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Death Certificate - Roy, Marilyn J_1/4/2016
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'i :‘ 1i., 1,,.-n,ftot?-},--,11iiV.Trizi,;,,,s1,..fil;:;??,,414,-;,r=j1f,s3,p,... ;'7-„,:: 4,..„..-.,,r:t,,,,:, ‘,....--'-.-,-A .,.;;J....,-.i.tTlii- '''1,.:. 0 c.... z..-. li-Ocal:No,000203I7c.-‘1!. i k. -,,:c:EDFI;No:,000000486607:-.4...i- ±-, !. ,:siate•Nd..060982 ..1.-:;:z;.ji- A.Decedeptp Legal Name(Fit s,.oale.LIPP , -• 1;. •• Isia:indenNnsilf tensne;,, / 1, % aG ^. ?211s Of Deeps3 , 4:c4tt y!Dea11;9!oJytay L „ . , --.: MARILYNj.RoY-, 'S .:-i r '' . :: t t: i :7 " ...'7'. CHAMBERS. ?,... . a•3:- ...-:;:-. .,,-,,. FEMALE "t02:30 AM 5.. 1.•.-: ,:ett12125/2015/.•,-,'”,.. ' t 10.1f pea!,Grand In A Hospital •-3, /.- 3 E ,. ,10a. If Death Occurred,Somevetxre Other Than A Hospdal,-; s l' ,. "-r ( ,';".:• :":,.., 0 Hospice Fealty El'Oecedenesliame t 0 al uting Hecrong-temiCare Fena-rt" Dyes ON0 0 DTI-known 0 ICP,tera 0 Exi?ergecitY I:NePaqineni 941,h-t I]Degdc"-"j :0,ht1e1 1SP:0°M "I" i ''\- -r' I,'" . ., ' ." ,fr'''' N- i''' -- -r... •" ;e Ii.Fear/Name(II Not Intnan.Gne Sweet and Itzeiber) I ; .i • . zi : K S., 1 - z 5 5 , ---. , -, ; • • •• • t .: a :,., . : , ; . 1963 WEST 850 HIGHWAY SOUTH • . ' • , • z. "/ 5 ,., It % -; t • .:%-; ; % t I'; i ..12.City Or Town.State,Arai Zip Cole; 1 -•' - . • , ,, ; J : ,13,,croalty Of.pea,ta ; :,; :, : ,' 14.,Marital Status/a Tene Of Dee . . H... 3/4, ' .," = ' : - - • 0 ma=...db vini.;d:Bers.;.,:tai b cii,'...' .i.t. FORT BRANCH, IN 47648 ' - t - ;III- •., 2-II;;:.. •:!'-'›n'.. , GIBSON ........ :::::: •?..It.t.- ;.;,•: El widoweIsi„. 0'-1!%e5."1-irnelD ubor•- I; 15.Suvning Spouse's Name 4 ••; - '. • " ; - it- 15e.Of lAginGne Maiden Leaner:la ; 4 -> ' .' 33163 4De c eden ts U w;,e]Occ' pe\ce 11.?(L•US2''''-3 r a.n.e•-ssA:-n n:.;,.tY . ; k t RUDY ROY „ AD DISTRIBUTION . % : NEWSPAPER . . . ' INDIANA ..:' - ; : - GIBSON • • •••„ ''I- -, ..•- II -, FORT BRANCH-II •.. ..•.-1I' -, .. ., 18c.Street And Number. :, ',- 0 No • I 1963 vuEST 850 HIGHWAY SOUTH : , z I ; ..,I t i % ; a ; --, .: , ; • I. ; 47648, ; 0 Yes . HIGH scHbot-,GRADuAtE OR GED . ..., . :, : .• 22.Father's name(First.araSe.Last). , ' - i; ,," ".,, : ; : :: '. 23.ticiner's Name(First.„Middle,Last) : . --,. ., 23a MO1ner'S Maiden Las!Name 3 I ; It • • -. t -• "..X X• .4 4- I • '• ; 04 . . • . % 4 ; • -x x X :-- : : X ; • • ; ;4 OSCAR CHAMBERS ' . DOROTHY CHAMBERS ' . : , . I ADLER". - I • .% : i 24 ko-srfl Nsme .' . 24a,Relationship To Decedent i,, • 248.Marne Address(Street And Nurrper,Gay,State,Zip Code) • 's ,%1 • • 4,3/ .. •• 4 4.,.,-3- ,;114.' RUDY ROY " ': ./ " -: HUSBAND ,`--,, c - "• 1963.VVEST850 HIGHWAY SOUTH;FORT-BRANCH, IN 47648.-tr. -'..,',""...,... • . •. 3a.Method 01 osposton % 7 7; i. 253_Race Of DispasiOan(Name OICemetery.Cremate/.Other?lace)-- 25c.Locaym-City.yawn:And Site ,• . ' : '''. , ,' : :„. ',. N. , 0 Buiac.0 Camannnt poneb9n,0 ErennInmere . . • . 0 Renew al Fran State ' CI Ogler(SpeCify):....•' I, % • .. , ' PROVIDENCE CEMETERY.. .. .., k... / FRANCISCO, IN . .. - '-, •-• .:.v 27a FLneIaI Fir*License Ntasbeq / , • • -- -• 0 Yes..0 No . . I X . • -. 1 COLVIN FUNERAL HOME INC;425IN MAII■1 St., PRINCETON,IN 47670 .. •• - - ; c : FH83005671 ; '. t• • ; 278.Signatra Of IndianaantralServiceLicensee:; , % • ; "- 0 ,-.. " i . i ; .. ,i 27c. License Nutter(Of liCensee):' '., , . 7 7 7 ? A JOHN W WELLS;BY ELECTRONIC SIGNATURE.. .i ,'-% ; %, ..,- ;" /.. --- / -t. ;.,.. / ; If FD01009940 . --," ?: • . . .., - ; -% '„,- •,' • ' 28.Part I.Enter The C11844.01 Fyent4 -Diseases,inpries,Or Compfidans-met Ol'rectly Caused The Oran Do Not Enter Tit-mina Events,. . • • -' ' --. •b-cerraL ()aint 4,. Such As Cardiac Arrest,Respiratory An'eab Or Veariontar EibriTiaIion Vahan Strong The Etiaogy.Do Not Aotrar late:Ertel Orly One Cause On • A Line.Add AdditinalLiries II Necessary_ . • , ' ". z 4 X, Ss I..., 4 4, :". ;; :7.‘7 i % 7, 7 1' ' ' 77 Immediate Cause(Final Disease Or Condition Restating In Death) Al CARDIOGENIC SHOCK I 4 • . 4 ' ;:1 . : . : • - - 3 • ' MINUTES . •% ,. • • . . . Geacelialn List Canadians'. If Any.leading To The Cause Listed On B. LAYOCARDLA I_inFARC110N. .."1.. , ma-K,A...A.-- -... ns..•'• , - HOURS s--- Ire A. Enter The Una/tying Cause(Disease Orlraiy Thal Initiated --i ._ - -.0,7-7 • The Events Resung Iri,Dealh)Last, " ' C. t CORONARY ARTERY DISEASE X X .-- 4-4 •; • , , I• 3' '.. 4 L 10 YEARS fr. . II . , ' .,. ' '._ , , - . - • . a keiTERL PIDEMIA X : : ; ' ,' 4. - i x . 1 : • . .: 2 I. 3 I . (26 YEARS Pat IL Ereer Other 5Kthaft,..Cscsit,InCKGPSKI211.21Laet But Not RestItalg In The Underlying Cause Give,In Part I , '213 VVas An Att.cpsy Pertained? .. ••••.0 y,:s. 0iio-• ,,- ,.• : ---• . -• TYPE 2 DIABETES - ; , I- -- • 31.010 Tobacoo Use Ccvnpute To Death? ' 32.ItFemale:; - • 4 4 I 4 3 : i . 4 El'4.,Prin."Val Pit Year Or Prer SW D• 'EL ' onsoia® 0 Namal 0 Accedes 0 Aaddera 0 Pek‘g Invisagerachn 0 Yes 0 Pt obably 0 4,;'0 thikre-nn ' . l•.". :. t ... 0 piatra:aw.,eZa P..0.1 o ow m t a • ;De any.; 3;- C I Suicide El likkli.lo t Be Deetrnined 3 -.-; .1. ;I : ; .. 34.Dam Of InILIIY(MectlarDaY1Yaer) 1 ' 35-Tee Of lnemY '-' : :",- - 1147(EG,Decedents Home,Cantructeen See,Res'aurany Wiccded Area);.• - 37.-Ircry At VOarr ...., , . . I NiNcE.Z!PF`de (. • "'"-. , : - • N '''. , : : ; ; -. : i i ', '• '' ;- ;-,.. i . '• ". ' " ' ' 1 . . . . . .` ' 33.Descnbe Ilaar Ireury Occurted • . , . . - t' -S;f0364474A.1- Dilak . `.. ...' '---.--- •41.Signaare;Osperson Certning Cause Of Death: 4 3 .i. GIB -h... - '•-• 'i ..-:',,' ,„ • 42. C4AMer(plea Only One) ; - I ':. : ,... • . ROBERT D.BOND', BY ELECTRONIC SIGNATURE , < k •4 -4 '4, . % 4 - :1 -.3 ' . .ID Candying Pnisician - Dc - ,-0 Head,Officer 4 ;-• • I., 1 Al Nara&Actress And,no Cala clI Per"F^cattY'XI 9.au."CI Dern ..? .•:: .; ''. ; - . ' : . '. : : ,' t . , ■ t : % .. i. , .,„ . ; i '. • , - - '. . 4. , ROBERT.D.-BONO',685 VAIL STREET,'PRINCETON, Ik47670 '‘..,---' .1 -, - .......,/ .- : •. ' 01030202A-- . '. • .• 12/29/2015 .•• . t '4, BRUCE:BRINK JR,VIA ELECTRONIC SIGNATURE '. %;:. ; ";:. / 1":;. i i 3 i •.- , -i. i .; .,. ': ,--.DEC:29:2615 .,-, s. . .• ; ,.. ; y' t. x .. •. AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)t,. :: t. j ; 7:. t: z i; ,.. .,: z.1; .. (;ti;...'6(t) -,.-51.7„:0,8 I-too 0.-.._le lo 1 012 _ „. - , ... , .i. "-,:: 1 ,(----,:. k, : :. ,..,- ...,, ,, : ,...- - ,...; , ir --, -- _, ',, :--- -i: ..- ." ;' fin-l. ' ' ? ;,' i- - i -3:-. ,- "-- ; .---.t- -1' - -,.;:.'-i' 4-- --14.,,:z--,sie,----. . --- c i 4. ; -33,,,. .•;:i.3:3 x 31 4 . ;33i 1 4 li 4 .o .1-11.•F:t 1 43.3;t _4.-2:i,,•.8,..-2 0a...4 F.i -- .5 3 X.":• I. s• x... •4 I sit--ilk's c r -..4'...>:, F.c.,...- .:.Sia$S Form .31ss •).-fitNtiou iBTATE:.Ths Social Sou:Laity 0 is being rectionadpy this safe egeficeordert,Furst&naspornsobBly.•Risclosrelydls5•Ka 7 a??......1(1rIlitimprtflot Zti..::;,11 I re;:.7. 4.,..WARNING'" ORIGINAL DOCUMENT NASA MDLTIC01:6118088CIUSa.OlibiDOn BPECIWINBIFE SEGLIRITYPAPERAnOTHE GREAT SEAL OF T1-IE STATE OF INDIAPIAON BACK TnAT-Kci,".;*. ...tie:inn nanu manna-in yvi I(SW anats RUFIBED,41PUZINALneleal11.ENT HAS HIDDEN VOID ON FRONT TliAT,APPEARS WHEN PkOTO CoPIED:k"' il;Z:-.:,-,".'te..?...„,`",.S.