,, _\\ %.; •- . -, 27a FtnemlHome License Number./ be , • .. . . `.. '.,. -,. . , . 0 Yes 0 No - . DOYLEFUNERAL HOME, 520 5 MAIN ST, PRINCETON, IN 47670 .: ".•; .., FH1G400010 278. Signetire Of Indiana Funeral Service Licensee:." ' . ' " ; ,. ; -, ", $ 2- -, •, .' I 27c. License farther(Of Licensee): , ' . . BARRETT W. DOYLE•, BY ELECTRONIC SIGNATURE .; . : : -- ' / : H. - ,' FD29500009 . ' . . :•4- „•4"Cause,,Of Death'(Seelnstructions And Examples).:_-' :-•••-• •••• '-,`: , /,. , . Approximate , 28.Part I.Enter The Chain Of Events -?Diseases,Injuries,Or Compticahons-That Medd?Cabsed,The'Deeth.Do Not EnienTrenninal Events Interest Onset Such As Cardiac Arrest,'Respiratory Mast,Or Ventricular Fibrillation Wthout Showing The Etiology.Do Not FU,breviale.Enter Only One Cause On -' To Death A Line Add Addtinal Lines If Necesiary. , • ' • • :. ''.•' 7: • ,: t • • ' ": ' ; : , 1 '''' • ; . . . Immediate Cause(Final Disease Or Condition Resulting In Death) A GI BLEED 1 : '. ".. , ' 1 . . „ , t , - 1 HOUR ' . . • • . . , . . • Sequentially;List Conditions If Any.Leading To The Cause Listed On ' , ' iiin bo,,,,...,e.,„....;;;„A Line A. Enter The Underlying Cause(Disease Or ifitsy That Initiated , I/ .z•". "-,i '' % t 2' ,.. aa k t . . -,. . ' • ' ' • The Events Resulting In Diath)Last . . . ' • . ' . , ...• Part IL Enter Other SA ,Laryc,orocttions Coedit-ie....a to Death But Not Restleng In The underlying;Cause Givin In Part I ‘.....,„.• 29. VVesAn AL4opsy performed-7_ . ,... .., ,,.,,.., c - ' ., - 0 YeS'... 0 No , :'• -. ' 1.- .. . 4 30. Were Autopsy Finding Available To Complete The Cause Of Death? • . CORONARY ARTERY DISEASE RENAL FAILURE.RESPIRATORY FAILURE. • • .‘.' ..' •-• b. ; . : „:,- ...-.... , „ - ---- , . - • - a- 0 Yes 0 No 31. Did Tobaccc Use Conthotte To Deathy •' 32.If Fenale: , , . , .-, i , ; .„!. • „. ;, f •., ! ",•? 33..Manner Of Death: " - ' . . e • 0 No P.,,,-nafle,e rieCee Ell Pralg:14 in.&lam 0 Not Pri-pers.es 4....ione.:,421:a0 oic..ch„„- 0 Nasiral 0 HGriode .0 Accident,0 Penerng tovntigsaon 0 Yes 0 PrObably 0 No 0 urea:p.:4i' _ ..., - - 2 - . . : , , . , 1 D NA Ferret e...Pow.ry141.an Ta I jou e. Der , CI lavrookif Prhea Vt.fro Pas re" i i.: 0 stickle 0 eoOte Na Be'Determined ' ,. I 34.,Date Of Injury(MontIVDay/Yean 36. Place Of nPay(E.G.,Decedent's Home,Construction Sae,R 135taUraM, • , .. .. , ,' , ... y , WC,d An? .) .37. Injury AtWork? Eyes 0,N,o • . ',. 38. Location Of Injury-State - - ., •, 38a Coy Or Town , - , . .350 Street 8.Minter 4 '.. 38c Apt No - 38d Zip Code r . • . , .. , : • - ■ 11 ' . , „ • . ;• • , . , „ . E. ,: ; . . . . . 39. Describe Hoes Injury Geared , ', . . . - - • : ' - - -. \•• •'' •„ .....' „,. CID"r5P-ty C,--4.... - DC..e.t1SP•ers .. . , . . . . et signswre,:Of Person Cettlytry Cause Of Death: ' - ' ..., : •z .-•<- ,. y -.' .:' :7 ',•. ,..42.Certler(Check Only One) :; -.,. ; • • : . • ' . DOMINIC.t CEFALI , BY ELECTRONIC SIGNATURE ‘... ‘. i •-•'.. '. ".,, "; :: H .7.7 •0 cartilyilvPbisician - 0 datiner :• 0 Heath Offier 43. tlaille,Address And Zip Code Of Person CerLfwg Cause Of Death: ; : -. : : - ' i -; •" . ; : ', = ' 44. License Number • ' : •45. Date Cectfied . ; . •: . ...„ ,/ DbMINIC CCEFALI -415.WEST COLUMBIA STREET[EVANSVILLE;•IN 47710 .1• ,, •••"/".,-; :. 01049.088K> ,4' ..‘' 01/02/2015 ' . •• . .„... -... ' .' k •-• ' --.‘ .. ••■, -'‘' ... a - -' --- 1 %.--.%/ N' Nt, 48. SignatureefLocal Health Officer. 1'-• , --.. -;; -, .‘• ', i- ,,,. '',. •,, ;',, ' ',.1 i f. 7,. -," .',:• ,-.-• 49>i For Registrar Only -Date Red(MonVDaylyear):' '',, 1 ROBERT KENNETH SPEAR,VIA ELECTRONIC SIGNATURE ".. "t. - t :-.. ....? .•". ...:••:..! tIAN 062016 . k ..' Na 7 , j ',. f f? ? Z- .., : i ; .: j AMENDMENT TO CERTIFICATE.OFDEATI1(ENTRY.OR ORIGINAL)• -; ; :.:. i i- ; -:. ; ; ... : 3; -,.; ; : -,.;;.. ,, :, , .. ,....., : .., , ...,,, ., „ i. .,,,,, .1-.. %, . / t. .'-''' " t t -""'''' I %." -t.,..'''''' .1. ..,•,,,...., , , nvoi 2%, - -• r t 7. ' . 3 ., ; .L.• , . -: .... ".% .. . .'• ‘. /'4 %", ; .. 7...1, 4 f '' ....'it, .--"-<''''. sji.;-1.\:. tg, -3 1.-- Do -..2.8,2- ..,-- „ ,t., t , < r i, „, r„ , ,, , ,... A , . ,• - ... N. ..".., , \ '.• ' , Z.,... / i C. 2,' •... t.. ' ti C , ( c ' Z' :.'„' ... ,.c.. i : ?. - 1.: ....; .% A '13 7; ' t 't. I I!• •,. r, 7 i":.., ; t .:; % :: -;-. ::: ;i. 1 ; z‘.-; -; t t . ; .%,..;•. t: .; t ?; t• 5 :• ■• t t t i 1 t % 7,-: 7 • I:. ;: .; tf. :• ,.:.: i t State Farm . .•--•'.,,1 WpA3 R',A TEINNTIGa E:aS.TA.N..TE:LYRF*R_D SOcC'iaUl S. c a/s beinUg iTequestReEd b y itis sGaR BACKGROUND N SPECL WE S eCU , APER AD THE GA SEAL OF HE ST OF NDANA N BATHT , . a TSOMORANGE TOYELLOW WHEN RUBBED ORIGINAL HIDDEN VOID ON FRONT THAT APPEARS WHEN PHOTO COPIED/ r..-. sa.--....a-e....a.................-mi. _ . . . .