Death Certificate - Owens, Roy E_9/10/2015 vidni-7.1Y.Yb.-vr\it':.YY..W:'vi:,A2:-S IL.14e:Tli"Ar:-le-tldr.-sf >ti--ri.Y • ' Y.rn rj n..3ra-41 eii'.. Y.4i:-9iji<JY,W::-tic%e'1 .ilG=ri:.t=;
cl�a ":" 17i 'h 1 ' INDIANA STATE DEP TMENT OF HEALTH r x c' �I rp cc-" I';w1 -
� `1.-..c4,-;-‘-:-.4.< 'S I CERTIFICATE OPDEATH( !1 ' 3 clI' II r <Aa Y.
t Local No;0001'00 . "EDRNo}000000453977 :_ < :`state No028859: "` ,' ^ 1i
:1.DeceMi'sl a,Name(Ferst,Maite.lash" .. y^'' rIa•Meide)Name i Offanale)• .'.,+ -.2 Se ,,3,Time Of Death 4. Dare Omen P'orcvtay Barg r.
, ROY:EOWEN- `:i r s , 5 ':.," ` < . ... ' . : %_� iMALE� 04:10 PM 7. e3611 312 0 1 5/ i
. . 94I ) A ..th ''' Dare, -4.°n .I.,. Mates a: 4. \.
Hosoral-
' y` OMo pes Faby ❑IDeceoe li Home ❑NuSngHme agamCare FSS
0 Yes 0:No 0 Unkrhown 0 lrr taaet.D Emergency Department OUyadem 0 Deaden Amval_ 0 Other(Spemh) ''.
It Fad1Gy Name(If Not Ins:aMq Gee Street and N'mper). • -; --
GIBSON GENERAL HOSPITAL .
:12:City Dr Town.Star.And bp Cox .13'County a Death rum
14. Manta)Shears At Of Death
- - ®Maned 0 Married.Bin Separated D Divorced
' PRINCETON, IN,47670 • GIBSON - - El 1150o"e0 ..0 Never i0 Unknown
15, Snttng Spouse's Name 15a. (If WL'e)Gire Maiden Last Name IS Decedent's Usual Ocaeaaon : 17. Kea Of®umal.MUtty
. , BUSINESS OWNER' ,
EVELYN OWENS HOBSON OPERATOR PRINTING COMPANY
'1e. Resideae,State . 18a. Carty / '18b. CayOr TOwn. .
INDIANA GIBSON • • PRINCETON ,. • -
18c. Street And Number - 184. Apt No 18e.Zip Code 1S. Wide Cey Limits?
0 Yes 0 No
2408 OLD HWY 41 NORTH . . 47670
'19. Decedents Eduraa ' 20. Decedent OI Hispanic Coogan ' 21:Decedeurs Rau
SOME COLLEGE CREDIT, BUT NOT A `
DEGREE NOT HISPANIC White '
22.Father's Name(First Middle.last) 21 Mdciet's Name(First Middle,Last) • 23a.Mother's Maiden Lan Name
JAMES OWENS BERTHA OWENS . MANNING
24.In-Year-CA Name" 24a.Relationship To Decedent 24D Mating Address(Street And temper.City.State,Zip Code)
' EVELYN OWENS SPOUSE , .• 2408 OLD'HWY.41 NORTH, PRINCETON, IN 47670
..
. 25.%aced DSwi7m
25a.Method 01 Dspos:am 250.Race Of Dispositon(Name Of Cemeery,Cremabry.Ode Race) : 25c.Loczacn-City.Town,And State '
0 eiial 0 Cremation 0 Donaton 0 Entombment ,
D Removal From State
OOther(spedfy) WARNOCK CEMETERY PRINCETON,IN .
26.Was Cana Contacted', ' � 27a. F,eeral Hens License Number..
0 Yes 0 No "
COLVIN FUNERAL HOME INC.425 N MAIN ST., PRINCETON, IN 47670_ FH83005671
27o. Sgtahre Of Indana Funeral Service Licence: 27c.License Number(Of Licensee):
JOHN W WELLS , BY ELECTRONIC SIGNATURE FD01009940
.- Cause Of Death(See Instructions And Examples) ' Approximate
28.Part I.Enter The ChemOr'Everts -Diseases,Iryaies,Or Cmpbcafias`-That Dreamy Caused The Dean.Do Not Enter Terminal Events Irceivat Onset '
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Vhthae Showing The Etiblogy;Do Not Attreviate.Enter Only One Came On To Death '
A Lee. Add Addtinal Lines tf Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A ASPIRATION PNEUMONIA i t 1 WEEK
A+bN wareaePo
Seyuetially List Cond.ens, If Any,Leadlrlg To The Cause Listed On B" yblo waGrwva,
Line A Enter The Underlying Cause(Disease Or Iry'ry That Irritated : •
The Events Resulting In Death)Last C ,
0...bl6wat4e4earax44-
D. ...
Pan ll.Enter Other Big ni m Ste Na Rest/0N In U C sal Gms 5 inn 29.Was An Autopsy Performed? O Yes 0 N r '
i1r�Ies t 30.Were Autopsy Fining Available To Complete The Cause Of Dean?•DEMENTIA,CHRONIC RENAL INSUFFICIENCY ■ �. � , - 0 Yes 0 No `'
31. Did To6a00 Use Catriplte To path] 32. If Female: 33. Marne Of Der
❑Yes ❑Prodaoy®No ❑Unknown 0,a P,a awnvab,Prrw 9 Pn,y,w,�@a 4Tr.alp Q nenmaaw ei Nq..n Wean ao.n Came 0 Natural 0 Hmedee 0 Accident 0 Pemdp lnvestigatas
❑xnw.r.n.a<P,.aa:ao a.r. ..aSt.: nFFF'yaanuup'�'1,..4nirt inn To wa.r, , 0 Snielde 0 COU.4d Not Bepremuned
34 Data Of lnpay(MpnsvDayNea) 35. Terse Ce Iryuvy J C 36'Pte&f4i$(E G,Decedent's Home.Constucton Ste.Resaaant vosesea Area) • 37. hurt'At Nkxki -
. 0 Yes 0 No •
38. LOraton Of Injury-Stab 38a Can Or Town ��p�38ti Sec.APL No. 384. 2A Code °
GIBSON OOIQNTY-AUDITOR
I 39 Descnee How'terry Occurred _ 40 If Transportation Injury,Speay- .
O C,..no-w. Dn.r'w Owe...Qo.n
,I
. . .,.•
41. Sigtattae.,Of Penal Candying Cause Of Death - ail.Certfr (Check Only One)
MICHELLE L. SNYDER, BY ELECTRONIC SIGNATURE - ®Cendww Ptrysitian ❑cpio er ❑Has OSs:er
' 43.Nana.Address And Lp Code Of Person Cetlyvp Cause Ce Death: - - 44. License Number 45. Da's Certted
MICHELLE L. SNYDER , 1808 SHERMAN DRIVE, PRINCETON 1W 47670 • • . • 02001984A 06116/2015 .
_ 48. Add, is Funeral Service Provider • - .. 4L'Akan: ..
C� r
• 48 Sgnatze d leaf Met OTrer.' - / 49. For Registry Daly Da'e Filed(Mantl,Deyn'ea)
':I BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE .'- , '. - • : • - c t 'JUN 17 2015 -
AMENDMENT TO CERTIFICATE OFDEATH(ENTRY,OR ORIGINAL) : ,
; : 9 : - 1
SLaR Fob 53395. ATTENTION ESTATE-..ltpSOaal,Seandy#is 6eirlg re4resled by 111s state agetleY w ortlar:t�PJabUe'7espohsAQaY Disaosure is,wllnnry and dwte w1T berio pennant'{a.refusaL
.-`-A' ORIGINAL DOCUMENT HAS A MULTICOLORED 9ACKGF1OIJf D ON SPECIAL WHRE SECURXTYPAPER MW THE GREAT SEAL OF THE STATE OF Ih'DW ON BACK THAT' `
_• _ 1NARNING:' ' RN FROMORANGE TO YELLOW WHENRUBBEOORIGINACDOCUMENL HAS HIDDEN VOID ON FRONT THAT APPEARS WHEN PHOTO COPIEDZ."5'te-/ \-r