Death Certificate - Peach, Shelly_2/17/2015 P317p9 . s^�. P^i ,ta rr-'- T r a.:n 01 4:II I a;[Oa I ail a gi ifg g: 3krei'l. �- Pkr-k- � r-1 r- -.•. INDIANA STATE DEPK'RTMENT OF HEALTH 1 ••
r = CERTIFICATE OF DEATH • ..r.P:
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•'Local No 000258 EDR No 0000004'11617 State No 053024 r�
;.Deceyea.s Leoa Nacre(Fast,Mica 1 a. Maioen Name (It female) 2.Se. 3 Tmeo:rxas. 4 Date WDean p.:o-'sDa.. , '1'
SHELLYALLEEN PEACH STONE FEMALE 06:00 AM 10/21/2012 1
57 I Morns I Days ( sours I ::cotes CYNTHIANA, IN
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c Ever in U.S.A.:med Fortes? 10.If Deati Occrrea In A.nos:ral. tea. V Dean Docudea Somewnere One:Tna-.>Hosa.^.a'
❑-.as;.'ce Fa>L'i 0 Hance 0 g(ti
0 Yes 0 No 0 Unknown 0 Inoater. 0 eme:ee:c>Den:^'en:0.^xtent ❑it as an am:al ❑O•rer(Soeodi) (�Fjsa'
Poat/Name (I:Not irsruton,Gee S:ee:am Numoer) "���
8326 WEST 900 SOUTH J
12.Cci Or Town Sate,Arc Z,:Cxe :3. Ccury Of Dear 1<. Mental Status At Time Of Deem III ,
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0 Marco 0 Marred,Eat Sewz:ad ❑Doomero
(CYNTHIANA, IN, 47612 GIBSON 0nbawec CNeve:Mame: Cunvion ��'yyy```���'''}}}///]]]
Suninng Saunas Name 15a. (It :e)Glve Malder.Last Name 15. Deceoenrs Usual 0auoaton 17. Kind Of 9u5reSSArc:utly ,p f
LICENSED PRACTICAL
DOUGLAS PEACH NURSE HEALTHCARE
:9. Reecera-Sate tea. Cana :Ep. Cary Or Town
INDIANA GIBSON CYNTHIANA ,
t5c.Sleet one Number t5:. APL No. 1Sa. LP Code tat.Inside Coy lies' J
0 Yes 0 No l
8326 WEST 900 SOUTH 47612 ` i
I 119. Decedents Education 20. 'eceoent Of Hispanic On;n 2:. Decedent's Race
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'ASSOCIATE DEGREE (AA.AS) NOT HISPANIC VThite a'
22.Fathers Name(FIRE MICS:0,Las) 23.Mot'ers Nare(First.MgGe.Late) 73a Meters Ma cen Last Name
FREDRICK OWEN STONE RAMONA DELL STONE POOLE IIIITh
24.L-:wants Name 2<a.Relapmsnp To Decedem 240.Mang<Ddress (Sate:Arne Ntxnxr.C.y.Sere,Le Cote)
(DOUGLAS PEACH HUSBAND 8326 WEST 900 SOUTH. CYNTHIANA.IN 47612 Jr '.
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I 25.Place Of Disoos:ton 0
2a.Method Of Disposnon 25c.Race Of Disposition(Name a Cemetery,Crematory,Omer Pace) 25c.Locator Czy,Toss:t And State
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Ls aural p Cremation 0 D Raton.0 En:pmprnen:
❑Removal From Sate T
0 Otter(Soeuy): CLARK CEMETERY OWENSVILLE. IN D
25.Was Coroner Contacted? 27. Name Afro Complete Address Of Funeral Faotry 27a. Funeral home License Nemoen i
HOLDERS FUNERAL HOME OF GIBSON COUNTY, INC., 319 SOUTH MAIN STREET, m
or ❑N° OWENSVILLE. IN 47665 FH89000021 m
le. Signature Of Inaaty F•reral Service Licensee: c 'Li rr
License Nm (CI Lcensee): o
RANDALL K DIKE . BY ELECTRONIC SIGNATURE IFD01010177
Cause Of Death (See Instructions And Examples) Appro.enate D
28.Para.Enter Tre Cna'r.05 Eveita -Diseases,L'yu-ies,Or Comp)oatians-That Deecy Causec The Death.Do Not Enter Tee-.final Events Interval: Onset
Sr_,As Cardiac Aires;Respiratory Ades:,Or Ver t:icar E,orilation(MChom Snowing The Etiology.Do Not Aocee'aiate.Enter Or::One Cause On To Death D
A Lira. Ada Adc,iral Lines C Necessary.
D
lr,.menire Cause(Final Disease Or Cc.'reaion ResuO ng In Dean) A METHADONE TOXICITY HOURS CA
Dui I,t>...Ceyvra ri m
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Secuen aly List Cono.nons, Y.Any.Leaong To The Cause Lis:ec On B. a,b c.
Lee A Enter The linger wi;Cause(Disease Or Injryv That Ii:ateo o.mlv..- - ("
T,'e Events Resulting In Dean)Las: c
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D. I{�.Eas
Oat 11.Enter OnerSian`-a-Gn.rno-sCO-t-o_,nato Der,But Not Resume;in Tote U:eening Cause Grin in Part I 129. Was An-2Wsy Ped>'rec+ �
E Yes 0 No I }}}"'
NONE 130. Were Lwow Lrv19 A afaole C.. .dee a Cause Of Derh? ®vas 0 No I
Dlc Tocarao use Cootie To Dea:n, I32 itF erne¢. .?. N O-x m. �,
❑„n.a•. 0 a„-a-., ee ad. . ❑ ,Pes x - _ I 0 Natural 0 : Noe 0 ^e^t ❑ "r9 Investigation I A
❑Yes ❑ oosblY 2 = 0 Jn.:M' I 0 ti aea. Cr,.-er,.,sty.Diet. 2 I 0 B.eude 0 JD,:,,e...;,-.,„c-
ot9 D e :nec
Oz Date C loury(.cunDayi'ear) I 35 7 n O:I ry to Plase Of Iffy lEa .eceoent s:tome.Constnuton Ste .esa.,a.t Wooe:=:ea) 37. ITF. 'Wool I '1\
❑yes p Na {cps/fit
13_ _ocationgenu-:-Sate 35a C.::Or TOwn 13e:. lreetst:eater I __- -. He 13.c _.:Cox I /13 51
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<' ]art" ESY,oC.:141;taECt Death I '2 _.
■BARRETT W. DOYL BY ELECTRONIC SIGNATURE _ '___.e- 0 11,1
: ::ate. ess .:. - Esc.Cx_r d.Ca-s-�Ceetr .._. et le:
BARRE TT VII. DOYLE . 520 SOUTH MAIN ST. PRINCETON. IN A7670 --_ 11125/2012 . {I[?
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cc ro:Rec:saat Only w_FAec 0.s:-.Ca:Lew' 1 ;kt
IBRUCE BRINK JR.VIA ELECTRONIC SIGNATURE NOV 25 2014 4 4i.
I AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) I I j
36 Iq odd- �to0 -001 . L( -oar 1
(96- 11-36- 100 - &D4' I `15 -0a‘ •
".Sate For..52395 T-NTION EST ATE:The SooalSecor„ytIsDeng recuestep oy mis state agerr:c Deter:resue resoonsicib:y. Dlso.cs_re is vosntar:arc there w91ere no penecy:x refusal .
ATTENTION
WARNING MULTICOLORED ON SPECIAL WHITE SECURITY THE OF OF INDIANA CgT A'URNS RO ORANGE OY LO5IHEEN RUBBED ORIIGINADOCWFNi h HIDDEN VOID ON A APP AR ENP OT COPIED