Death Certificate - Padgett, Imogene_8/14/2015 r t �i_. .:r-'42-• C�. : �`_ - ^�sE: -'.Y • • ' - • 1- -nt-ar` , -10/1-• ='_: ,� f...:.--}r-.5'-` cam% L-a.
l ela� c ct t INDIANA STATE DEP YNIENTOF HEA r .
ti 1 1 a CERTIFICATE OF DEATH i
3
,� � Local No 00029 ,EDR:No 000000462700 !State•Nd 038041 'x... k '`((.
" '21 Maiden Name'(ii fr510-,.' -,,, 2 Sex, „> 3.,Time Of Death.„c 4 Dare Of Den,.Q4Ot ayrtearf. [
1.Deceoat Legal NameIFrst,Ma.'le Lary )'. . .
` ' -- .. PHILLIPS . ."° FEMALE '04.34 AM -.-_ i 46'08/06201 5
I5
Forces? 10.'t Dear Occurred In A Hospital: ten. 1:Dear Ord mad SomeWiara Other That A Hospital ,.
...• 0 Hoaj ice Fertility ❑-Decedents Hone 0 Nursing Hcenelu4brm Care Faulty
❑Yes ®No ❑Unknown ❑Iroawete 0 Emergency Departi,ent Dupeeent 0 Deis do lVfr+al D oew ISp?ch) . , . ,
11.FarAH Name(If No InsdYwm.Give Sweet and Number) -•
GOOD SAMARITAN HOME AND REHABILITATION CENTER •
' 12.City Or Teem.SITS.AN Zip Code - 11 Canty Of Death 14. MamslStmu At Time Of Death
0 beamed 0 Married,But Separated 0 Oivo. d .
OAKLAND CITY, IN,47660 GIBSON. 0 weaned 0 Never.Mania 0 Unknown.
18 Srvivusg Spouse's Name 15a. (If Wde)irve Maiden Last Name , 16. Decedents Usual Causation 17. Kaid Of StsnessAMUSly
RICHARD PADGETT HOMEMAKER DOMESTIC
1e.Residence-Suva lea. County 180. City Or Town
INDIANA GIBSON FRANCISCO - . •
18c.Sweet And Number 18d. Apt No. 113e. Zip Code 1St Inside City Limits?
0 Yes D No
306 EAST WOOD STREET 47649 •
•
19.Decedmrs Edtcaton 20. Decedent Of Hispanic Ongee " 21:Decedent's Race •
9TH- 12TH GRADE; NO DIPLOMA NOT HISPANIC • White - '
22.Fanners Name(Fast Midde.Last) • 23.McMrs Name(Fast.Middle,Last) 23a.Mothers Maiden Last Name
•
WILLIAM PHILLIPS • ETHEL•PHILLIPS BROACH
24.Inbfinent's Name 24a Relatonsrep To Decedent " 24b.Mailing Address (Sweet AM Number.City.State,Zip Code) ,•
RICHARD PADGETT SPOUSE 306 EASTWOOD STREET, FRANCISCO, IN 47649 •
I 2s.Place O(QapOShcdtl .
25a.MewW Of Disposcpn 25e.Place Of Disposibon(Name Of Cemetery.Crematory.Other Place) 25c.Locaton-City.Tann,AM State
0 Baiet 0 Cremation 0 Donator 0 Entombment
0 Re:naval From State
0 CL"Yir(Spear)-: ATKINSON CHAPEL . . . OATSVILLE, IN
26.Was Comer Contacted? 27. Name And Camplea Address Of Ftmal Fatty - - 27a. Reseal Ha t e Number.
0 Yes 0 No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671
270. Sgr atae Of Iraana Funeral Service Licensee: 27c. License Number(Of Licensee):
RICHARD DEAN HICKROD, BY ELECTRONIC SIGNATURE FD01012153 •
Cause 01 Death (See Instructions And Examples) Approa hate _
28.Part I.Enter The Chain Of Events -Diseases,Injunes,Or Complications t That Drect)y Caused The Deatn-Do Not Enter Terminal Events Irteval: Onset
Such As Cardiac Arrest,Respiratory Arrest.Or Ventricular Fibrillation Without Shdeilg The Etiology.Do Not Abbreviate.,Enter Only One Cause On To Death
A Lim, Add Addtnal Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A CARDIAC DYSRHYTHMIA - 5 MINUTES
ow a to..•caw.°04
Sequentialty List Conddians, If Any,Leading To The Cause Listed On B. RESPIRATORY DISTRESS 15 MINUTES
Line A. Enter The Undaytg Cause(Disease Or Iryvy That Initiated A wej6aa �rn
The Events Resulting In Death)Last C. PNEUMONIA 2 WEEKS
Ow to tor a•ca.....,a oa
D. -
Pan II.Bear Other SS But Not Ressleng In The Underlying Cause Dian In Pant 29.Was An Autopsy PMOnned? O yes 0 No " "
CONGESTIVE HEART FAILURE 30, Were Autopsy Fading Available To Complete The Cause Of Death? 0 yes 0 NO ,
31- Did Tobacoo Use Contbtta TO Dealt? 32. It Female: - 33.Manner Of Death:
❑race ®PrMaWy❑No 0 Unknown 0 bt^w-•mew.s..• 0».two a...orc..e 0 ia.+v e,a tv...ewx 0.7.00.e ' CO Naval 0 Homicide 0 Accident 0 Penang Investigation ,
0 hcn.wM1 S.4.p.4 a Oen To,pew em.nm' 0 Mineen•mvw4•s.'TN Pei Mar O Suoee O Cale Not Be Determine!
34. Date Of Iryury(MofbVDayrYearI 35. Time Of Injury 38.,Place Of l:µry(EG..Decedent's Home,Consuucton Ste Restatrant YUOdee Area) 37. Injury At Wit?
0 Yes 0 No ,
' 38. Locaon Of Irlury-Sae 38a. City Tam 380. Sweat b.w.:ber 38c. Apt.No. 38d. Dp Code e
E
36 Describe How Injury Occurred . 40. If Trayspdrvtan Iryay,2ea'y: .
0D....a.... 0..w.e' LU° ' 00,••W..") •
41.Signature,Of Person C.'v'ry1 Cause Of Dealt • I - \ 42. Gerber(Check Only Life)
MICHELLE L. SNYDER, BY ELECTRONIC SIGNATURE l 0 Ce:t3+ngPhysician 0 corona 0 HeatO6�^ i
43. Name,Address AM Zip Code Of Parson Certifying g Cause Of Death: -� - 44. License Nunoer 45.Data Certfied
t
MICHELLE L. SNYDER , 1808 SHERMAN DRIVE, PRINCETON, IN 47670 i . 02001984A 08/12/2015 .
46.Aeedpnal Flintri Service Proidet - 47. •Akan'.
48.Signature of Loco Heath O:Srsr t... 49. For Reglsrrar Only -Daa Flee(MastoDdyfyea):
BRUCE BRINK JR,VIA•ELECTRONIC SIGNATURE ` • •. i - s t - ' • : - • AUG.13 2015 - - "
71 _ - 'AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) ; ..
I�a.� �3 r'1 D3 • :
State��Fo/riln�0p.49�5k�AT�Tt�E/N�Taiou ESTATE:The Soda)Suitor g is,being requested n ardei to pursue reFmnsgt6ty- Ots..lostae is vohauary and them wdl1 rn Penaty fgne4aat
.. \Illl�RAl'•s3/'e. ORIOINAL•OOCUMENT HAS A MULTICOLOFEDBACKGRODN ON SPECIALWHITE SECURITY PAPER'AND THE GREAT SEAL OF THE SU-TEOF INDIANA ON BACK THAT?'
r.F1f1L� �`��.1• TURNS FROM ORANGE.TOYELLOW-WHENHUg9E0.:ORIG INA40pWMENTMAS NOPE7NMOD_ONFRONT'THATAPPEAAS WHEN PHOTO COPIED f ).