Death Certificate - Collins Jr, Merlin F_4/26/2016 F - � yFFl .la• l pq
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e ail. ,.• ,.�..w .- INDIANA STATE DEPAR y - .' I '•. _ 1 0 7 8 917
Y , CERTIFICATE OF DEATH
' Local No 000025 EDR No 000000365968 State No 004678
1.Decedent's Legal Name(Firm Mode.last) 1a.Maiden Name(If female) 2.Sea 3.Tone Of Death 4. Date Of Death(MOnttvvay(Year)
MERLIN F COLLINS JR MALE 12:10 PM 01/21/2014
68 Months Dana Minutes 07/27/1945 ANNARBOR, MI
9. Ever in U.S.Armed Forces? 10.If Dean Occurred In A Hospital: 10a. If Dead)Occurred Somewhere Other Tnan A Hospital
0 Hospice Facity 0 Decedents Hare 0 Nursing Hanetorm-term Cart Fealty
®Yes 0 No 0 Unknown 0 Inpatient 0 Emergency Departmem OU>atent 0 Dead on Afiaal 0 Omer(specify) OTHER
11.Featly Name(If Not Insttuam,Give Street and Number)
900 SOUTH 100 EAST
12.City Or Town.Stem.And Zip Code 13.County Of Death 14. manta)Status At Time Of Death
®Marred 0 Marred.But Separated 0 Diwrced
PRINCETON,IN,47670 GIBSON 0 y 4idowed ❑Need 0 Unknown
15.Sorvnug Spouse's Name 15a.(If Wde)Glve Maiden last Name 16.Decedents Usual Occupation 17.Kind Of BusnessAndusty
VIVIAN COLLINS LEWIS MEAT INSPECTOR US GOVERNMENT
18 Residence-State 16a.County 16b. City Or Twin
INDIANA GIBSON PRINCETON
16c. Street And Number lad.Apt No. 'Be.Zip Cade tat. Inside City Lirvs?
115 NORTH SECOND AVENUE 47670 0 Yes 0 No
19.Decedents Education 20. Decedent Of Hispanic Origin 21. Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Fathers Name(First Made,Last) 23.Mothers Name(First.Mode.last) 23a.Motors Maiden last Name
MERLIN F COLLINS SR JOANNE COLLINS TRACE
24.Informants Name 24a.Retort onsNO To Decedent 20.Maimg Address(Street And Number.City.State.Zip Code)
VIVIAN COLLINS WIFE 115 NORTH SECOND AVENUE, PRINCETON, IN 47670
25.Place Of()Hoar.=
25a.Meowed Of Drspos toil 25o.Place Of Oispnsiam(Name Of Cemetery.Crematory,Other Place) 25c.Low.on.Cny.Twos.And Sate
0 Burial 0 Cremation 0 Donation 0 Entombment
0 Resnwal From State
0 Other(sperdyt WHITE CHURCH CEMETERY PRINCETON,IN
26.Was Coroner Cantaaed? 27. Name And Complete Address Of Funeral Faddy 27a. Funeral Home License Number:
0 Yes 0 No COLVIN FUNERAL HOME INC.425 N MAIN ST., PRINCETON, IN 47670 FH83005671
27o. Signature Of Indana Funeral Service Licensee: 27c.License Number(Of licenseet
JOHN W WELLS BY • IC SIGNATURE FD01009940
�+ `l Cause Of Death (See Instructions And Examples) Approximate
28.Pan 1.a[rt. Tl$C in Of E -• ;..Inrynes,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset
Such As GSAdiiac AAt e'�ss en:natter Fibrillation WWout Snowing The Etiology.Do Not Aobrev ate.Enter Only One Cause On To Death
A Line.Ad dd:unal Lines If Necessary.
Immediate Cause(Final Disease(IQr k.Qiion Resulting In Death) A. CEREBRAL DISRUPTION d•.wro..a�.....vor IMMED
APR26CC o0
Sequentially List Conditions. If Any.Leading To The Cause Listed On B. GUNSHOT WOUND TO HEAD IMMED
Line A. Enter The Underlying Cause sea Injury That Initiated
°'wto•°'�°'O"^m
The Events Res W:yp In ye C.
(�/n��� o..wro...ra...wo dry
GIBSON COUNTY AUDITOR D.
Pat II.Enter Omer -e .. , i- •n• •. y to De- But Not Resulting In The Underlying Cause Groin In Part I 29.Was An Autopsy Performed? Q Yes 0 No
30.Were Autopsy Fbgvg Available To Complete The Cause Of Death? Q Yes 0 No
31.Dg TOOxoo Use Conttbue To Death? 32. If Female: 33. Mama Of Death:
❑Yes ❑Probably®No ❑Unknown 0 Nyeor.t wew•.ev•. 0 n.wa.n:...co o.w 0,wnwt an p,owewa.e 42wn a ant 0 Natural 0 Hannde 0 Acddert 0 Pendng Investigation
0.uq.wt OUR .-4O Can To.N an..O..e 0 wt....,ew.wv wee trio Povwor 0 Sridde 0 Coed Na Be Determined
34. Date Of Injury(MonsvDay(vear) 35. Tone Of Injury 36. Place Of Injury(ED..Decedents Home.Canauction See.Restaurant Wooded Area) 37.Iryay At Work?
01/21/2014 12:10 PM ALONG RR TRACKS AT 0 Yes 0 N
36.location njury-Stas 38a. City Or Town 38b. Stem 8 Number 38c.Apt No. sad. Zip Code
INDIANA PRINCETON 900 SOUTH 100 ROAD EAST 47670
39. Despite How lryury Occurred • 1 t. 40. If Transportation Injury.
Qavw ti.w ❑e. •+•.n OktwkskAmo
SELF INFLICTED GUNSHOT WOUND TO HEAD
41. Sgnature.Of Person Cen`yng Cause Of Death: - l 42.Certiter(Cneck Only One)
BARRETT W. DOYLE , BY ELECTRONIC SIGNATURE 0 Certryng Physidan 0 Coroner 0 Heath(Meer
43. Name.Address And Zip Code Ot Person Cec'ytig Cause Cl Death: .1 44.License Number 45. Data CeSSd
i • )
BARRETT W.DOYLE ,520 SOUTH MAIN ST, PRINCETON:IN,47670 t _ f 02/03/2014
46.Adaonal Funeral Setae Provider. - . '/ l j i' I 47. 'Akers:
,7
48. Sgnatire of Local Heath O:oar 49. For RIMIStrar Only •Date Filed(MonwDayrfeark
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE FEB 03 2014
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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State Form 5ait TTENTLON ESTATE:The Social Security a is being requested by this state agency in order to pursue responsibly. Disclosure is voluntary and there will be no penalty for refusal.
mT' (7/05)