Death Certificate - Hillard, Ernest M_9/15/2015 111 II ' • . - ca-'1,-...:c. . ,:::-?‘"C"- <-■ (7. -'ri:1.-- ciiie,..-1--ic. - ":28' -,'18'8
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cfr..i -..:-. ,.'', Local Not:000380, ' ----,,abFii465000000468949:,/ /3. -I, t tN'• 033422,:-ii .s. .:. :::
• .,-.,Decepe;rs Legal Marne(First,.1.fddle.Last):,s I.. .•. .....- npla:-Maiden Name(If female).,•' "v,t.,.ns I 2_Se!,c •hh i 3...Tirne Of Dean.a> 4. Date!):Dean piontAPaYt?'ear) ;
ERNEST M HILLARD JR r 'a `..t ; .- 1; .1" I-:, -<,. It.-%i, -.:"-a, <":. ta .; a..: / ... aa: MALE -: "a a 1805 ; - i .. /"0711412015
Forces? 10.If Death Occurred In A Hospital: -, /- : i (. , 10a. If Death Occurred Somenmere Other Than A Hospital 't, I •
.,. ,-, ----
,.c,- ,.... LI Hospice Facifty 0 Deccedents MOM, -Ei Nursing Home./Lorg-teml Care Facaity
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0 Yes 0 No 0 Unknevm 0 Incatent 0 Emergency Deoanment atoaf ent 0 Dead on Arms! ci cu.4,(sk.sy) , •
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• It Fealty Name(If Not Ins:Amon.Glee Street and Number) ' • --, '. 's,. I.', " r. - '
DEACONESS GATEWAY • -- - • i .
' 12.City Or Town,State.And Zip Code . . 13.,County Of Death 14, Marital Stasis At Time Of Death ' -
,., , •
. El Marred 0 Married,eut Separated .0 Divorced
NEWBURGH, IN, 47630 a . --• . - WARRICK . 0 Imoo,..,,c, ID nine!Marriccl .0 Unknovni.
15. Surviving Spouse's Name ' 15a.(1!Wfre)Give Maiden Last Name :- ' 16. Decedent's Usual Occupation 17. Kind 01 Busitesslinclustry •
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DIANE HILLARD NOIRFAIiISE • ; . i • SOUTHERN INDIANA TIRE : RETAIL ' I
IL Residence-State lea.County ' . " / 166. City Town ,.
INDIANA GIBSON . . . - FORT BRANCH , . . ..
15c. Street And Number - . , . 160.'Apt No. lee:Zip Code 18f.Inside City lin-45?
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501,
Yes
- - SOUTH CENTER STREET . % .
. . 47648 0 0 NO
19.-Decedent's Educator; 20.Decedent Of Hapanic Origin . - ' 21. Decedents Race -
HIGH SCHOOL GRADUATE OR GED ...,. • .
COMPLETED. ' NOT HISPANIC • , . . , White ' . .,..-
22.Fathers Name(First.?Addle,Last) . . ' ' r.• . 23,Mothers Name(FAA.Middle,Last) 23a.Mothers Maiden Last Name ,
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ERNEST HILLARD SR • . . MARY.HILLARD ,PORTER
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• 24:Informant's Name 24a.Refazonship To Decedent ' - 240.Wading Address'(Sweet And Nurnber,City.State,Zip Code)
DIANE HILLARD SPOUSE . ., . ., : • 501 SOUTH-CENTER STREET, FORT BRANCH, IN 47648 •
25a.Method Of Disposition 25b.Place Of Disposition(Name Of Cemetery.C.:erns:ay.Diner Place) 25c.Location'City,Town,And State
Et iiiii.31 0 Cremation 0 Donation 0 Entombment . •
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0 Rernfwal From State 'a .
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U Osier(Specify): WALNUT HILL CEMETERY . . FORT BRANCH, IN
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26.VJas Coroner Contacted? 27. Name And Complete Address Of Funeral Faulty . / "•. ." ,. 27a. Funeral rne License NUMber.
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r2t Ye4 0 No
STODGHILL FUNERAL HOMEINC";500 E PARK STHWY 168, FORT BRANCH, IN 47648. FH10900013 . . .
27b.'Signature Of Indiana Funeral Service Licesee: 27c,License Member(Of Licensee):
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' ANDREA LYNN VINCENT, BY ELECTRONIC SIGNATURE . %, .; : : - . - , FD21400005 -. ..
-c au se Of Death (See Instructions And Examples) " APPrOxiinate
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' 28.Pan I.Ever The Chain Of Events -Diseases,Injuries,Or Complications-That areq)y Caused,The lia.Us.06 Not Entei Terminal Events Interval:Onset'
Sucn As Cardiac Arrest,Respiratory Arrest,Or Ventricular FiDritlation Yhthout Strowir.g The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
-A Line. Add Additinal Lines If Necessary.
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Immediate Cause(Final Disease Or Condition Resultng In Death) A. LEFT MIDDLE CEREBRAL ARTERY ISCHEMIC STROKE ACUTE
. . . . ; , -.Pa to,4.•cayiwn..,..Orr . .
.1., Secuentialty List Con:Ace*, II My.Leading To The Cause Listed On B. SEVERE CARDIOMYOPATHY WITH EJECTION FRACTION 15 PERCENT 1 YEAR
,. ts.a a us..•ca-sso.n.CA
Line A. Enter The Undenying Cause(Disease Or Injury That Initiated , • . .
The Events Resulting In Death)Last c. .
• 4......ic.....•c...........04
Part II.Eats Other Smnarant Condtons Conftuf no to Deal,But Not Resulting In The Underlying Cause GMn In Part I 29. Was An Actor's).Perfcemed? . .
0 Yes 0 No
NONE - - 30..were Autopsy Fischng Availatle To Complete The Cause Of Dear.? 0 yZ.5 0 NO
c-, 31. Did Tobacco Use CentrIbute To Deal'? 32.II Female: , ' • 33. Manner Of Death: • .
0"....-iar.,.a Avn Past en. 0 8, ....8 Trio.b... 0 ige.Neiwt.OulPr■Knontwenno.,..oto.en IS Natural 0 eiorkide 0 Acciaent 0 Pending Investigabrin
0 Yes 0 Probably 0 No 0 UnInown . . , .
0,.....n..we ee,P.......in Den Ts l nen Baer.0.a .0 Unreel•nein;war 18,...,.., 0 Suicide 0 Could Not Be Deieneines
!; 34. Oats Of Injury(MontaDayrf ew) 35. Taint Of Many 36, Place Of Ireury(E.G.,Decedents Home.Cor.stsuotion Site,RES:rant,Wooded Area) 37.Injury Al Work?
P"' . ' • 0 YeS D No
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38. Location Of Injury•State 343a.City Or Town ,..360. Steet 8 Number 38c.Apt.No. sad. Zip Code .
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S: 39. Oesothe How Injury occurred , A 40 If oTrnanSnOneOen sntur.
y, rter t(00ernanto nner 5
OCT..darnel)
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It. Signature.Of PerSOn Cemfying Cause Of Death:
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42.Cerffier(Check Only One) -. . . .
ZS' RACHEL C.LACKEY,BY ELECTRONIC SIGNATURE . ..
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: El CertfOng Physician 0 0:goner -0 Heith0115cen- : ,
43. Name,Address Anc Zip Cooe Of Person Certfying Cause Of Death: ' 44. License Nester 45. Date Certted
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70. RACHEL C.LACKEY ,600 MARY STREET, EVANSVILLE. IN 47747 - 01073421B- • \ ...... 07/15/2015 ...... z
46.Additional Funeral Service Provider. , . 47.'Ayes: .
AEA 8igrature°float Heatri Officer.. •
RICKY B YEAGER.VIA ELECTRONIC SIGNATURE ' ti, % %. I % i% : ; i . . . II, JUL15 2015
- a " a a a a . , : 'AMENDMENT TO,CERTIFICATE OF DEATH(ENTRY.OR ORIGINAL) ' ' '. ; . , ; '; S: f z. r. ::g „ 1 ? :
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tal.e:Firn 53395 ATTENTION ESTATE The Social Security li is being requested by this state agency GI°Olt to rxicSiii resbonsibiAly: Disclosure is voluntary and triere,v88 be rioperalty for rph.t3L0;.'SiT
.WARNING• ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND SPECIACiZhi.ITE SECURITY PAPER AND THE GREAT SEAL OF THE STATEOF Wou■N A ON BACK THAT di.,;:-.
- TIIITJe ronu IIRSAltele TO Nrn1 I nix wHFN IA MAIM_fIRtGINALDOCAJMENT HAS HIDDEN VOID ON FRONT THAT APPEARS WHEN PHOTO COPIED.;": tlii,8;i:51' n .t