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Death Certificate - Glenn, Vaughn_4/25/2013 1 4,.., _:. z., .a- -.�-.>,. . �>.c.,.. ��.�.F.r t � 4r _1� ,.. .., 4 _ • - w, DIA1AS • i • ' ' ` • _,_. , :, CERTIFICATE OF DEATH : n - Local No 000177 EDR No 000000221273 State No 042789 I.Decedents Legal Name(Finn,Mdse,Last) tat Malden Name(If fer..ate) 2.Sex 3. Tone Of Death 4. Data Of Death(Month/Day/Year) VAUGHN OLIVER GLENN MALE 06:20 PM 09/25/2011 68 Months Days Hours Mn^es 08/16/1943 GIBSON COUNTY, IN 9. Ever in U.5.Armed Forces? 10.If Death Occurred In A Hospital: 10a. if Death Occurred Somewhere Other Tnan A hospital El Hospice Facerty 0 Decedent's Home El Nursing Horne/Long-term Care Faulyy 0 Yes 0 Na D Unknown 0'resent 0 Emergency Department Outpater.I 0 Dead on Amval 0 Other(S fy) 11. Fac6ty Name(If Not lnsftuton,Gfve Steer and Number) - GIBSON GENERAL HOSPITAL 12.City Or Town,Sate,AM Zip Code 13. County Of Dead It Mantel Status At Tome Of Death 0 Married 0 Married.But Separated 0 Divorced PRINCETON, IN,47670 GIBSON D 1Vdowed 0 Never Marled D Unknown 15. Surviving Spouse's Name ' 15a.(if Vdtte)Give Maiden Last Name 16. Decedent's Usual Occupxbon 17. Kind Of Business/Industry BETTY GLENN MILLER ENGINEER RAILROAD 18.Residence-State 113a. County I80. City Or Town INDIANA GIBSON PRINCETON 18c. Street And Number 113d. Apt No. 18e. Zip Code 1St Inside Coy louts? 306 NORTH 8TH STREET - 47670 ®Yes D No 19. Decedents Education 20. Decedent Of Hispanic Ongin 21. Decedents Race HIGH SCHOOL GRADUATE OR GED COMPLETED NOT HISPANIC White 22.Fathers Name(First Mdde,Last) 23.Mothers Name(First Mdde,last) 23a.Mone s Maiden Last Name HARDING GLENN ALBERTA GLENN CROUCH 24.Informant's Name 24a.Rtlaaonsaip To Decedent 240.Mating Address(Street And Number.City.State,Zip Code) BETTY GLENN WIFE .. . , 306 NORTH TH STREET, PRINCETON, IN 47670 25.Place Of Disposition 25a.Method Of Disposition 250-Place Of Disposition(Name Of Cemetery.Crematory,Omer Place) 25c.Location-Cit.Twm,And State 0 Burial 0 Cremation 0 DonaSon O Entombment 0 Removal From State O Other(Speofyk MAPLE HILL CEMETERY - PRINCETON, IN 26.Was Coroner Contacted? 27. Name And Compete Address Of Funeral Fatilty 27a. Funeral ROM!License Number 0 Yes D No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671 27b. Signature Of Indiana Funeral Service Licensee: 27c. License Number(Of Licensee): MARK R.WALTER, BY ELECTRONIC SIGNATURE FD01013010 Cause Of Death (See Instructions And Examples) Approximate 28.Part I.Enter The Chain Of Events -Diseases.Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset Such As Cardiac Arrest,Respiratory Arrest.Or Ventricular Fibnllation Without Sacming The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death A Line. Add Addipnal Lines H Necessary. Immediate Cause(Final Disease Or Condition Resulting In Death) A. CARDIAC ARRHYTHMIA _ IMMED n...ia.s.v.......dy, Sequentially List Conditions, If Any.Leading To The Cause Listed On B. ACUTE MYOCARDIAL INFARCT MINUTES Line A. Enter The Underlying Cause(Disease Or Injury That Initiated o..eto•••v+.:...or, The Events Resulting In Death)Last C. SEVERE CORONARY ARTERIOSCLEROSIS YEARS O..ia A.A Ca..-..on 0. Pan II.Enter Omer Si:m avant Cotillions nonthButaw to Death But Not Resaung In The UnOerryirg Cause Ginn In Pan I 29.Was An Autopsy Performed? 0 Yes 0 No 30.were Autopsy Finding Avaaabe To Cmpete Tne Cause Of Death? 0 Yes 0 No NA 31.Doi Tobacco Use Cone tide To Death? 32.If Female: 33. Manner Of Death: ❑Yes ❑Probably❑No ©Unknown 0 AA e,.awt s.Pee... 0 Ps.0 sue.oapse 0 w .,e w-r pee an apse. 0 Suicde 0 Hattiede 0 ecdmena 0 Pending InvestgaSm D,..Pre-at a.ma-.e 0 ons%s w.e.we one, 0 u....,e.'"'..."•••ris pee r.. 0 anode 0 Could Not Be Determined 34. Date Of Injury(Month/Day/Year) 35.Time Of Injury 36. Face Of Injury(E.G..Decedent's Hme,Censuuction Sue,Restaurant Wooded Area) 37. Injury At work? 0 Yes 0 No 38. Laa:on Of I.yury-State 38a. City Or Tom 38b. Street 8 Number 38c.Apt No. 38d.Tip Code 39. Describe How Iryury Occurred <O.If Transperatos Injury, ty. Dt..ce .. Be...�. s' Doe-.11 41.Signature,Of PersonCemfying Cause Of Death: 42. Ceni'.er(Check Only One) BARRETT W. DOYLE, BY ELECTRONIC SIGNATURE El CeetFAng Physician 0 Coroner 0 Herb OrCer 43.Name,Address And Zip Code Of Person Cep fysng Cause Of Dealt 44. License He nber 45.Dap Cerufied BARRETT W.DOYLE , 520 SOUTH MAIN ST,PRINCETON, IN 47670 09/30/2011 46.Adana:al Funeral Service Provider. 47. 'Akan: 48.Signature of Local Health Officer 49. For Registrar Only •Date Filed(MonWDayPYesp BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE OCT 03 2011 AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) ` I•: 1 , x(1:or. Sate Form 53395 ATTENTION ESTATE:The Social Security z is Oe+4g requested by this state agency in order to pursue responsibility. Disclosure is voluntary and there will be no penalty for refusal. g NRA-20 . (7/05)