Death Certificate - Windsor, Phillip l Jr_9/9/2015 _....- _ __-„ ...... -. ....,.. _ ........ .--, .....„ .
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.1.Decedents Legid.Name(FirsVN 41)49e,Last)i(ttit -.,--.. , -,..,....-4- vtitlac Malden Name'tif famele),,,,i tv,.„(./. 42.Se ,....,,O vt, ,3.,Time Of DeaM......„, 4. Date Of Deatnt(Mccin/Dayiyear)...„ 4'
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3; PHILLIPEVVINDSOlk JR-i r ' \-\ ;1 -- , .,-- -,. ,, ,- -- -,,,, .s , . : ..,-,. ...MALEC '''''‘,11:30 PM ; . .;.-' ,,-..08115/2015' ..,•5:k.. ''...
. 10.II Death Occurred In A Hoarder ' ., . / ) 4: (, . .10a, If Death Occurred Somewhere Other Than A Hospital,- b .- , '-..,- .f ,,,- ••,, ••..., .-
'''.: , .;.:'-:, .7;--..;'" Li Hospice Fehity 0, -Deacienr1 Hare 0 Nursing Hatierlong-term Care Facity
... El Yes 13 No 0 Unimak; 0.1nPatient 0 E.,,nii,‘„y Depahmeni Oa'int 0 Dead on Arrivt4I 0 nuy,,,„(Specify)
iit. Fatty (II Not In-canton,Give Stem and Number) , , • ,, . . • . .
' 10167 WEST 550 SOUTH .. . . „
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12.Cay Or Town,Stns.Ard Zip Cade ' 13. Canty Of Death 14.manta'SAPS At Tune Of Dern
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‘ " 0 mamen0 mamma.But Separated 0 DiVcced
'.. OWENSVILLE, IN,47665 . .., • . GIBSON . - 0 W4lowed 0 Never mimed 0 unknown
15. arriving Spouse's Name ' ' 15a. (If titstfa)Giye Maiden Last Name 16, Decedent's Usual Occupation 17.4 Kind Of Bussnessmatestry
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CRANE OPERATOR UNION LABOR -
. 18. Residence-State 18a. County - ,..,, 18 . City Or Town .
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i.' INDIANA GIBSON ' . OWENSVILLE.- . . .
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lac. Street And Number . , • . " 180 Apt No. 18e. Zip Code 18f,Inside City Limits?
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10167 WEST 550 SOUTH :. . ; . No
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, 47665 Yes N
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19.Decadenrs Education . ' 20. Decedent Of Hispanic On9th , , 21; Decedent's Rs"
HIGH SCHOOL GRADUATE OR GED
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i. COMPLETED ' NOT HISPANIC ' • '. White •. .
iU.Famers Name(First Middle.Last) 23.Alomers Name(First,Riede,Last) 23a.Motets Maiden Last Name
PHILLIP L VVINDSOR SR . . . PATRICIA CAUTHEN• • UPCHURCH
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24.Inter-arts Name 24a.Relationship To Decedent ' . • 240.Mating Address(Sweet And Number,City,State,Zip Code)
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PATRICIA CAUTHEN MOTHER • 10167,WEST.550SOUTH,OVVENSVILLE, IN 47665
. 25 Place Of DIspáito,
25a Merced Of Ltisposticn 258.Place Of Cisposison(Name Of Cemetery,Crertiabacy.Other Mace), 25c.Location-City,Town,And Sot, tt •
0 Bona, 0 Crematin 0 Danaton 0 ErcornOment
0 Remora/From State . ..,
0 Other(Specify): WALNUT HILL CEMETERY . .._ . FORT BRANCH, IN
r Was Corner°reacted/ 27. Name And Complete Address Of Fuieral Fealty . '' "'--. ') 27a. Funeral Home license Number_
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0 Yes 0 No .
STODGHILL FUNERAL HOME INC,.500 E PARK ST HVVY 168, FORT BRANCH, IN 47648 ,FH10900013
2715. Signature Of'Wane Funeral Seneca licensee: , ' • 27c. License Number(01 licensee):
ANDREA LYNN VINCENT, BY ELECTRONIC SIGNATURE . ", • • - • ' ' •.. ' FD21400005 . .
•Canute!Death (See Instructions And Examples) - . ' App.-palmate
23 Pal I.Enter The Chan Of Event4 -Diseases,triunes,Or Complidatoris•Thai CaltS'ed The Dealt Do Not Enter Terminal Events Intervak Onset
Such As Cardiac Arrest Respiratory Arrest Or Ventricular Fibrillation Without Shoeing The Etiology.Do Not Abbreviate:Enter Orly One Cause On To Death
A Line. Add Adddnal Lines If Necessary. . . •
Immediate Cause(Final Disease Or Condition Resulting In Death) A SEVERE 3 VESSECCORONARY ATHEROSCLEROSIS 80-98 PERCENT OCCLUSION YEARS
• pa p.m•capita OS
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B. CORONARY ARTERY ATHEROSCLEROSIS -
Sequent*LiSt Ccoddizes, If Any.tearing To The Cause Listed On
• Line A. Enter The Underlying Cause(Disease Or Injury That Inrtiated . . . . Da to(Ciat•Capons C4
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. The Events Resulting In Death)Last ' C. . •
b„....,.....ticeitiobut de
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Pan II.Enter Other SGE&,gn5 Ca)LtigasS5a4182aptsjn But Not Resultng In The Underlying Cause Gnie In Part I 29.Was An Autopsy Performed?
IZ Yes 0 No
30.Were rescue"Aran;Available To Complete The Cause Of Death?
) MODERATE CARDIOMEGALY,MILD EMPHYSEMA . 0 Yes.0 Na
31.Did Tobacco Use Ccednetie To Death? t 32. If Female ' , . 33. Merrier Of Death:
0 PA P.7.•var.,5.0 l'w 0 PcKnin PPP.0.I:1.V'. 0 Nat,..w,"w...:.,....we.,c on.ons.e. 0 Nasal 0 Homicide 0 Accident 0 Penang Imengaton
0 Yes 0 Probably 0 No 0 Unknown
0" •A Pea..53 P•P Pin.IPP'•NIP, 0 Lews-n•P•nbia wee,P.P54 This 0 stiode 0 Cosa Not Be Determined
34.Data Of trimly(Month/Day/Year) 35. Time Of Injury 36. Place Of Inky(E.G.,Decedents Home,Construction Site.Restaurant YVotscled Area) 37. Injury At Work?
. „ 0 Yes 0 No
, 39. LCCraCil Of Iran-Van 38 a City Or T own • 380, Street a reinter 38c Apt No. - 380. Zro Code ',
39' D'ucto.Ho-may 0mnd , 40. II Transparence NOP/SPOON: •
044440314,4•4 014.41w 04444414.4 0011441,444/41
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41. Swann;Of Person Certbprg Cause 01 SWOP: - - 42.Gentler(Cheek Only One)
BARRETT W. DOYLE, BY ELECTRONIC SIGNATURE 0 Gabbing Physician N Coroner 0 Haan Ofrizer
43_Name,Address And Zip Code Of Person Certifying Cane Of Death: 44. license Number 45. DVS Cabbed
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BARRETT W:DOYLE , 520 SOUTH MAIN Si, PRINCETON, IN 47670 . . . 08/19/2015
.. 1 48.Additional Ft11111411 Service PTOViCer. - .
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48.Signature of local Health Oecer ' • 4- „ t ..? --. -., -, t ,i .. -,-• 49 For 4140344114 Only -Date Filed (Montpay/Year): • 2, . ...
BRUCE BRINK JR VINELECTRONIC SIGNATURE . ", t.. - AUG:19 2015 .
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‘I . I : .... k ; t z. t : : - ; : ', 2 : !AMENDMENT TO.CERT1FICATE OF DEATH(ENTRY OR ORIGINAL)
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Si".1<523-cli's ATTENTION ESTATE The Social Security p ii being requested by this'stile agendy:th Order,tapUrsue responsthileyi DisclOstire is voluniary4 there will be no penally foirkusat
N/A R N I NG. 0E3GINAI:DOCUMENT HAS A MULTICOLORED BACKGOUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT sPAI OF THE STATE OEINDIANA ON BACK THAT" ...•
. •-TURNSEROM ORANGE.TOYELLOW WHEN RUBBED.ORIGINAL DOCUMENT,HAS HIDDEN Vs ID ON FRONT THAT.APPEARS WREN PHOTO COPI ....c-
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