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Death Certificate - Cloin, Robert H_4/28/2016
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PRINCETON IN:. " ;:'" 7:- , .."--#4.. ,,, ii ANEver e1 t)S.Armed Fercest,.-- Afkli Death Oconee In A Hosplal: ,,,•..„, •,,,,`",<.„ .s.,,N;, ! 10a,11 Dean OcrredSonewlwre Other:Nan A Hospits& ••:.*.-: 'r ....sc.,■,:?• 1.,=`,..„, -‘.7,...--.. ,.., a.... ty "' .....„, c 8, tf ...,..„ ', '', ,:" " .. .,.„. .:„ ff. rt ,....,,- : 0 mi.iime f.alii, ?..0 DeCadenie kcini;: 0 Ninrig HOneeng-teiti Care Faaliti. kt, i . .; ,, . :.. C. 0 No l 0 Out-can 6 trieiNNu 0 Ert-er-alty Depanment.Oulpaieir Elbeed.m Arnvel / ': -."... i'• ;j' ,' r ''' "- ' .•• s I 1.-.;Faty Name(I1 Not Instance.Gve Street and Number) ...; ',.. ; ,:: i • •1' S . i -; 7; : ; % 1. 'I:. ;-... 1 .; ; ‘, ' ,;' •:. ;- i Z ''' r• • COMMUNITY HOSPITAL NORTH; •'' = : --- :. - .: 1 - : < ::-, ',: ; : ;• -... : (.: :.; ; ; ., ; , .: ; : - . : = , - . ,. , F INDIANAPOLIS,IN 46256-1695 I ' -: :'" . ". ; ,,-- , Th. I MARION 1 ----- --- ;,' . 0 v‘45°•1°1• "P Nei...MaTied .0 Unini ' ', ,i. 15.,Surviving ostseve Marne.,;„ - \ ‘,,, r - .< „ 15e,(d VW„epve Mellen IS Nene? •,' : 15. Decedent's Owed Ocaroake , 'Iv lend Of Eltenessinatstry; I il --, -,; c), :::- • . ', t . ' ' . ' ...--. - '. i 'Hi' , 0. PATSY L.CLOIN :- ', .: . . ; : .. . , OSBORNE r i 1, .-„,x : j :< xi TEACHER ' ; - , EDUCATION j -. . . ! : ' %'r • ', , ; ' ; ' ; : . 1. f.... ....- ‘,.. '', % ::' i ,t; ) 1 : , ; , ' •-, • : -:- :' ..,„' k. t '‘ 1. .', ' e t ` ••• i . 679 SOUTH,COATICE LANE,: -: : k j.,. i ..: . ;=.. t . s ; , ;. 7, z- j::: -- - ,{ •:. ‘ - -. :47670 1 , Ye, .. O „ , . , 1 n Fediers Name fttn 1,401e.1-astr ':. "--;?. • '...• I„: :-"-%, - -- - -- i '-''', 23.MOthe s Name(First tootle.Lest). z •- ',, -,...••• ;23a.Mothers Maiden Lest Name -1 .::.5 i::, '5'. \1 . '" ;.' ; ''''', 1, -:-Z;-':' ‘?.1. !: t.; i..■ ':\t, '7 .:, '7,C- 7 7.7 lir ...{ • c %. ,.'":. ", ‘.. 7: ..- : HERMAN T.iCLOIN1 ; : I ; C ; 1 :: <i II :: I' -i RUTH:F:CLOIN ? :, I = : : : ::: HUTTON t.:,:' 24 7n3.Nam! - I:: : .... ; ,,, / 24e,Reabcris`pTo Decedent: ^ 24b•MMILIO AOdreSS;IStreel Ana Malta%Qty.St:&.bp CO0e) ', ,,- - --.. -.... ; ' V , k .-} ; ,"- PATSY I:CC-01kt,-; "--;-." '' . -/.. : VVIFE:-',/ . ,St.%•:::: .7%/.2K:' 679 SOUTH:CURTICE LANErPRINCETON,IN 47670 '-:.-<:: '.....1.--: -- :, - 255.Ile7,od or P!posocn -- "., , - • : 2?Mace a Dsportcn(Neme Of Cemetery.Cr anetcry,Other Place); 25c.Location:gay.Tor.And Sta .:, : ; Z, - • 't ,-.., 1 x - .5; 0:&rid 0 Cr+1504 0 bo"atir 0 Enteral?Pinant : .r.. .E -: : i • ?.? '. „! ; % 1. :- ' - , : i- r ' , ; ': - e '' 0 4;a:a Froth Sate ,. 0 Oar 15Pearyt; : :. ' • " \ FORSYTHE CEMETERY \'=,---- -' -...: '' 1. OAKLAND CITY,IN --• ; :. '''' : '- -, ''. - i . • 27a Funerel Hone License Nine: •!'. a Yes..0 No ,, ' : • .- ! , COLVIN FUNERAL HOMEINC,425 N MAINIST., PRINCETON,IN 47670: ; 'N. ;% 1 % FI-183095671- ':: :. : ••:, --, f. I 27b.Scrolure Of Indians Funera Semce Licensee ,.. : ',:: 5 e ••t. - -7,. : •1. 1-, I I 27e.Ueense Number(Og Oceisee) :: 1 1 ■ „IRICHARD DEAN HICKROD, BY ELECTRONIC SIGNATURE:I--. < .: •:. : :- .: = : FD0101215r; :. 1. ", . . , ...- ; i ,,.....',28.Pert) Enter f he Chain Df Events,Ciseasel,Inures,0:CanpicatonS-That Dtieady Diiuseci The Death.Do Not Enter,Terrninal E4en:s . •'..,„;,,N;,, ', „ ...;" , .,Interval:Oriel..., .,, ■..„, , Lac Arrest;Respiratxy Arrest,Or Ventict1as Ftlxilabon WCiout Slithsing The Etiobgy Do Not fq?Ixe.mr. Enter Onli One Cause Ony -,,; , ....,. ,..-.,\ ,,,..„To Death,. ‘ %•',...,,, Alec Add Addtwal Ines If Necessary. '1 ,. ; ,.'' ‘„ .-.:, .„, z. ?, ?. . 7 / 4r, lemedate Cause(Rai)Disease Or Condition Resulting In Death) i.k, .:SMAL_CELL LUNG CANCER RECURRENT t., 4' ; t 4.• i.-.7. . $ -18 MONTHS' I .. . i • .i..;:, •,' ..,:, i: ; - : ; E‘' ' ' .t.. ' s.. ';- E'. • ''' r..-..:.'C!'' 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