Death Certificate - King, Charles Grover_7/6/2015 CERTIFIED COPY OF DEATH RECORD
City of Mt. Carmel. IL
DECLDENT'J BATH NO REGISTRATION ['`9 2.1 STATE OF ILLINOIS
DISTRICT Na 7b STATE FILE
NUMBER
REGISTERED /8 MEDICAL CERTIFICATE OF DEATH
NUMBER
Type or PNRI in /DECEASED-NAME FIRST MIDDLE LAST I SEX DATE OF DEATH wow.,DA..TEAR)
PERMANENT INK
See FunmlD..ctoa. I. Charles Grover King 12.Male 13. June 6,2000
NLSPR11.or Physicians COUNTY OF DEATH AGE-AST UI:ULI I VeAR UNDtH 1 DAY 'DATE OF BIRTH NORTH DLY.YEAR)
Handbook for BIRTHDAY IYRSI 'Ga wY IO
a ,s
INSTRUCTIONS M. Wabash 5.. 93 sb. I sc. I I sc.November 13, 1906
CITY.TOWN.IMP.OR ROAD DISTRICT NUMBER HOSPITAL OR OTHER WSTITUTIOID,a UE Or NOT IN EI;YER GIV[STREET AND,AAGERI if'OSP.OR iNST INDICATE D GA
OAEILR Ru EVATENT(SPECS,
A sa. Mt.Carmel 60. Wabash.General Hospital • ec. Inpatient
BIRTHPLACE Y(fCqIVTY�ARO STATE OR MAi,&D.NCVeR MANHILU. NAME OF SURVIVIJI,SPDUa IaE,Oen NAMElr Mr cl "SET,CEASED EVERa
DECEASED FCef_NCBW'TWfl YREOWED,DIVORCED(SPECIFY) I ("SED FORCES,EYEStao
tllnOdiian'a ea. Married en. Dorothy Steckler Is. No
B
+m. Tool Die Maker !KIND Tool Mfg DE tart IDOUNTY
YESVJ!
aa. 401 E.4th Street IIb ._MLCarmel Inc Yes Inc. Wabash
g A.c LODE t1"1:-e la.r.e I+C AML,..u. rHISPANIC OnhcI('ISPEOFY,Oa+rtS-.YESSPECVY WORN.LEMAN PUERTO RICAN
R)(SPECIIT
ne.IIIIn01s 11x62863 IWhlte • ry. ENO YES SPECIFY:
rAinen-r:AME r LLB I MwuLC LAD, lawmen-NAME ruu. MIDuLe IMAIUCNI Lola/
+E. Charles A King In. Lurene C. Caley
1 trunMAN.a tJMe I...L.a.-w../ ,.LIAIA,NJnI. MAIUg4I..UL.AAM,,E,vrs:RRgEETeeRISeO�NO DR RFC-Dr'OR TORN SLATE.DII
2 va. Dorothy King ITrb.Wife 17c.Mt.Carmeryl,ILtr62863
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�� BETATEH INSET ANO o
DUE TO.OR A5 A CONSEQUENCE OF `_`'rt{
CONDRYJNS.IF ANY
KYGCH GIVE RISE TO (D)
IMMEDIATE CAUSE(a)
STATING THE UNDERLYING DUE TO.OR AS A CONSEQUENCE OF
CAUSE LAST. (C)
4 PART I. Owe panto.*onus mvtup a cos y rot 7ES ideip5 me ART I. AU o OrbY unmrrsva..,yyu nen
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N DATE OF OPERATION.IF ANY I MAJOR FIN G5 PERATION 0 re MALC.ORs•nuo•••c..h•RU AR.A
P TOLE LIONUS/
• 2`�^. NOD. 2OC. TES Q NOD
auiunuyav,/AI,eM1urne O'N''AJeu Ju•. LAB LVnuNcn tart MCUPEAL HOUR OF DEATH
A\2'CA$T$JOIN NB'JHER ALIVE ON INER IFIEDi0ESNOI Ci
21a. /1 (L.s"(iG I21b. NO Inc. 4:40 am
'V,He Lea I Gr MV IWVWLeUe.{Kl U AI I He I1Mc,DA,LANJ HLALc AND We i J.HL IAUJe'SI Si AicO. 1 A.�GN/a I H.DAY YEAR(
22a.SIGNATURE X. LY/)(Ir/ �//G,
N:,IMc ANDADJneaa ur Le E 1• rL 22b. fLIE N t .AtleH
22c. Lawrence P Jennings MD 430 College Drive, Mt.Carmel„ IL 62863 Ix2p. 036-063272
/.MAL orHI.ehw.o rH,S.L+w.u JInwl.,INN Lori.iron 0 m On.me.I .N N AN°WRY KISR•YJL\EDw RI
22. puvsr ee.7.—SDER oR uEmcAL Eaw
BURIAL.CREMATION. I CEMETERY OR CREW TORY_NAMC LOCATION CITY OR TOBH STATE DATE MONTH.DAY.YEAR)
aM^VAL.ISFECIFO
2 Burial . 2Ab. St. Mary's Cemetery 24c. Mt.Carmel, IL 12-c.0610912000
FUNERAL HOME TC..,•
. aRl,e Yrel.I� _ e 527 Mulberry Rte . 6286 _ —____
®aa 25a. Shor'-Cunningham Funeral Home 527 Mulberry St. Mt. Carmel, 62863-
FUNeR L DI ORS SIGNA.ORE FLNEaAA srgc•GRS uV1G5 ICENSE NwSER
\25o. r 2x. 034-011192
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I HEREBY CERTIFY THAT the foregoing is a true and correct copy of the death record for the decedent named herein and
that this record was established and filed in-my office in accordance with the provisions of the Illinois statutes relating to the
registration of births, stillbirths, and deaths. j
Date 3U-iu /_,3 , o-1 D�%S Signed 11/ — 4-
REGISTRAR
[SEAL]
BY /t/
/DEPUTY
REGISTRAR
96 - '"a- 303 -D04 Ibs-CR3