Death Certificate - Gibson, Agnes C_3/23/2016 ,�■ INDIA` 1 '- , • _ LTH, ❑
t f # ' .' .' CERTIFlCATE OF DEATH ! .
4,140 �,
Local 000142 EDR No 000000466643" State.Ni 041537 iWx(fir
. 2.❑ecaants Legs)Nm(Fast'MiMle,Lea). la. Maiden Name 01fenale) 2.Ses 3. Tone a Death 4. OSe a Deal,., ..
'AGNES C GIBSON' - - • _CREACY • • FEMALE - 17:30 .. 08/30/2015' '
6
94
Made Days Nan was 05/09/1921 EVANSVILLE, IN
N. 9 Ever.,U.&Armen Faces? 10.11 Deer Occurred In AS1ce{tr 3Howee Fa try 0Dece its Other re AL1ceprM
M ❑No>Qin Fatty ❑OamOer[s Horne ®Nursvp Nm+NLaparm Care Faofty
❑Yes 0 No ❑Unknown ❑Irneflan'❑Fnlago,Depaaeb aaaaem ❑Dean al Amen! ❑Oaten(Specify)
' II.Fealty Mane al Not bee2aa.Give Street and Hurter)
GIBSON GENERAL HOSPITAL-SNF
12.City Or Tacl,Gate,AMZO Code 13.Coaty01 Death 14.Mental Same N Tema Dam
Fri ❑Ma ed❑Marled.Bu Separated ❑Diwalced
- PRINCETON,IN 47670 GIBSON 0%Waved ❑Never Maned ❑Urwcen
• I5.Siswwip acme's Name • 15a N 1We)Give Maiden Lan Mm 18. Decedents Usual Oaapartal 17. ICd a BatesafOasiy
SEARS EMPLOYEE SEARS
,V R.Resideru-Stara tea Casty lea.Cry Or Tam
INDIANA GIBSON PRINCETON
,, lac Sweet AM Winer lea. Apt.No. lee. Zip Code 181. mode Can limo?
E9,• 1808 SHERMAN DRIVE . 47670 ®Yes ❑No
se 119 Deadens Edrowal 20. ❑.cedes Of HVivc Cngi 21. Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC 23.Mews White
�Made.test) 23a Mots Sr last Name
• 22.Fattmts Nam(Fast Ma.l�
E ROBERT CREACY ADELIA CREACY CUSICK
• 21.I tanarts Name 24a.RSaevslip To Decedent 248 Matey Address(SWIM AM Member,City.State.Zip Coda)
▪ ROBERT GIBSON SON • 214 4TH AVENUE, PRINCETON, IN 47670
25.Plan Or Dispose=
., 25a.Medea a os0OSSal 25x.Race a Dispperson(Marne Of Gele'en,Crematory,Odder Place) 25c.Manton-City.Tam,AM Site
I. O Baal ❑Cremona ❑Danewm❑Entombment
w ❑Remand Fran Sob
▪ ❑Ora(SPetyt ST JOSEPH CEMETERY PRINCETON,IN
O 28.Was Comer Contacted? 27. Name AM Complete Address Of Fawal Fao*ty 27a Rowe Hama Lama Hunter
I
a 0 Yes 0 No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671
' 27b Sig esse Of Iniara FumrM Sawa Licensee: I 27c. License Nutter(a Licensee):
- RICHARD DEAN HICKROD,BY ELECTRONIC SIGNATURE FD01012153
• Cause Of Death (See Irintuclons And Examples) Approcmae
Y 28.Pad I.Edda The Can Of Everay -Diseases,Injures,Or Canpiratiaa-That Diealy Caused Re Death Do Not Enter Terminal Everts Serval Onset
Such As Cardiac Arrest Respiratory Arrest.Or Ventricular Flbaation Wehout Shoving The Eliobgy.Do Not Abbreviate.Enter Only One Cam On To Death
1 A Line. Add AOderel Lams If Necessary.
O
• immediate Cause(Fret°'cease Or Con ton Restttly In Death) A CARDIAC OYSRHYTHMIA 48 HOURS
p
a..rar.aa.a/oce
B. DEMENTIA 10 YEARS
Sequentially List Caadne, If AM,Leading To The Cause lined On Date ear.Gras°ce
i� LLine te e Av.erEtns M R eTaer II tilg p M n D D anntp h Case(Disease Or tr im That Initiated
Last C. HYPOTHYROIDISM D
l 0u waa 44.44.-4.44 N
D.
Pan tl.Enter Omer ocnet5AloMitsattgatCsancsteuziona MS Na Manta;In The IhOMytp Cane Ciwn In Part I A. M4s M Autopsy Pertained? 0 Yes 0 N
saMy 30.Were Aaopsy Frdtic Avaiamle To Canaan The Cane Of Death/ ❑Yes 0 N
.ry O Dodo TNRITS
11.1.Old Tabscac Use Canals To DeaM7 32.If Fable: it Marrs Of Oaf
N] ❑Yes ❑Probst*0 No 0 Umala n ❑alme..via-err... O n.-•r Ie.a owe. ❑wn.e ae....e-.v..ao-.aa., 0 Hata❑CalHomes. ❑Accident ❑Pendww aresdprm
❑wr.m-a oat..e+4co.w*.,Iw>°' ❑te,R>LQGaMdNa BAeaMmreO
34. Daealnaay(MattDay/laed ]5.TmeaInjury 1 (E S Commotion 9th.Refavas Nboderf Area) 37.trSay N Wont/
❑Yes ❑No
t• 39.Locawm Of fitly-Sate lea City Or Town I 1E 3.T:w_ilt a Humor 384.. Apt.No. Sad. Zip Code
-- -' MAR 2a 2016
39.Desalce How flay Dwarf - 40. II Transpatawn lazy,Spea7
❑c rasa- ❑..--v-0..4.....00-04.46
41.Spawns,Of Penn Candying Cause a Death e_-- 42.Calder (Cheek OW One)
KRISHNA MURTHY,BY ELECTRONIC SIGNATURE GIBSON COUNTY Al DITO-0 Cemfryp Plnsidan ❑Gazer ❑Neat0mra
IQ q.Name.Adsess And Zp Code animal Catyyvp Cause Or Dean 44.License Mummer 45.Dae Caere
dil KRISHNA MURTHY ,685 VAIL STREET, PRINCETON,IN 47670 01031888A 09/03/2015
oN 4e.AddtaW Funeral Salvia Provider. 47. 'Aids:
q' 18 Spann of local Heath Ol5cer - 49. For Registrar arty -Da Fit Idea s'Dayteea):
-
• BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE
SEP032015
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)Ia (-Ice -'01- y04 -ODp 4 ) f I - oa3
4 '_Sae Fan 533S5L1 ATTT1E%NTTION ESTATE The Social Seaady 0 a bang regsested by this state ageiry ii order to pursue responsWddy. DctlosSe it wUa1'ay end there al➢ben?PenalY far refusal.
'Ai -. -- . I1. bl::.T RNS FROM00 OORANGE TTOO YELLOW WHEN WWHHEN RUBBED.O�RIGINNAAL ON DOCUMENT NT.HAS HIIDDDEEN SDD OWN FROONNTTTHATTAPAP TPEARS 1.:WHEN PPHOTOO OINDIANA i'N BACK THAT� 7: