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Death Certificate - Brooks, Anthony_1/27/2015 .--,• '40/54-,...-z&•,/). ;,,,-, ii• ,•.- 5,, './cf,”::`7,,:t. .; :. INDIANA STATE DEP ..,TIME T.,,oF HEALI HI:r-,,....,::t7,4 :iir-..?:w,,, i,ct-3-rftir.-••---;.;;< , .,s •••-• s - _ • 1 ; •••-= ''..----4"-:tt .-•••'t '•'t • ••-i-:WERtiKICAtEd&:ISEA171-11Th=t:';' a i. --,•• ••;-,',---•-:_,-t-.•:,.--(,.:,...-rn.,r,..--,L tk.--;-...q. u.,.: , ,2 st-tr.1 As.-S, ;-.'0'..% 3.";.-"T -"".. -1 ;i i ? ,0 st • 1'f7f,'.., 11.e..-.Y..,r•0 't•t,r1•'7.77,W.47•-•••:, -7 Z 3.•7•••• t % t•.•• 777;77-7..f.c. : .%%• .. :7(7 •77 :.(f... • •••••••- • 4. i••• '% 5 7.-" 7:, 7: 7" ■77 •E. .••••: ,• -.I %%5'•1 ilit.%:70%•711:”.•'.777771Ir71,7711hic, "; t 1? --. tt...;•.t..i b773:7:1!ift't • •'7, 1-1 ' - 000008 - -'. ' . 1 000000425775'; . ( '' "-- oa13oa,- i':-. , -- :. ;i • ,- --- , Local No ‘. ‘.. ,±..EDR No . A:Decedert's lerwi Nama.(First,Middle.13512k3;" ,,,.. '---.„,,. ":A2,--fe ;15..';i4a7zbiTt90Thr.01 len-WCI c'T°''... -4‘5.” '2'Se'C'0-f e --.. '.•,'-;13m*°f P eirill..,ii' '1:P*9-C32,1"Tcth(T'..;.7T,craT..,„ ...,` L' •r“-...„-\ 4! i -T f ''s" tt ' e • ANTHONYa BROOKS•.r. s, r -.. -,-.... , .: .f .,--. ,.. .::::: .....--c. c,.,. .:: . ....,s .,--... MALE:' ,‘."-‘0S20 AM I: :et e/-01/08/20155 - i' 46- r 7. „Mor.i."5 :55/ Pen' ,- / Hosts I 7 5 ;I:417;A°7 k..? 2”. ',., 09/1e/1968i t. ;FOeT WAYNE:IN ;: 9.'Ever m U.S.Armed Forces? t 10,If Berl OFtred In A HOSpeat 't ,t" L ; : 70a If Death Occurred Somewhere Other Then A Flospital .0 s. 1,- ,; --,...,- zsf o Yes'S Not 0 Unknawil CI imatent 0 Eml,"?'"ri DeParlsrentb?..4'atia-0 p•ai;`4niv41, .5 Ober(5PeeifY) % ,f7 ,;•• ,,-„ , . , -:. ..-CAUTOMOBILEACOIDEGF . ' 11.Facity Name,Of Not lomat:al,GIVe Street and Number) ' • ' : f ', L 3 7-, :: 5 : % 7' - • t' i % L' r' . 7:1 1230 VVEST:1000 SOUTH ' , ' - - „ ' ;. 1 7 % 7 %% s ; . : ; . 12.Ccy Or Town.Se.And_2111Ccde f ff. •' . HAUBSTADT, IN,47639 < ' : ..5' t, :c ..--"- <5 t ' ' • " 7 .., ; . S Married 0 Married;But Separated 05Driated .: ■ ,. „. -.., _• , ,...f 15a_(if wtfe)GiveMaiden Last Name Z' ' . y8.Decade-its Usual Ocoasation ' 17.:ICIrsd 0113usymsMnclusty 0 ., '0 ' 7. 5 . . / •%. •% 7 :7. •%. 7 ‘% . S 7% %- S. .. • % -7, • • ; 77 i 7 " • % 4 • •• • ' • • % r • t- 7 : .7.' % . .7:: LESLIE Att BROOKS - - , „ , BORUFF 5 ; ; ; 5 %. , 5 < MANUFACTURING 5 : % : AUTOMOBILE < % INDIANA 5/ "'• c : . GIBSON - : --; f'''--. ..,''''' --, HAUBSTADT :/- • , - 5. 18d.Apt No ,. • Ifle. 24:,Cede ... 181,state City Unra7,, s ' f i ' • ' ' . , - : '..: ; : ; '.; #'. '' ' - ' : ... ; : ' • ' • , 10252 SOUTH QUAIL CROSSING ' 0-Yes 0 No - : 47639 1 : 5 . 19,Decedents Educabon 0 %. :t '- • 20 Decedent Of Hispanic Ongin •: •:,,.,-" , h. -21i.Decedent's Race; , , .. -'''. ' '' • • ' ,..,,. BACHELOR'S DEGREE(BA,AS, BS) NOT HISPANIC --: -',..-:- 5:-\:. BIabk orAfridan Arrierican '- , . 5. .-- • 5- -- . ..:>' . ....--- , •7 22.Faders Name(First Mdcle,Last)t t • - t t, ,t• 73„)Actner s Name(First.Midaffe,tas1) t , -. t ' 23a Mothers Maden last Name'; ::-•....: . ' 5. „ - , • ...._ t f: ,.. .,. 5 t ., t , , . d t , . . . ANNANIAS B ROO KS:JR ' JUANITA1DICKY : MACK , . : 5 t 24,IntmaTs Name' , ' 245 Rsetatshp To Decedent - 24b Me Address(SbeetAnd Ntsnba.City.State,Zip Code) . ' • -'. . - ., • ., .:.;.: LESLIE BROOKS . : . - WIFE ' -,. 5 - -5 .,- - •:- 10252-SOUTH QUAIL-CROSSING;HAUBSTADT:IN 47639. .- ' , ..i- --, 25a Meted Of Disposition ' . ! ; 250.Race Of Disposibon(Name Of Cemetery.Crerrissoy.Other place) 25c Lotaor:City.Tone And State ' ; --; „ 0 Budel O'CrtfrabOn 0 Dora*0 sntombessra 0 Removal Fiorn Stye ' . - . . , El Caber(SCeadY):. -,' - WALNUT HILL CEMETERY ',...,./ FORT-BRANCH;IN - - ;. ;Was Coroner Coe?: i: 7 27. NaalaAre Complete Address Of Funeral Faotry t tt,' : '‘. 7,• t. r7 ••"".: •• N. ? •5: • 5.. !.”77, 27a.Fuleal Monte Li:ens?Number.. 0 Yes 0 NO : 1 t ; STODGHILL FUNERAL HOME INC; 500 E PARK ST HVVY5168, FORT:BRANCH,IN 47648 %, FH10900013 '27b.Si;raare Of Indare Fuseral Service Licensee: , _ " , f I ; 2 , f.' s i a -, •:, f ; :,f ,. 27a License Number(Cl licensee): ROBERT S STODGHILL, BY ELECTRONIC SIGNATURE i 55 %,-55/ / I- "-- ' :, '-',. . : • FD01024378.' ', "----' t' ". . ./ •: ''•- --..„ ,„5,. ..„ .. --,..s4Cause Of Death-(See Instructions And Exarryles) .• .„„ ' . ' App•oximate , 28.Pan I.Enter The Chain Of Event' -.Diseases,WlitrieS,Or Complidations That DirecUy Caused The Death.Do Not Enter Terminal Events • ; . , ` .c"' ', ' Interval Onset " Suds As CardiaeArrest,Respiratory Arrest,Or Vent:radar Fibrillation thrOutShoding The Etiology.Do Not Abbreinate.Enter Only One Cause On : A Line. Add Addeinal ynes r Necessary. ' , . : % .:5 7 s, :( „ t t. : 7 :'I e Mm'edia;&Caine(Fisvil OiSalSe OrGOrcItion Restdingh Death) A.' MULTIPLE BLUNT FORCE TIRA LIMA: 7 : Lnt U Lead To Cane Ldded On B 5-' . .. , , .. • Line A. Enter The Underlying Cause(Disease Or Ireiry That Initiated r.: : 7„ ..' ,,„::'•, i .di , ‘; i .„, The Events Resulting In Death)Last '. '‘ ' i " • % : 7 ; % := 5 :cutIP"45e'reem•90;... . „ . o. ? i -, : r : : , ; . . - .• • „ . - . Pen II;Ermr Olnef Bictocest_Csq75223.1..C5044n919_121511113 BeyNot Ressler,In TM tassetying Cause Ghip In Part I,, .. 29..,VVas An Autopsy Perfeyrnecr? ..,' ",0 ye; 0 1,1;.. i It : UNRESTRAINED DRIVER EJECTED FROM MVA DUE TO ROLLOVER 30,,Were Autopsy Firattno Available To Complete The Came Of Death!. []No LEesnis- .— r . 7.7 .... - '. i .7. ' •- 31.DM Tobacco U3e COntnbtke• To Death? . 32.Ufernale ; 7- :, d :i :, \ % t t ; 7; ; - . • 33. Manor Of_Derly i : ,- ',, L 0, > ■ ,... ti r 0 tiOi Trent..f;eveitt 0 i;r4.....;T.:. 0 ntif're-0;M GU ProP41,C.1.2 Cori Otbse. 0 Uttar 0-rcr.ki;:te A,,csickirg 0 Peridng Irrneardaton 0 Yes 0 Prepare/0 No 0 UnOiown , , . i % • i , 0.4.14.4-'.IPT....43 C.7;T°I;••••5.51.line' 0 'unc&n...1Priren■c;n11+Few You ,. 0 soda CI tolad Not Be o:(5.-anine" a ; 5.5 :, : 34. Data Cl Injury(MC41121/Dayrf 00 , ". ''." ,:• 35:line 04Injury, '•-f' .; • ' 36:Place Of Man(EG..Decedent's HOMO.CCOStItC6011 Site,Rerateeilt.,11,000011 Area) S 37.,IretryAt Wady?, i ', •'.'', - 01/08/2015 • -- •', 0520AM 1230W1000S . , 5., 38.Lorton Of Initry•Scam f :,„ '',. ; ' 38a. City Of T own : ^..,, , -, um;spec&N,r,bef', . .7 • .7. -‘. S '7 ‘ 1.'7 t t %' : -• ' ••' •7•• % .7 7 t 7. 7. t . . % . INDIANA .., -5 •. ‘ 5 `I : HALIBSTAIDT‘ 5 5 5 _ 130 WEST 101)0 ROAD SOUTH ' ' ''. : : . ? • . : 47639 I 0a— 04....... e s e s e r e s Dose(sp.ea f! 'f- . ,. SINGLE CAR ROLLOVER MOTOR VEHICLE ACCIDENT , .; BARRETT W. DOYLE; BY ELECTRONIC SIGNATURE \ s :-s .:. -.. 5 . ,.. , c -0 Certtiim Ptristian., [S,Ccioner3.- f 0 Heim osseri 2 s ,s.. , , s 43.Name.Ackress And Zip Code Of person Cerrs2 Cleat,Cl Peat"- „ ' • ' ; 44. License Menber' c; . 45.Dra Cert5ed, i 1 ;.? 1 ' I: .t, . . . , :- . BARRETT-W.DOYLE , 520 SOUTH MAIN ST, PRINCETON, IN 47670 5.- < ' -, -, . . • 5,5' : 5-' 5 ,, ...• 01/12/2015 < 'is .. c ::- C .-1- .. -% :.' r."' .. :\-. - < •- I .--- . 4 ": 1' .. SI hi: 4'' .- ," - -'4 .c '''''', 1"'""1/4 t''''',, 48 & cf5! ... BRUCE BRINK JR VIA ELECTRONIC SIGNATURE ', ?-5:: % '-'5 . 1 I -: ) i..- i t: '::: I5 % ', -5 : JAN i 3 2015 -5- 5 ; -5 • • z.5: ;5 -, %. e ( < 5,- -; ,- , :: ; -AMENDMENT TOPER11FICATE OF„DEATHIENTRY.OR ORIGINAL/ = = t r 7' 5 1-.. -: t t t •.:. % d •: 1 62-6-I-27 (irD!''''---•0 : -0 a,- II-- R4 , - ,, - , -: ;;• ,, ,.. . . . „: : -.... .„ • „ , , :„ , , -,, ,., ,._ . , •.%, "Z :7" : ; "i; ; .-: ; ',- ,i : :r3 • , '"' ,. ,'S ., '`..-",' ; • S ,...: ri •-__ • ::.: ; :: ' i: :?..; I " e'f. Z .-:: i I -1•,11'---f-' •::••; :• -, :;, ,..1 --•• : .;? :‘ ? ; ;,:•:.::-.,. ,), .•:- .•::: :..- -•:?.: ---•• - frt-f•71• , ItState'Ecyat 53395 .AMON.EST.Pae. t >t.-WARN! .a....esy. #is . requested-by this State agency in ofdeuLOpufsue respassibiEtyl Discknure iS volmrpry re there writ Wee penatty.forrefusat:...,.....• : i it!....... • . ututilNAtalgthff HAS A-MUL ED BACKGIROUND ON SPECIAL:YliciITE SECUTiftY PAPEPANO 2J-1:4 CIREATSBACIPP,THA kap.?''''''trif;.-BAs OKI-'.1'%41-1.,Ct:Sdy,'• • . RR&FROM ORANGE T 0- •W WHEN RUBBED..•RIGIALALDOCAJMEPT. •:HIDDEN: •0 s'N FR.NT.THAT APPEARS WHEN PR•T• •Fi a' ,-:'lle>,....1.../ "t7-t..„77re..„."7••••■"?: r.7.irtn.74.7777/1•7er;:sr-"...1%.":971117":77.‘•-"rtitat•tr7.4%.°77.6.-M•0;7.At7/1-%.“1.7r07%,tt:r e . , s i, , 4 C:74n-ar-,:tVC?fr:17It T1f2f;a3`.-.14:71Ti.17<i--CYC ita.,-Ilt'Kr".V....11,7711.17-"H r.V,/rtit