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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
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• '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
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Carl xV. Elliott AIale (.. 106:10 PM u March 13.2004
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I-I 1 302!Mill Street . . .- -
Lliazletony, Gibson
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Th IN,. Gib:inn Ilazlcton ‘ • 302 N1111 Street
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Sharon Elliott 302 Mill Street P.O.Box 226,Hazleton,IN 47640 Wife
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Nark R Walter
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cc;rn 74. SIGNATLAIE OF FUNERAL DIRECTOR 24b LKIME MAW 25 NAVE ADDRESS ANDLC:NU NUAASER OF Pt:NEPAL MPS
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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
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I 1.7.DATE FILEDO.Ape.Car.Vaal .
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33 AWFMEIt OF DEAN 34 OAT!OF 15 1 345 MAE OF 14 WAIST AT 550.1,5 Na (*SCRIM roan/AM OCCURRED
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\>x soHo6404 State Form 13110(R5/1-99)
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