Death Certificate - Anthis, Karon S_9/9/2015 rrc•.AT-.'.V -.f>. =r+.'-1 l bTn -.l '. ?-4.-1k/f _• :' -...ti, rn_
\` ` < t CERTIFICATE OF DEATH'. a t 3\,
:, - Local No 000205 . ,EDR No 000000355484`' state No054653'' .
a ...,.J \Taw Mahan Name'(IW female),,,, 2 Sex a 3 Tine Of Death 4. Date Of Death(MoratvDey, 'r i
f Decedents Legal Name(Fast Middle,Len)'r - Death
KARON S ANTHIS).k ii r `` " LEWIS - - FEMALE .,--08:24 PM ,',.11125!2013(
74 Maratha pays / "015 i Maples i i. t. 03117/1939, :PRINCETON,=IN
9. Ever ei U.5-Armed Fortes? 10.If Death Ctnared In A Hospital:
❑ osp Facay ❑Decedents Hone ®Nursing HaieLo,g rm Care Feoby -
❑yes 0 No ❑Unknown El masters❑Emergency oeparmera wpaxr 0 D m o�nm.-ai, 0 IDs � O Sanere Other Then AHoptal - S , : / Y
.
• II.Faciky Name Of No Irmo/son,Give Street and Number) .•
. GIBSON GENERAL HOSPITAL-SNF -
12.Cory Or Town State,And Zip Code 13. County Of Death 14. Manta/Stasis At Tune Of Death •
•
0 Yarned 0 Married,But Separated ❑Divorced
PRINCETON, IN,47670 - GIBSON ❑I/Mawed ❑NeverMamed .0 Un`no, n '
15.Surviving Spouse's Name 15a. (If Wie)Give Maiden Last Name 18. Decedents Usual Ocapavn 17. Kin]Of Businessend tray
GIBSON COUNTY
•
FRED ANTHIS t ; TREASURERS OFFICE GOVERNMENT
18.Residence lea. Couray 1BE. CM Or Town
•
(INDIANA IGIBSON . PATOKA•
18c. Scree And Number 18d. Apt No. 18e. Zip Code 197. Inside City Limits? ,
• ❑Yes 0 N
351 EAST 350 NORTH 47666
19.Decedent's Ed aeon 20. Decedent Of Hispanic Ongn 21. Decedents Race •
•
•
• ASSOCIATE DEGREE(AA,AS) NOT HISPANIC White H .
22.Father's Name(First,Middle,Last) 23.Mothers Name(First Made,Last) 23a.Stollen Haden Last Name
HOWARD LEWIS BARBARA LEWIS HILLQ .
24.Inbmte is Name 24a.Rda-.pnsnp To Decedent 24b.Maly g Address (Street And Nunber.City.State,Zip Code)
FRED ANTHIS HUSBAND . 351 EAST 350 NORTH, PATOKA, IN 47666
' 25.Slate Of Disp•spon .
25a.Method Of Psposi`en 25a.Place Of Dispoaton(Name Of Cemetery.Crematory.Other Place) 25c.Locaton-CM.Tam.Arid State
0 Baal ❑Crernaaan ❑Do atcn❑Entombment
❑Retrial From State
❑Other(Specify): OAK HILL CEMETERY PATOKA, IN
26.Was Coroner Canoed? 27. Name And Complete Address 01 Final Faafty 27a Faunal Hone license Numbr.
❑Yes 0 No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671
27b. Sonata Of Indana Pineal Service Licensee: 27c License Number(Of Licensee): '
JOHN W WELLS, BY ELECTRONIC SIGNATURE - FD01009940
Cause Of Death (See Instructions And Examples) ppprmsinate
28.Part I.Enter The Chan Of Events -Diseases,Injuries,Or Complications-That Dietary Cauied The Death.Do Nat Enter Terminal Events baervat Onset
Such As Cardiac Arrest,Respiratory Arad Or Vetariwlar Fibrillation WNout Showing The Etiology.Do Not Abbreviate.Enter,Only One Cause On To Death
A Line. Add Additinal Lines H Necessary.
Immediate Cause(Final Disease Or Cdndaion Restating In Death) A CARDIAC DYSRHYTHMIA • 3 WEEKS
R.m m..•co,•m.e 00
Sequentially List Condeions, H Any,Leading To The Cause Listed On B. ELECTROLYTE IMBALANCE 3 MONTHS
Line A- Enter The Underlying Cause(Disease Or lnjay That Initiated - w.pr. Am
The Events Resulting In Death)Last C. LEFT VENTRICULAR FAILURE 10 YEARS
a.vNMAv.a4e m'
D. CORONARY HEART DISEASE , 25 YEARS
Pan II.Enter Other S Eke Na ResUeng In The Underlying Cause Ginn In Part I 29.Was M Autopsy Performed? ❑Yes ®No
30.Were Autopsy Faidag AvalaNe To Complete The Cause 01 Death? ❑Yes ❑No
TYPE 2 DLABETES MELLITUS.PERIPHERAL VASCULAR DISEASE,DYSLIPIDEMIA CHRONIC KIDNEY DISEASE
31.Did Taeacm Use ConiMU.e To Death? 32, If Female: - : . 33. Marne Of Death
❑Yes ❑Probably®No ❑Unladen 0
0
Me D,nt yawn NO ❑P'.7..'
-Des.ea DANA ❑as eerie.eelv.tevi,.,n ago ax. 0 0 Neon!❑Hotiade ❑Accident ❑Pending Imesbgalidn
❑reeler.+ax r,eaws°Dn.:,ir„,Ban ❑u+wntrninciViAn The vie ❑Suicide Cade Na Be Delemtlnad
34, Date Of Injury(Ma tJDayNea) 35.Time Cr Iryury 38. Place Of InAry(E.G..Decedents Home,Construction Site,Resaaad Wooded Area) 37. (Tay At Work?
❑Yes ❑No
38. Location Of lryay-State 38a. City Or Town 38b. Street 8 Nanber. 38c. Apt No, 38e. Zip Code
39. Desmce Hoe lrEay Occurred • 'TranspaI er K
OCA Oaew '❑a.nosh
41.Sigatne, Of Person Certifying Cause Of Death: 42. Cersea(Check Orgy One)
KRISHNA MURTHY,BY ELECTRONIC SIGNATURE 0 CertltnoPhyfiaan ❑Coroner ❑Heath Oder
43.Name,Address And Zeo Code Of Person Caddying Crate Of Death 44. License Number 45. Data Certified
KRISHNA MURTHY ,685 VAIL STREET, PRINCETON, IN 47670 01031888A 12/02/2013
48.Aedreaul Flinn Service Provider 47. 'Akas.
.-
68. Signature of Local Heath Mar. ' . 49. For Registrar Only 'Ora Filed (MonevDayrYeal
e.I BRUCE.BRINK JR VIA ELECTRONIC ROr:'!C SIGNATURE . : : s . • DEC 03 2013
?AMENDMENT TO-CERT F1CATE OF DEATH(ENTRY OR ORIGINAL)
r ,
� out q o�a os s, �
State Fenn 53395 ATTENTION ESTATE:The Social Seairdy Cis being ra4,e51ed by the ease agency jn Order,to pursue responsthd'y Dtsclaae a voki ntay and there w4)be no penny fa refusal
ORIGINAL DOCUMENT HAS_A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT f,'
'-„.WARNING...TnIONS.FROM ORANGF.TOYFI I nW WHEN RUBBED.ORIGINAL DOCUMENT HAS HIDDEN VOID ON ROW THAT.APPEARS WHEN PHOTO COPIED.,- T.--- -