Death Certificate - Simmons, Marvin R_8/24/2015 s° "' � r, INDIANKS'rATE DEliA&TMENT UhRiEACTH s•it• / s CERTIFICATE OF DEATH, '. s �`
▪` �` Local No 000135 .EDR No"000000464924 e < State No 039589• \ ,<,
1.Decedent's legal Warne'(First Midde Last); - - 3,, la,Maiden Name'(If fema) s. -2 Sea .3..Time Of Death . 4. Da•eOlDeeet.(Mmt,Va
MARVIN R SIMMONS . •°"` tg,;MALEs ''''"03:28 PM -.' 08/19/2015
10.If Death OCaneb th A Hospital: , 10a It peaitaaared Sornewttre OTa ThaA Hospital '
: 0 Yes 0 No 0 Linkmen 0 Irpetem 0 Emergency Department Qupaten 0 Deed on Anrval ❑Hospice Faaly ❑-Dececems Hare ®Nursig Hmnertmptem Care Facility ..
❑Oro;15pedy)
•
11.Fealty Name (If Not Ins:SPon,Ghe Street and/Jumbo? ..
RIVEROAKS HEALTH CAMPUS • • .
12.City Or Town State,And Lp Code 13.Canty Of Death IA. Matra Status At Tax Ol Death
. 0 Marred 0 Marred,But Separated 0 Overcee
PRINCETON, IN,47670 GIBSON 0 Wda ed 0 NeverMamed :0 Unkpxn.-
15. Sus'iatg Spouses Name 15a. Of W b)Give Maiden last Name - • ' 18. Decedent's Usual°capstan 17.Krid Of BusiessAndtetry .
POWER PLANT DUKE ENERGY :
18. ResgerCe-State 18x. Canty ' . 1So. City Or Tam.
INDIANA GIBSON . . PATOKA - . .
18c.Street And Number , 18d. Apt No. 18e. Lp Code 181. Inside Coy lime?
423 WEST CHERRY STREET 47666 ®Yes 0 No
, 19. Decedents Edurat n 20. Decedent Of Hispavc°nun , ' 21. Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White -
22.Fe ers Name(First Middle.last) • 23.Mdhera Name(First.made,Last) 23a.Mothers Maiden last Name
UNKNOWN UNKNOWN OPHILIA SIMMONS UNKNOWN
24.Informants Name 24a RelationaPap To Deceoen , ..- 24o.Maibg Address (Street And Ntsnba,City,State,Zip Code) ' '
CLINTON R SIMMONS SON • - 1751 NORTHWEST 24TH PLACE,CAPE CORAL, FL 33993
25.Ran Of Dispoarm '
•
25a.Method Of gspositon 259.Plate Of Disposison(Name Of Cemetery.Crematory.Other Race) : 25c.Locasts-City.Tam,And State
0 Banal 0 Cremaxn 0 Cinnabar 0 Entomb/nerd
0 Removal Fun Sxa _
0 Other(Spedfy): OAK HILL CEMETERY PATOKA;IN
26.Was Cosner Contacted? 27. Name And Complete Address Of Funeral Fadity -' • ' . ' 27e. Funeral Hone License Number
❑Yes 0 No COLVIN FUNERAL HOME INC;425 N MAIN ST., PRINCETON, IN 47670 FH83005671
270.Sipneure Of Indiana Funeral Service licensee: - 27c.License Number(Of Licensee):
RICHARD DEAN HICKROD, BY ELECTRONIC SIGNATURE . . . FD01012153 "
•Cause Of Death (See Instructions And Examples) Approumete
25.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Deaths.Do NW Enter Terminal Events Interval: Onset
Such As Cardiac Arrest,Respiratory Arrest.Or Ventricular Fibrillation NAthatt Snowing The Etiology.Do Not Abbreviate.Eraer Only One Cause On To Death
A Line. Add Addoi nal Lines If Necessary. \
Immediate Cause(Final Disease Or Condition Restating In Dean) A. RESPIRATORY FAILURE ' FEW DAYS
- i ?sew toaacetwe oe
Sequentially List Conditions. If My,Leading To The Cause Listed On B. ADVANCE CHRONIC OBSTRUCTIVE PULMONARY DISEASE YEARS - -
Line A- Enter The Underlying Cause(Disease Or lryuy That Initiated 9..ua... on:
The Events Resultig In Dean)Last C. ' . • - _ '
- 0alO,n. sot '
, ,
Par II.Enter Other S+m .•tons anti etno ten Dean BLit Not Resulting In The Undetty'ng Cause Ginn In Pant 29. Was An MAasy Performed? 0 Yes 0 No .
OLD AGE 30,.Were AU:Way Finding MOW,To Corndete The Cause Of Deccan? 0 Yes 0 No
31. Da Tobacoo Use Contibtae To Death? 32. If Female: 33. Mama Of Dean: ,
❑Yes ®Probably❑No ❑Unknown
0 a`a..vs we.,vie v.., 0 n.p..ru mi.aDe.e 0 Nome.'eta n.cwtwe.eDenote.. 0 Natural 0 Honticde 0 Accident 0 Pending lnvestgason
ID canna•'a'o4.w C tai.rem w e.v..o.e 0uae.,:n.a.'ven" e..vat ■ 0 Sddde 0 Could Not Be Determined
34. Data Cl Injury(MandvDayNear) 35. Time Of Injury 38. Place Of Iz ry(E.G.Decedent's Home,Consuston Site,Restaurant Weeded Area) 37.Paey At Won?
0 Yes 0 No
38.Lccaton Oflryvy•State 38a. City Or Tam 380. Street&Netter ' 38c. Apt No. 38d. Zip Code '
Si Desenbe How Injury Ocaared 40. II Transportation Iruy,$, troy:
. 0LM.rRe tt ❑e.e ea U- '❑oo.No,M
41. We9ne,Of Person Certifying Cause outwits. - • - 42.Certifier(Check Oily One)
RAMESHBHAI P PATEL, BY ELECTRONIC SIGNATURE 0 Caddying Prysvan 0 Canner 0 HemOS5rer .
43. Name,Address And Lp Code Of Person CemyLtg Cause Of Death: • u. License Hunter 45. Data Catfied
RAMESHBHAI P PATEL ,685 VAIL ST., PRINCETON, IN 47670 - 01040266A 08/21/2015
46.Addtona Funeral Service Fuvder. .. 47. 'Akes'.
48. Signa+ae d Local Heath Oyu. - y' <9. For Raglstnr ONY -Dab Flied (MnndVDayNea): ..
`6 BRUCE BRINK JR,VIA'ELECTPONIC SIGNATURE ` ; 'AUG 21 2015 .
. . 'AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) ; - . .
• a6 64 -ay° 303 000 33a Cat .t,
e f''''''''";.,''''''''''';•,,f .Ca Stat• e�Form 533;9 5 ATTENTION ESTATE_The Social Sec stty R a bang requuested?b y the state agency pn order to pursue reappnsibiity Discbsl/le is voaatary;aia there wall be no penalty fa re'useL
``•:WARNING ORIGINAIDOCUN T HAS A MIICT1COLDHEE)BACKGROUND,ON SPELL WHy ECURIYST HE GEA SA TMOF ThDIANA ONBCI THAT
tom . .: L M E I MDP O EARS WPHOAT D