Death Certificate - Bostick, Roy D_7/6/2015 ``"^- INDIANA STATE DEPARTMENT OF HEALTH 10 3 919 2
ei--ke�y 'I CERTIFICATE OF DEATH
Local No 000066 EDR No 000000452934 State No 029860
I.Decedents Legal Name(First Middle,Last) la. Maiden Name(II female) 2.Sex 3. Tyne Ce Death 4, Date Of Death(MotYNDapYear)
ROY DALE BOSTICK I MALE 03:00 PM 06/04/2015
59 Mona Days Hours Minutes ' 11/09/1955 INDIANAPOLIS, IN
9. Ever in U.5.Armed Faces? 10.11 Death Qctned In A Hospital: 10a. If Dear Dccurred Somewhere Omer Than A Hospital
❑Hosoies Fads 0 Decedecta Hind 0 Nurstg Hotmeiongtemn Care Famay
❑Yes 0 N ❑Un'udwn 0 Inpatient ❑Emergency Deoarment Ou^JaveN ❑Dead on aural der( wily)
GARDEN
11. Facility Name(If Not Isetuson,Give Street and Number)
7244 NORTH COUNTY 250 ROAD EAST
12.CAy Or Town Sate,And Lo Code 43. County Of Death Ia. Manta)Saga k Time Of Dean
®Mamed 0 Maned.But Separated 0 Divored
PETERSBURG, IN,47567 PIKE 0 Widowed 0 Neer Maned 0 Unknown
15. Surviving Spouses Name Isa (II WJe)GNe Maiden Last Name 16. Decedents Usual Occupation 17. Kind Of Bustressktnetry
WILDA BOSTICK WRIGHT BOILERMAKER LOCAL 374 MANUFACTORING
18. Residence-Sate 18a. County 180.City Or Town
INDIANA PIKE PETERSBURG
i&. Steen And Number .180. Apt No. 1 13e. Zip Coo* 181. L1sle ON Limits?
1706 WALNUT STREET 47567 ®Yes 0 No
19. Decedents Educator. 20.Decedent Of Iistar.c Ongr. 21. Decedenrs Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Fathers Name(First Mande,Last) 23.Mothers Name(Fast,Mode.Last) 23a.Mothers Maiden Last Mane
CHARLES BOSTICK RUTH LAYAINE BOSTICK GREEN
23.Informant's Name 24a,Relationsrvo To Decedent 240.toeing Address(Street And Number.City,State.DP Code)
WILDA BOSTICK WIFE 1706 WALNUT STREET. PETERSBURG, IN 47567
25.Place Of Dusoosirn
25a.Method Of DrsposNon. 250.Place Of Disposition(Name O:Cemetery.Crematory.Over Rare) 25c.LcCaeon-Cay.Town,And State
0 Bumat 0 Cremation 0 Donation 0 Entombment
p Removal From State
p Other(Specify): WALNUT HILLS CEMETERY PETERSBURG, IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Fa by 27a. Funeral Home License Ntmcer:
0 Yes ❑No O.D. HARRIS& SONS FUNERAL HOME, 705 E.WALNUT, PETERSBURG, IN 47567 FH83005524
27o. Signature Of Indiana Funeral Serene Licensee: 27c. License Nunoer(Of Licensee):
GRETCHEN A. HARRIS . BY ELECTRONIC SIGNATURE FD20800011
Cause Of Death (See Instructions And Examples) Approximate
28.Pan I.Enter The Cnain Of Events -Diseases.Injuries,Or Complications-That Direaty Caused The Dean_Do Nm Enter Terminal Events • Interval: Onset
Such As Cardiac Angst.Respiratory Arrest Or VentrrnAar Fibnfatiol Without Showing The Etiology.Do Not Aairevia:e.Enter Only One Cause On To Death
A Line. Add Add:final Lanes If Necessary.
Immediate Cause(Final Disease Or Cadmon Resulting In Death) A CORONARY ARTERY DISEASE 10 YEARS
a.nix a.a,'a.Q e,=on •
Seguerla'ly List Cand'vms. It My.Leading To The Cause Listed On B. DIABETES OVER 20 YEARS
Line A. Enter The ng In Death)Cause(Disease Or Injury That Irivated
a.m.o-...roo.m.am
The Events Resulting In Death)last O
,,,...,c.,..„dws.nv 0o
D.
Pan e.Enter Other Sio-dcant Condoms Contnbutmo to Death But Not Resulting In The Underlying Cause Grad In Pad I 29. Was An A toosy Performed?
❑Yes 0 No
NONE 30. Were Autopsy Finding Available To Complete e C
thause q Death? CI Yes p No
31.ON T doacoo Use Contx&xe To Death? 32. II Female: 33. Manner Of Death:
p'° "9 "rce ewe., p .v".a rut.a'est 0'et .r-et a,e.rerwe.toowe T :. 0 Natural 0 Honicce 0 Accident 0 Penang Imesoga•4on❑Yes ❑Probably 0 No ❑Unknown
pr...mow.ase.rwtooutTormrsee..oat p: ee,eon:.w.w..rr p Suicide pCould Not BeDetermined
33.Date Of Usury(MorttNDayttear) 4 35. line 01 IrgoN 36. Place Of bile y(E.G..Decedents Home.Constastcn Sae.Restaurant Wind Area) 37. Injury At Woo.?
•
p yes p No
35.Lacaion Of Injury-State 38a.Ory or Town 380. Street S Nvnoer Sec. Apt.No. 380. Zrt Code
39. Descnoe How Usury pruned 40. II Transywaoon tryury,5 my:
pd..e.do.ni p ' po..,is wt
A1. Signature,01 Person Cerayeg Cause Of Death, 42.Cer4,er(Check Only One)
NATHANIAL,D:GROW BY.ELECTRONIC SIGNATURE 0 CemMng Prysician p Coroner .0 Heath ewer
43.Name:Address And Lt Code Of Person Cet lyeg Cause Of Death: _. Leense thumper 45. Date Ceri.Sed
ti!' •y
NATHANIAL.D.GROW , 106 WESf PIKE AVENUE, PETERSBURG, IN 47567 01044324A 06/19/2015
36. AdC,i nal Funeral Service Provider. 47. 'Alas:
43nSignzture of Local Health()xer. , = 49. For Registrar Only -Date Filed (MonovDay,Yeary
•
HONE-STO K'FENOL• VIA'ELECTRONIC SIGNATURE JUN 23 2015
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
� Co :INN • 96-Ia-D t) -a0`I - DO). IS3-path
State Fenn 533 ATTENTION ESTATE:The Social Secuny a is Doing requested Dy this state agency in older to pursue responsiortty. Disclosure is voluntary and mere will be no Donal)/for refusal.
(7105)
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