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Death Certificate - Kozar, Georgetta M_8/10/2015 W i+? L r2.6:�Y..05-iii•—irei ltratlSc"-ILtSMO•Vilt-.Flt • :• 3!*tal—Grill t erv.' F.,JB� s i`.£ L _s; r t I-0— /{� `,> /� � ,.,� ,1�JIj s%`I+iND ANA'CERT FICATE•OFTflfDENTAOHIREA �l'fs !Ir�'il. i%�III *�L��� rG'd Kit- / i 7 i -,bp.--� '-rite-fir'--.-s--•----iY\ t ir' it `; � .Ty�t=# �R i 1'n'rl ' . / �� f a, it t i I i�.4 �ia,� local No10002181c--.. #,,,..- No 000000359099 n! `t Sate-No 058074' 1 1 Oece5erxc Leal Nems;(Fn j& 1e Last).". .lffi/! ifi / Ii."r'a "'t Mellen Name dfat'llr5 st l'/i X12 S*x-xf 5.3. raiale O1 D.,T,' .,,{�% a Dataam O4ap{we� + t ir'' .GEORGtTTA V'_'e f IR44Lr li iir ::::1 !!ly!/I i+Jy1� .1 / 1i %... .cc�'d1�1 : 'if,EM k{ yl}I r I i}'! 1%.II�lI .Gr#.I ri.013:/ 1}iiE. ' GEORGETTA,M'KOZAR a*� .; \ Q\'i -."`�• S% COX° « `�`•"�. FEMALES \Lv1020�PM�I+C`.'�a 12li6R013 Si~ A HOSpnn„s Iv> 1 1......1:11157.-7 { / G \ 1...::::.."5.71 "• . 1D '6'z lt`1`wa V i :<,••mac "'fL�` 4try, slaty' t Wsocr ecY y ®Denderes Han ❑Nuseq HmrotngpnmCae FxaYy it 'r�111 :2.,-J;-t,! II❑Yes. No t❑unww.n t host m t Emergency Delnamnera Wtpadma ❑Deaden Arlr el ❑Ores(SPeaM 11 rlt b } �f ;It r \ ;f 1 ttFacaty lame(If Ne lfuMfaLGye Stem and Ne•meri\ t• ♦ \ Y S. •ice r( ;1 \ ✓- 'L .y t � ' �Cx - F 627 POCK ST - '->"--."44--:-,"'.• t T" `3 y•t-N� " ' �. .7: 1�. ` t.,..?, ) 12-Cty&Tpsf StnAIe24Cade. / -. 1 1 ,1�1f ,3CanF/a iem l7- nr rl ,d lot Mar1d 51St,At TmeOfDaT;l ; f. r' • ,:. 't ` •, \ \ t A , _� r +1,t� 1 v Lt r -Mamedt fA'1°°out ream ❑Ddeced . i OAKLAND`CITY;IN,47660/.' ( _ f r " `r IB ? �/ _O,vtmaad . t;Newrvaxa C7 UnMw«n s z r,•' < , t '.`� t GIBBON � fT * 1 - 15. Spouse's Name C •\i' h l t \ MY Y 1 Y 15a(f We)<ve Me llen le st Narro+ 1`M1 4 XZ6 De cW mtt U SUlOaqeR m«a 17;C ro Or r®n-,es fe\UY '% t t Y 1- �r i . 3 1-' ,. .. r nR ti- 1 1 v, ,E' n ! 3J•1. < DON.KOZAR 40:1',. .,;`,..4.31-' A i ' ( It/L 11 'I tI HOMEMAKER I,. HOUSE i 19 Peskence 3p....,:.;;;;;,--c. - 1Ba::Cajiuy y fad_C1yaTO75 l.. ' r ' "w 'g:::-..);<;:l.: 4t; INDIANA i i1 1 a' 1 . 9At� .,.t_ ? JIIT'r. OAKLAND CITY%'" ( t ',pc; ti -ti i , ^N t.. ijtl '1..a v i•. w o GIBBON r ac•SOeetAM RISME ".••r �., - \ V: > '•\ J _ tad.Apt Not 19a Le Cak1-.> 1M Lsside C%ItMY! - "It. -t'" ri .ttw - r n 'i'T , -t , # 1 4 '% 4` "2'�, y 1 i - P ix /' r" .` ' a. ; 4760 1®(as ❑No•1 627 POLK ST � \ .�.�. ` t ��. ` ` 4"2"-` � c 19 Decaarr Edurabon r: i - l r tr• 120. Baa ,t of armpauccrgn :it 31 i lr 21 Decaenri Raa t- ,' z. -'• HIGH;SCHOOL,GRADUATE OR GED i ti \ \'..7Zc' • Ze,, ° -„' L/ 1 r 1 it:- 1 n'' 1 COMPLETED •`-' C. :w INOTHISPANIC �' �•: (White - - tell "-N ^1 - :~`• s" 22 Fe8el.Name(FutLMia1e Lan)t14 r. x r, I t A . 1 y 1 :0 23 McL.seitt e(FntJM6a Last)r ,- t vxrt 2 •na o ers Ltaaenlas?N eta , i GLENN'COX •,k! ' ii P> .7.- •'' _ t ..•. 1' S'� !him . DELOURIS COX - - Z. - GENTRYb"n•1J I 7 4 I .24.Int:man's Hams ,' ±, >:\ 24*RetabnsHpTo Decedent."::y+ -248 Msenp Address l(Street AM Nana.CAy.State La Code)c' r/^ H �t . Ir ! IDONfKOZAR;'l . ''- 5. �'t If..,,' HUSBAND, r. ' 'D'.^ i 627:POL.KST -0AKIANDCIIY IN47660 ' ,i;`,..'+-f ,`:� 4 •: ',Li '' I . f , '2'V F:: " - $ a e-'25 Place ef t3aais+udn !.". V. C. ! Y >' y . i. '1 > 25a.MCT00 Of DUposewI..A' r 3+" li 258.RaceCfQsposrsa(Name Of Cemetery.Cvenubry Omer ReCe)l 25c Loredm City. To n.AS0 Stara �._ 1 i y tk j 7" © pa1;O Cranna, ❑Iaaa ❑Ermanlmee <'t -` ; ' L r- b o : r J R--1'--;1.1.: . it ❑O1h (SpaoM ' x% '.44 'k- }' MONTGOMERY CEMETERY ..:10'..“ OAKLAND CITY;IN / ' n.,,-....- \ 25 Was Cotner Contacted?w '�•i 27 Name An Camara Address Of Flnerel F itY r sit \ - " F t , .•A' IP 27a Fuieral Harts Limns*Number . / _ t LAMB BASHAM.MEMORIAL CHAPEL ZINC 226 E WASHINGTON STREET OAKLAND CITY ' '`'I F '`®':Pitt NO i ni ". 1 4FH83005312-" %.t f ■ I •. .s. IN 47660x . • x .r, ,4 i I l� . br P•: `.ZEE.:SpnaanEBAS AMrBtaLtensee - > ,1 \" --- f. . 27c.txe16589ec(plsamms) (JERRY LEE BASHAM BY.ELECTRONIC SIGNATURE• t.1 , - - r -, m,. FD01016589 1i" P 'C t..- 7 .1.........:..,_ i 1. .'^•c 4,i Cause Of Dath;(See Instructions And Exampta)" ✓ '. Apprp.anate . . ''28PM 'Eier Tim Clai Of E enis Dseasts:it:Ties.Or Conpicattt -Thal O em Cased The DOth3DO Not Enter Tennmal Events H •Y y ' Interval One(. . . • ir suit"As Cardac Aired Respeaay Anon,Or Verdi-kola:FiWlatian bttiois Shca4ag The Etiobpy Do NS Abbreviate Enter Only One Cause On f? . ,,t-t y 2 To Daum Lr r 4. '4,1-'9e' Add Addtslal Lines C Nerasss . '''•, t r ''. \ t.-4 .'✓ 4 - 21 i ti \ 3 Jti:rd.. .i•L • i'•IImmeda:e Cause(Friel Disease Or ad Den Resta:111On Deem) A- ATHEROSCLEROTIC CARDIOVASCULAR DISEASE ?' "lye ` Y — 20 PLUS YEARS ' 2h, v ' > �L2 v_ric r r .4•. t Sequent ally L t Cond;ions R Any Leading To The Cause Listed Ony B:�, .. „ / , « s` > 4 r. b ce t - t s.` is 1 -r Lm A. Enter The Underlyaq Cause(D sease Or 4ytay Thet Initiated '+ I 'a. tar•Isar t % 7 r I ' t. ✓-V :r H A iF c�` l Yom, i' s l' The Events RPwbmg Iri Dez01)Ian ; �' < C. • - < 'w•'. 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S ; <." :: A -1 l l I # _• , , % _ 11 f p DARLA R.'GROSSMAN.,545'S. BOEHNE CAMP;ROAD EVANSVILLE IN'47712 ` ? ' 01033767A -t- .122012013 C Add;enm FrxMrel Sernn Punter.=7-4,„:4:e.' tiY i - i "t. -.".;;Z2.,„, ✓ l 'J Kt5:, 1 r ,f , 1,: 47 n Aeas. 1.:::,-,t,‘,3;4"<4...-„„, , •x �� t-V {. 4 \ Y k. s e r. s ' !w>t ai ds..e I r T! : t- i #r # hi.; • K i w ,.Y,i H 46 &zits,Of Ines H•-21,see„,„ �in.,.t'� 1 }I.n! i4-• 'f'' t;,�A r a w r ,y'Yj 4-4/71, 4B For Raglrlra ONY Date F4w(M neypryfyem7�.'•iR '.r, r 1rift, BRUCE BRINK JR'VIA ELECTRONIC'SIGNATURE J1 Ts..a.I1.'.0.1R1I! j� .•11%'::A to,,ii ti''^ (r- iu'C ;■ :..DEC 20,2013' I�s 11 PC { n b `4 1:4f �'`Y rr\`.1x".� -i 1 1 1l AMENDMENTT0 CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)1. , S'Cq,4 " Y ea\ 4 ,"Et. min r(2 i �7'/l a i 4 `''a r 7 % rfl (i , r C f l%/ r i r .;4--i:( J'LI Ti t r ,✓/y:'j'!'''F/"sf4+y-si1` i Ili t C{la ii� •UaraC7;oO, c.„., .V•,Oo.� r-:,4 .'. nl•4-'4rt,, y 1#� % r+$__ c.� 1, ✓- L3^ F 11i�t.�1. i. 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