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Death Certificate - Elliott, Carl W_7/1/2013 -IS11§11.idalitiALTC1113,METRECORDTOF(DEATilro-RIGItitifctOPYINTILCAT-THIStOUNTY'SIHEALTH;DEPARTMENV 0 1 9 6 7 2 larr:ardri..-----•-tx_vn-..........,:sHH-tarrerscs./.....drourvan-u-Ra...nretz-rile-...tilir-nonzust-end-•.---(24.-ntertir.•isa...,..........rtirsarrini.a.,.1 -.. • 'ATTENTION ESTATE:The Saul ity r Ls . Fob's:a:Ts:PhiA tasresposti'En;sgri.c&:;4:?z.‘iwer.;;:s INDIANA STATE DEPARTMENT OF HEALTH , • • vet:iv:Italy and Mora wil ta no poney for talusal. FA :- '-i;--.-ri 1 --ii*-,r) i t CERTIFICATE OF DEATH = - ',Local No r, -., - ,c,i( fi ' '-t- State No. CL......."--:-.. "I THE RECORDS IN THIS SERIES ARE CONFIDENTIAL PER IC 16-3i-I-10 . 'RINI ' mc"sm-Nn't 'yin le44 Lne) : SET k nuE OF DIA TN I a DATE OF DEATH tun.0.,n7 . Carl xV. Elliott AIale (.. 106:10 PM u March 13.2004 • > --i m i ENT LAST sifavro w i Kfrsp.i. t j 4.0....., :AA. Ita-PaCE OF DEADI 10..a env on.sninix....) U.7!ANse.-0.0PCE57 ._Lt n ...........-,,A OTAIDA 0 Nang Mr.. 0 Cew(S/7.41 i 1 , i . 0(Rraaina,t' Coos .. ..--_ - ; -- 12 6.. ---- t"... 'A -:0 .• Et FAL-CEANAVE Tin e.e..iati pr.ma AC mat': : lc-ore.renrili..00AT/Oti OF DEA Il• S. COUNTY OA DCA:It I-I 1 302!Mill Street . . .- - Lliazletony, Gibson r---, m u,re . . .. .,.,, 0 13 paint STATUS 11 SurrYINC SPOuSE in DECEDENT S USUAL OCCUP1.1144(C.v.Ant at.r. Qt. POND Of BUSINES.'NOUS'AN -C ISosay, f/......re.or:win) I. -- es.,sag mast 41•marc tit Coo nr ter terse; ' ' -a M z-c Marl-led T ied , . Sharon Van Patten _Truck Driver - -- rucking P r-0 0 I 0. RESOCNCE-SThif i COuNIY 77c CITY.TOWN OR LOCAT7N i la STREET AND NAME, 7C...:: i4 ".-fi, Th IN,. Gib:inn Ilazlcton ‘ • 302 N1111 Street -rim n Ile LIP COCA I, D.SDE CITY 79.7775 14 CITIZEN OF I,7 WAS CEMENT OF r.S.R2JRC OF.010 II RsoE_........,...c.... I: DECEDENTS cotr.Anak I .7:t. V 185 20,41 C01-55.7A55 ig Ira 0 ir. 0,Hr..,Cl... bac.wt..... tSp.cry Ply AV...!pas amplest CC) 0 0-q-1 , • M 0.A., 4700 174 ON•A FAA", U.S.A. Pusan Aare Rat es i EarearaSPoNfaty 0)-123 Cal.}0-4 et 5.1 7.:-.) Z.Z : White I. ,.7....) w.6,F......i . N No U Yes It • rrEns rroa•H(Hut A4*54 Lae II MOTHERS rmERS 45.54 Wye lacy Madan&,nn) -f- -....N. .?,' n".1'17 Allen 1. Elliott A lyrtle NValters ts 2 o b NT r• picot:us/as Nast(rr,m,..,6 70t uspa,0 ASORSSSISont yia..e.rtue o•An;San NuTto,.Coy cr TcwAt Sun Ze 07.1.1 20. RavaraNc Sharon Elliott 302 Mill Street P.O.Box 226,Hazleton,IN 47640 Wife e- r- > v. mrn-co OF DSPOSTC*4 0 Er-r-ern int CATE An0 P.-RCS OF OZROSMON Un a tre.er,ono"P sic LOCATION-C.72 a,To.,Sta. cn> IS:I eon: 0 CancA 0 8......:ter,Stw• caSw pfac.1 Mar 17.2004 0 CS 0 Darr., C Ore CSen ___. . I Ilanloton Community CcmClcry 11azleton IN -- -Z - ,„ic ION 224 DAR4OFA 5 NAME ND EYBA.U.F.AS LICENSE NC 23 WAS DEATH EPORTED TO COPONER7 Nark R Walter / FD01013010 p..• Di,, r o cc;rn 74. SIGNATLAIE OF FUNERAL DIRECTOR 24b LKIME MAW 25 NAVE ADDRESS ANDLC:NU NUAASER OF Pt:NEPAL MPS CA7 m C.:, (- L,Q.,455.ydatent, Colvin Funeral Home. Inc. F113300567I -FD01012153 IT, m-r. >r,r, . 425 Nonh Nlain Street,Princeton: IN 47670-m 24 FART I E-ew or con..-.a..or crOcacrs tam ca.-44.7 Me 0Y Dc nor•-ce Haroror in.....,....nu u...HirRi H-- 0 C Amen. C C ram ea'.a•n...,1“..•1•N.nes,I+.........c.............. "1 inoveni Baton 0-ao ora Doe. 0 6.ii:.7!"/"...tr';7•A7 -.2719-1 A-1-'0-7,-- A:. *u., 55.4221TI CA1S1 On • 6 c••••••4'`"'""" CUE M(OR AS•CONSECVENCE on rn 0 •niter:AI 6.4.1 ( r 5L-- :".63 11/2"--,:-n..i L' !L.,- -,z.--n•-• c2i;4S-- t e 0:ID c...,--,.-,.--_,,,. art To 107 an cON5tL7JtNt.t u, -n rr. . ...... < 0 5 0 ......,d,......,,..., DUE TO-:OR A5 A CONSEOUD.Cf OF) e. .........6. 5••-`. (A ,_, e 0 r- . --' ▪ 3_, up: __ A a c.,...v.e.c...cerceam-Greta,.ccestassec tate as-.1 Er nog,nee•Fr" 27 ASS DEM:ENT as WAS AN AUTOPSY 23e MAE AUTOPSY Para 0 In El sr(orao-on 515 0151, PurOfterin ioa Azusa P01 TO ROStPtimihn Vrat cerpi COUPWION OF CAUSE -.•• 0 "rt E/2 M U..c.NA) CF D(AN,(Yaw nol K M M NO No No Ls >(3 r-m a 0 29. CESIFiffi M any:Frac PA tscuis it AA.bat cl iv 1.4..044 Mr,ics.n.v e.1r as end ow at en u to tins.!.4 sne 7 T.0 (Ova On)r 0 MELLO!OF Ka Oat..bur norre.no-...rirr...rum.,r ty bona,etc totemic r cm WI tn.&re 1St.lie ea ri u.....isi I.awe C . 0 COROWP. On e.tar a... -_-nr re,...-...mcnr r.,,oka-c,aut.OCCurn4 I,r.ii r_i tea Int GLIC•arc dr.ia er trruiti arc en.r.anc.__ _ - .Z ff'•k71- m .= _ , ,, ycariann AND oti.5 OF cthonsi...' - ---•-- ---------- - '--- -71c-141M4CALLECENSE NO'- -2os"DLit SKHED titre.Day rwl rn C) , > m • 01 CI\11..---1 ri t- 3 i-1-'i ic.ttl 7 0 , I. !. I: 2/ T F mc 8 c 70 NAME AND A-COPES:5 OF PEP/ON:WHO C07.171.ETED CAUSE OF CDT.GUMS!)I tr)eAft...6 Daniel.1 Combs MDr702 Vigo St,Vincennes,IN 47591- 3! nEALTH(DANCE 'ATURE ' .1.-C-.C.- .11( 1XYA I 1.7.DATE FILEDO.Ape.Car.Vaal . I itioric :".5 7190 33 AWFMEIt OF DEAN 34 OAT!OF 15 1 345 MAE OF 14 WAIST AT 550.1,5 Na (*SCRIM roan/AM OCCURRED i'. Z M in c.,...... • m> >r M r Nous 0 Ansa; \t Z ii 0 0 4545,1 55.6.55aALA 344 PLACE OF 25.011-A.1 4.-..5 4o..irc.■4r.-n.c•Ac• Pt 50C1710,(Soso and N.s.• ev Pr's Ana Nurt...Cs r To..544) 0 SuCte 0 Ce.44 Kg tot bola."pc Moot*, Dew nAsC N 0 Airco .." 14g DATE PPCNOUNCED DEAD 0.A7Ack Day Awl 74a L0t0R 51,4O1 ACCOANI,I?..ri ra Sr..away error tasvorr ssIva.r.vs ,,'Cr "•ki kr. !•,.. :`% 6 \>x soHo6404 State Form 13110(R5/1-99) v•"-, 1••li