Death Certificate - Hart, John Robert_10/9/2014 i t t,:14. - ,.itt. .Gru , 6.0.4 ef,- LY:fa.ear•i°'�.a�j,°.6i CERTIFICATE OF DEATH( ! r,.:, ,1 V:5791 '` •t� 1 1=`1' '.+ �=
INDIANA STATE DEPM2TIVENTTOFHEALTH -
�i' ', CERTIFICATE OF DEATH
' 't Local No 000185 EDR No 000000402226 State No 038967 " /-
1.Decoders Legal Name(Feat Mile,Last) la Maiden Name(It lam..) 2.Se. 3. Time 01 Deathh. 4. Data Of Ceram(MorUUDayr
JOHN ROBERT HART MALE 11:30 AM 08/2912014
86 months I Dar 1 Hosts Minutes 09/28/1927 PRINCETON, IN •
9. Ever in US.Armed Forces? to.If Death Occurred In A Hospital: toe If Death Occurred Somewhere Omer Than A Hosrtal
0 Hospice Fade 0 Decedents Man. 0 Nursing HameM1afg"lenn Can Famry
0 Yes 0 No 0 Univ-owm 0 inpatient 0 Emergency Depart,en:O:teaUert 0 Dead on Anal 0 Omer(Specify)
It Faulty Name (If Not Ins:Arbon.Gwe Steer and Numbed
GIBSON GENERAL HOSPITAL
tz.City or Town,Stare.Arai Zip Cade 13.Canty Of Dee:'. tit.Mandl stabs At Ti:.Of veam
®Marred 0 reamed,gut Seantee 0 Divorced
PRINCETON. IN.47670
GIBSON O Wawed 0 Never Ma.:ed 0 Unknown
15. S.x..w3 Spouse's N sine II 15a. (It Aife)Gtve Maiden Last Name 16.Decedent s(neat Occvpadon 17. Kan cf Bosons/Industry
SALLY JANE HART 1LYMAN ARMY - _MILITARY
15. Residence-State I Ida. Coumy 180.Cary Or Town
INDIANA 'GIBSON t PRINCETON
tec. Steel And Number 190. Apt No. 113e. Zip Code 181. Inside City Limas?
803 MCCARTY ROAD 47670 0 Yes 0 No _
•19.Decedents Educaaan 120. Decadent O•HispancOngn 21. Deceden's Race
BACHELOR'S DEGREE(BA,AB, ES) INOT HISPANIC White
'22.Father Name(First Midde,Last) 23.Mainers Name(First.MMCle.Last) 23a.manors Maiden Last Name
NORMAN E. HART VIVIAN P. HART -MCELDERRY
24.Irr.nart s Name 24a.Rela'ionst'ep To Deceders 240.Mae;Address(Steer And N\mor.City,Sate.Lp Code)
SALLY HART WIFE 803 MCCARTY ROAD. PRINCETON, IN 47670
I 25.Place Of Dispassion
25a Wen=Of Discosnon 25e Rase Of Cm'soos:eon(Name DI Cemetery.Crematory,Other Place) 25c.Locazon-Cey,Tom.And State
0 Batt 0 Cremation 0 Comsat 0 Entombment
0 Record From State
O Omer(Soea:y): EVANSVILLE CREMATORY EVANSVILLE, IN
25.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Factty 27a. Funeral Hoene License Number
0 yes 0 No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671 -
27e. Signature Of inane F aneral Ser.ce Licensee: 27c. License Number(Of Licenses):
MARK R.WALTER, BY ELECTRONIC SIGNATURE FD01013010
Cause Of Death (See Instructions And Esamples)
Ar ln
On
SB.Pan I.Enter The;ham Et - , e tr ilr Com icatons-That Caused The Not Enter T Events interval. Onset
et
Such As r Arrest.Respiratory ArresDiseases,
Or Ventricular Fio Ga[dn VnM Showing The Etiology.Do Nes Aboreviate.Ent er Only One Cause On To Death
A Lite. Fri AdQ:Lnal Li nes
If Necessary.
Intnecala Cause(Final Disease Or Cortd:tian Resuming In Death) A NON SMALL CELL CARCINOMA OF THE LUNG MTH METASTATIS 3 MONTHS
a.eta u.we..e Din
Sequeoea'y List Crnceicns, If Any.Leading To The Cause Listed On 8 HYPO%IA AND RESPIRATORY FAILURE w 3 DAYS
Lou A. Enter The Uncerryrg Cause(Disease Or(retry That Initialed
o,.etcr..a_.__ vin
The Eve-is Reswtng In Dean)Last C. LEFT LOWER LOBE PNEUMONIA 2 V.EE%S
ate va.•v...am.oo
D ARTERIOSCLEROTIC HEART DISEASE SEVERAL YEARS
Pan U.Enter Omer: R' • a- .p • -n 3u1 Not:restating In The Uncerlyeg Cause Glen In Pan I 29.Was An Meal's).PerforPerformed?ded?
0 Yes 0 No
HYPERTENSION 30. Nero Autopsy Finding Avalabte To Complete The Cause Of Death?
0 Yes 0 No
31. ad Treacoo Use Connpae To Deem? 32. I Femme. 33. Manner Of Deah:
0 F-1.11'•••r m,°we.. 0 nos...u •••oeo..r. 0 turn..e..eun.n erAt..l,n.a one 0 Natural 0 Homicide 0 Athlete 0 Pending Investigation
❑Vet GP:opadly❑:lc O` Danger
0,••••••deeessiiireireu per Tr,r...eons one 0 tnce,e.,.rsaw..rute•e He 0 Suicide 0 Could Nos Be Determined
34. Data Of11 ry(tAcn:,DayoYear) 35. Time Of lrpry 36. Flare Of Iryay(E.G..Decedent's Home.constriction Ste,Retauraais Wooded Area) 37.betty AtWolc
0 Yes 0 No
I 38. Loc ten Th lap?-Slate 38a City Or Town , 38b. Street 8.NU^tar sac Apt No. 38c. Lo Cam
39. Cason,: 3ca rer 40. II Transpa•sin Iryury.�SpeOo?F
Dot.er Or.e..ee LJee ' 0 - I
41. Sget•-n.Of Person Ceryeg Cause Of Death. 42. CeriSer(Check Only Diu)
BRUCE CARLTON BRINK JR, BY ELECTRONIC SIGNATURE _ 0 cetying Peysldan 0 Coroner ❑Hee05-.r
43. Name,.ddress And no Code Of nerson Car:dyne Cause Of Diem. �- 44.license Number 45. Data CeaSSed
BRUCE CARLTON BRINK JR ,410 NORTH MAIN STREET. PRINCETON, IN 47670 02000610A 09/02/2014
46. Adddma Funeral Serice Provider 47. *Akin:
48. 5yna•re of Laical Heath O'-cart 49. For Registrar Only -Oats Feed (Mrh,Deyrrer):
BRUCE BRINK JR.V!A ELECTRONIC SIGNATURE SEP 02 2014
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
•
Slate Fe:1::3305 pRENTION STATE:The Soctal Secv,ry d is being re ve=nd e't'nso!s tare.ey in°Met to curiae resporseoLTy. Disclosure is voluntary and Ume will bi no penalty for reusa1.