Death Certificate - Hollen, John T_5/2/2014 ! 'E' :a'a-�lih�Pn'E' rid E'r E'{ 7$' ATIWIIl�'E r r._'.:
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(., c 10ERTIkidATE OE.DEATH % _ , ` Y , t -1
•` � .,LocaLNG 000073 •• ' _„EDR,No OO0000363366L's ' state N' 001468'.,. . '\ I.
1]Dec.,edeMSLegaSName:(int.ME?e,lasl)..:,' . .�-- `;test MakknName:Of fatale);.,:,: 12.Sex , 3..Tune OlDea:' 4. DreO(De '(Mo.Y.YDaytYear)..
JOHN T HOLLEN t .. --y � : ..•--< ' MALEi' -.04:60 AM I ::` s"01/09/2014
, 77 i : Months . -. 'I Days Hom 2 :Nmwn kJ _,
Hospital - -
' - . Q Hospce Facity 0 Deoederas Home 0 Nrs'rg HomeLargtem Care Fealty ' ,®Yes 0 No ❑Unknown ®lupatent Emergency Department nent Oa era 0 Dead on nnwal Q
Other(Specify)
11.Facility Name Of Not Insttuton,Give Street and Number)
DEACONESS HOSPITAL INC •
.12.'City Or Town,Sate,And ZipCode 13.Cony Of Death 14. Mental Status At Tame Of Death '
- 0 Marred 0 Marred,But Separated 0 Didart<d
EVANSVILLE, IN, 47747 VANDERBURGH 0%meowed 0 Never Marred 0 Unknown
15. Swvrvng Spouses Name 15a. Of W]e)Give Maiden last Name 16. Decedent's Usual(Yrupation 17. Kind Of BusicssNndusuy. .
SUE HOLLEN NEWTON : - . SIGNAL MAINTAINER RAILROAD
15. Residence.State 19a. County , lea. City Or Town
INDIANA GIBSON , PRINCETON
19c. Street And Number - led Apt No. iee. Zip Code 1e1, Inside City limas
443 WEST GLENDALE STREET - 47670 0 Yes Q No
! 3. Ce:edelt's Educaben 20. Cacedeni et iis:;:ib Ong !-31. Decedents Race
'HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC •..I White
22.Father's Name(First,Mtldre,Last' 23. nera Name(First.Middle.Last) 23a.Mother's Medal Last Name
PORTER HOLLEN ModMYRTLE HOLLEN COOMER
24.LTC.nt's Name 24a.Relatonsrip To Decedent 24E.Mating Address (Suet Ara Nwrbe.City.State,Zip Code) '
SUE HOLLEN WIFE 443 WEST GLENDALE STREET, PRINCETON, IN 47670
25.Pace Of Piposifm .
25a Method Of Dspof.ton 25e Race 01 Disposmton(Name Of Cemetery,Crematory.Other Place)/ 25c.Locator:-City.Town,And Save
0 Bwal 0 Cremation 0 Donaton Q Entombment
0 Removal From State
0 Other(Specify): COLUMBIA WHITE CHURCH CEMETERY PRINCETON, IN
26.Was Caesar Contacted? 27. Name Arid Complete Address Of Funeral Faoky 27a. anent Home License Number:
Q Yes 0 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
25.Pan I.Enter The Chan Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset
Such As Cardiac Arrest,Respiatwy Arrest.Or Ventricular Fibril/alien Without Snowing The Etiology.Do Not Abtreviate,Enter Only One Cause On To Death
A Line. Add Additinal lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A ISCHEMIC CARDIOMYOPATHY,DECOMPENSATED 1 MONTH
Sequerriaey List Condaas, K Any,Leading To The Cause Listed On B. ACUTE RENAL FAILURE ON CHRONIC
Line A. Enter The Underlying Cause(Disease Or Irgwy That Initiated • o°mLO 4.�c""°"OQ
The Events Resuttig In Death)Last C. CORONARYARTERY DISEASE
b..introaau..ew.e,on
D. ATRLAL FIBRILLATION .
Pan II.Enter Other 5gn.:.mm Conditions Contdtnd to Death gut Not Resdtrg In The Uraayi-g Cause GMn In Pan I, 29. Was An Atiopsy Performed?
0 Yes 0 No
ABDOMINAL AORTIC ANEURYSM 30. Vhre Autopsy Fetdcg Avalade To Complte The Cause 01 Dent? 0 yes 0 No
21. Did.Too :n us.Contrite Ta Deam7 •3 . if Female. - - . Z2. tamer Of Dean •
Q w van pent,. Q P.r..Al rep.00.oth 0 wPe.T..,ean.a:..Wc...so on,ac..n 0 Nateal 0 Hone 0 Accident 0 Pending Investigate n
Q Yes 0 Probably 0 No 0 Unknown s '
Q e.n.r,.as P.P.-.a con r.t.w kb.Toth O t+.A..an.a..w...m...ores.. O Stickle 0 Could Not Be Detrmined
34. Date Cl Injury(Mdndsvayrea.l 35. Tine Of Injury 36. Place Of Injury(E G.,Decedent's Home;Constructton.Ste.Restaurant,Wooded Area) 37.Bury At 4Mxki
0 yes Q No
36. Location Of Injury-Save 3&a. City Or Town 36E Street&Number . 35c. Apt.No. 33d Zip Code •
39. Describe How Injury Occurred . 140. If Transportation Iryury,Spedity:
0s'-.no-.r Q.. nee [J Peotemn Qrn..IWU,/
41.&give e. 01 Person Gooding Cause Of Dealt 42. Center(Check a'ry One) .
REKHA TUMMALA, BY ELECTRONIC SIGNATURE 0,Certifying Physician 0 Coroner 0 Heati�cer -
43.,Name.Address And Zip Code Of Person Ceniybq Cause Of Death: ---- - ' 44. License Mutter 45. Daa Cetted
REKHA TUMMALA ,600 MARY.STREET, EVANSVILLE. IN 47710 • - . • . ., 01060018A • • 01/14/2014 •
46,Adat':kcal Funeral Service Provider . - n. •Akers: -•
:'5ignau tI to c re of Local HeY o e /~, ,49. For Reaistnr Onty -
43 Date Ftled (MmdNJryR'sa):
RAYMOND W.NICHOLSON,JR., VIA ELECTRONIC SIGNATURE? _JAN 15 2014. - .
AMENDMENTTO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) _ , _ ,
V
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