Death Certificate - Dillon, Kenneth A_3/16/2015 1 � 4 INDIANA STATE DEPARTMENT OF HEALTH 350755
j CERTIFICATE OF DEATH -
I ''..i Lotal No 000148 EDR No 000000394402 State No 031073
• 1.Decedents VAT,Name(Fest Mode.Lan) la.Maiden Name(If female) 2.Sex 3. Tree Of Death 4. Data Of Death(MwntDaynear)
-
80 A oars Hon Males 1 10/24/1933 POSEYVILLE,IN
9. Ever in US Pined Forces? 10.If Death Ocoered in A tbspitat 10a If Dear Owned Scrnenitere Other Than A Hosptl ,
❑Hospice Faddy ®DeaderYs Home ❑Nursing Home/Long-term Care Fealty
0 Yes 0 No 0 Unknown ❑tripa.lent 0 En neM.y Department Outpatient 0 Dead on/WNW O Other(socyy)
11.Fadty Name(If Not btaitutim,Give Seed and Number)
6664 WEST 400 SOUTH
12.City Or Tom,Stab.And rip Code 13.Canty Of Death 14.Mental Status Al Time Of DVth
0 Married 0 Marled.But Ssaated ❑Divorced
OWENSVILLE, IN,47665 GIBSON 0 Widowed ❑News Marva ❑Undwn
15.Sent*g Spouses Name 15a(if WWe)Give Maslen Last Name 16.Decedents Usual Ocoyrion 17.Kid Of Btanessbtety
PEGGY DILLON GARRETT MAINTENANCE MANUFACTURING
18. Residence-Stare 16a.County 16a City Or Town
INDIANA GIBSON OWENSVILLE
16c Street And Number tea Apt.No. tea Zip Coda 18f.trade City Lnie?
6664 WEST 400 SOUTH 47665 0 Yes 0 No
19.DeWmrs Edastim 20. Decedent Of Repast Orign 21.DenGmts Race
9TH- 12TH GRADE; NO DIPLOMA NOT HISPANIC White =
22.Fadtes Name(First Wide.Last) 23.MoNets Name(Fest Wale.Last) 23a.Mother's an Last Name -
DEWEY DILLON AMY DILLON WATERS
24.Informants Name 24a Rdatronsiip To Decedent 248.Manng Adtress(Steel And Muller.City,State.Zap Code)
PEGGY DILLON WIFE 6664 WEST 400 SOUTH,OWENSVILLE,IN 47665
25.Place Of Disposition
25a IMTpa Of Dip osiim 250.Place Of Disposition(Name Of Cemetery.Crematory.Other Race) 25c.Lonswt-City.Town.And State -
O States 0 Cremation 0 Donasrg❑EntOmbment
❑Removal Rain Stare
❑Omer(Specify t OWENSVILLE CEMETERY OWENSVILLE. IN
25.Was Caone Cwtlated? 27. Mane end Complete Adfes Of Funeral Fealty 27a. Ramat fine License Number.
❑Yes 0 No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671
270. Sgnatwe Of nteana Firmer Set licensee: I 270.License Number(Of Llreseej
RICHARD DEAN HICKROD,BY ELECTRONIC SIGNATURE IFD01012153
Cause Of Death (See Instructions And Examples) Apprmdmate
28.Pan L Enter The Chain Of Events -Diseases,Injuries.Or Comp&atiaa-That Directy Caused The Death.Do Not Enter Tanelal Events ntevl: Onset
Such As Carden Arrest.Respiratory MesL Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate Enter Ordy One Cause On To Death
A Lire. Add Addeal lines If Necessary.
nmedate Cause(Final Disease Or Condition Resulting In Death) A. METASTATIC MALIGNANT MELANOMA OF NECK 2 YEARS
o..nor u•Caere 0,1
Sequentially List Conditions. If Any.Leading To The Cause Listed On B. p..ta..A e wt'
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events Resulting In Death)Last C.
w.to m•nweien oe
D.
Pate.Enter Other$yrdcatn Cotta's CenntpJp to Death&it Not Restltrg In The tndepvg Cane Ginn in Peel l 29. Was An Autopsy PMwmed?
❑The 0 No
NONE �.Was Awopay Fndrg AVaaada To Camwesa The Cause Of Deer*? 0Yes 0 N
31.On Tobacco Use Contrite To Death? 32. If Female: 33.Marge Of Death:
❑Yes ❑Pmbabty®No ❑Unknown ❑w A.V..suw.rv.. 0 P.O..si r..wo..w ❑,r.a.m..m'br- w..42 conwows 0 NaWral I]Nordcte ❑Accident ❑Peng Investigation
❑..o,....,.a.w.w,..now..., a.«. 0 bet tv ..p...,..a,..,,..P.V- ❑Suicide 0 Corm Not D.DeWrbled
34.Dim Of Injury(Mont vtayPlee) 35.Tone Of injury 36. Race Of Injury(E.G..Decedent's Marna.Constructing Site.Restaurant Wooded Area) 37. Irery Al Were?
❑Yes ❑NO
38.Location Of injury-State 38a.City Or Town _ 300. Street ILMmrj 38c. Act No. 380.Ip Code
39.Dewitt How Injury Occurred -
sw 40.If Tramputateg Wry,Speay
. pai-a . I}tea p .-Q� ,d
41.Signature,Of Person Candying Calm Of Death: - -- 42. Center(Check Only One)
CHESTER ROBERT BURKETT, BY ELECTRONIC SIG1'*ATURE - - 0 Ceddrg Physician ❑Can ❑Heathof5m -_
43.Name,Addess And Zip Code Of Person Cetit)xg Cause Of Death: - 44.Umae Mmne 15.Date Cetfied
CHESTER ROBERT BURKETT ,9200 HWY 68 P.O.BOX 550, POSEYVILLE, IN 47633 01029806A 07/14/2014
48.Amtenl Funeral Serene Provider. - 47.'Akai
48.Sgiaas of Local Mta^Jn OSU . - '49. For Rrgeuar Only -DoT Fid(MtnplDay1Yeap
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE JUL 14 2014
AMENDMENT TO CERTIFiCATE OF DEATH(ENTRY OR ORIGINAL)
a(0 - IV-3 co - /0) - 000 • ! S )-O I
Stale Form 53395 ATTENTION ESTATE:The Social Secndy#is being requested by this state agency in antes to pursue respprsibely. Disclosure is voluntary and then wdl be no penally tot radasal.
IVRA-20
(7/05)