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Death Certificate - Summers, John W_5/6/2016 r-- 37. c.(7-..... IlL7 .-..4=1.,•-•- frair,.4.,- I STATE OF FLORIDA - :-,,,,,,404.411?-0m1.1%7a,“IM:"Fr•--, .5:57 d'io-7.." --cs,' rethin-AUMIA.M.,-AMOYourrA,Yrilssanar,AM. Arrsialsyrq-st.WsTOOstAa/AANIA.YA v.A-- Al?,. 1 - -. - 7) ;.; n , ;THIS;DOCUMENT;HAMILIGHT2BACKGROUNDION1TRUEIWATERMARKEBTAPERXHOLDITOILIGHTITOIVERIFYIFLORIDAIWATERMABIBIl L k .Iy t.t. ;.. . -a 0 ° T., aw:J.--0 BUR-EMIL:6f 'VITAL. STATISTICS-:,-"..6 .J./. Ir-er°.• o III° "E"= 1 - o - " 0. 1,° °I•.*"..r 0 .° 4..,•-0 - ..' ci 1 0 ° p 7" 0 - -5( r,p0P je - a 0-frra " ---0 a a 0 0 °. ,•° .''' •0 0 ;,• .*felt:' * • ' 0•0 ° . 4 0 ,/01"'C1 • ;5 4 . ;La .P>5) "5, I":%531 11 k-J, ° ';42.,-; IV- ‘f-,4%..,C' .7 ° 0 o . "4- ....I. l' .N"fes 1-ct° ' c•-:t..° -1:-.-P't I Gele---IttitTIFICATICitt OFIDEAtrli; °,..,°e - .0 e .0';' ° °4-'e?41 1 aTAT7,E--FIL.E c N-- . M. BEpRi 9147 .1; aY d D ATE i ssi Er, o a. ctobe kO.7 2i14 DECEDENT INFORMATION STATEPILE‘DATE: 0ctober 22 , 2014..:. 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P- , A% X tI ' DATE OF DEATH: October 20;20141 " • SEX: MALE , • -- ; AGt::06J,YEARS l -• -4 . .., • t' DATE OF BIRTH February•19-1952 --. t-,n" • BIRTHPLACE: PRINCETON INDIANA, UNITED STATX '-', -•PLACEOFs_DEATH:INPATIENT - • > - •_ - .. „...--a.,,,..-:,...;... •• - - ' cr...:—..:--... „, . • :.-..- - • .,-..H• .',I te b,,)„.,.AFACitifri74;belioE OR's f REETT44/4iRESeg:ibl2AKE'MEDICAL CENTERte•-c ' -*-- -,-• -1 -.- ':,...,cf.,. 7,..:;.`, ...tP ‘s 0' = - TOCATIONtFbEATH;EiRiDENTO-NNii■NATEE Ci51.1141Y,14209- --- - •' -• •1 .'2 ',Pc , •- ; 1• • ;; 0.7., -(4/7 ', _/, a:ltd. ...-. - 2.--t- . ,-24.1., ' . -; --, -' t."1- " ' 3 ".. -;•'?...: :?-.:.,1 . . , suRvIvINV SPOUSE, DEC EDENTISSESIDENCE;ANDTHiSTORY`INFORMATION - • ,,:io. ,::- 33- cif,'4. k.'" tMAN----FtrIT—AliSTATOST•laRRIE. `3,-.-...r...-,*--,-<, . , ,„ - 2 - •s *e 4 2' - • • : ." - r' L-1: 3_,- SPOUSE(IF FEMALENAIdEN:N_AME): N1A4RY,22E WHITTEN - , --. . „ • - • J. -_, - ." _ - : , ,, v •' . '2s; -, ,.:-./. :RESIDENCE:4ga 1:4-0141-FRACE.STREEttPRINCETON,ItilDIANAk47676`,',UNITED;STATES-: COUNTY:GIBSON. ;,•■;:,' 4' ..“ 1.- .:-2 6606,13ATranis, INDUSTRY' FACTORY WORKEli,•MANLIFACTURING- "-cr-'•-.2 " ' _. 3. T -. 1,, . , • ,,-- , - .a ... --.! 1 1 a ,..-FiACEd X-MS c-CRY‘cir or Atncan Arnitican' Asian Inclian.. °Cpmese°I°. Filmulio : 'Natve Hawaiian '"-■ 'JapanOselj - Korean. : , _ ti›, "---,' :',, -■America:Viridian Oi NaSkan Native-Tribe • " -..-e,_Vietnamese, • _ Other Asian '' - • , " ' • : (r- ''', .. ;,'0 -Guarnian Or CharnOttO it Samoan.' ,- goof Pacific Iti.,• lAcp,, : •r P tp,:, ;5:i I I P N)cif..§R HAITIANfORIGIN?NS-NoTOF HISPANICTAITIAN,ORIGIgl „'e/ ' r ; . ' -. 1, i +.' ' • ,,,,,o-t-5-- •5:: 1 t . ,, Epu,ATION:AS6OCIATI'DE`GREE • ,., ;v. :1 .'..is 14‘ . EVER Iniiy.s.ARMED FORCES? NO • °.-1 L...'p. n 4 -sr,,- ....±:r _A: __."-• --__-. ___; t -„. r•• i .1 • , -:,*.c.1 'PARENTS7AND4NFORMANT-JINFORMATIONle. ' -9 3' .4".3. ' ' ' -19 .1' Ze ; . ..1 d ." 0 _ ,--E-; - -.,,a2ri - I- - • ' •,;_a ' ' • vote ,'? if , p •-• ''. -.I'd ' - ' i' ''''''''' Vir, • ,t, ,,, _•:: ii t ' . , .. , it- ' 4. _ i • ..7",...- FATHER: GAYLE SUMMERS .. r-,,,0--, ' . -• , .' ..!: 1.0" JD - .0. /he- /2.-MOTHER: ROSANNA--tlyMPHREYx-r • -„,....t, , 1,I LlINFORMANT:MARY E SUMMERS ce • -• i-,,- il ..• a. -- c,) , ....,,, ••.:.,.„ . .4 RELATIONSHIP TO DECEDENT:WIFE/ Au b. ...4 ' :1- t -" •--- , l''. ' 'y, •-•... ' ' 1., % 0. . . . ' • ,. 15 :rii4FoRmAkrsAbl3FtES : 818'NORTH,RACE STREET;;BRINCETOPN INDIANA"47670,..UNITED STATESc . - . --- % •- , TY. k :.*:', 1,2'pLACE.OF DISPOSITION'AND FUNERAL FACILITY,INFORMATION . . • ' ,:PVCEOFDISPOSITION:•60DIFELLOWSZEIVIETERY• 2 -. . *„: „ :.,. , , ,-.0 , t . , '--c.,0 . - /2,ir „----2 .-51 .P METHOD:OF DISPOSITIONIREMOVAL FROM STATE. 2-- il . -,-••2- . t.- ,\,-, -;,--- •- ci . c..-ici • . ■ •t . ., ,CI..,.;■7P±, • , at 4,4,4, . , • 0 : •,FUNERALOIRECTOR/LItENSE NUMBER: SCOTT-HICKEYLTF044604 : -. • - --;_ ,..,-, .. - . , •.,. 0-y , ,,.? 5 At.. .:r2FLNERACFACILITY: -i-i612E0W-AS;FUNERAL HOME -F040589c - ../_:-.•7 _ A . - , , -', i ••Pe5''''-i . • - ' I.. I 'e'' ri,-4,:' - , m - -1-- -'-- '---?4-ett: ` , , . ,', -', -r .- • uf 1: , . -'e LI, 71 I er ,Ate . 1,12 SII3AYVIEW,BLVD,OLDSMARoFLORIDA 34677 2 . t - - I - - .t ;=_...L,....„, ; , •, i • • ' s . 0 !;:c.+XCERii1FIEFi INFORNiATIONI ....,./, •:. 1 • -,. . , e., , • 'TYPEOF bEhfIFIER:'CERTIFYING PHYSICIAN - MEDICAL EXAMINER OASE:NUMBER',--NOT.ApPLICABLE2.",—;-,---..a, •-• M. i. ii., __31ME OF DEATH(24 hr).c0831 . 7 zt,';, . 4;• ,- . '. • , ....; • ,..: 5. ' 5... . , - "" - . 1.ft 5 1 0° CERTIFIER'S NAME: IRYNA IHORIVNA'CHYSHKEVYCH -; ' - '• c - ' " , -' "- QC! %. FIER'S LICENSEINUMBER::11;1E11,15145 , k "'7' -, c . -.S 0, '. . ' ._>73,g 4) ,- .. V./ • Fir/JR ,.. ..-).41'...-(7 1 ii.,;- NAME OF,ATTENDIN0pHYSICIANI(11other thariCertifier): NOT APPLICABLE% ' . • . • .. ‘, , " . .7't Ø-r , 1-. m _.„__. _ ., 4 I.s._.-, nk .. r...-, heir: __ _ cb.,,-;g . tn.9: • . , ,,, , • : • ID • ,y5CAUSE OF DEA:T-1141ND INJURYNNFORMATIONc` ."..; , ( ": '',., _ . -.". . ' . .y. ' - I, . ti; .2 , • -'1"• '‘Yr '• '' ' 6 . 't MANNER OE DEATWNATURAL rie . ' ' .:.'•.: 2 ' 2 ' ' • 2;' - . Ill 17-' • ,5 CAUSE ORDEAT_Itide'PARTI•-' and-Approximate Interval:, Onset to J' Dh:-. - ' - ,. lia12614detrARREST .: MAY(0 6'2016 ,-, ... - :), - ")...,-.. . „ , . i•—,ti""iztESpIRATORY/ZAFiDIAC.FAILURE ,. - . . ; • • - ; , • v°2 ' ). - • linvii.C. ; " \-• '2 it. . -., . .=...A ....-, . , - --_,. , ,. 4-.:.:/- srge it "' ' '•' ff, % nGIBSON,COUNCTY.AUDITOR '' ''' • . , - , . - . • , - • - . _ ••. -.1. - 7-"'"." r . • . , : • ,.. .:' i',7. ' ' . o -' ..0•12°' I": ..• - -. : • '.6i;:.;• G " '7 'ilin..22? .° . - cv- r . - - PART,II-OthensignificantconditiOns contributing to death but not resulting-in theunderIVng cause given in BART I: ',.- • VC-, •---).- ir ' . 4," j -,,, . - ..§ , ,LAUtOP,Sy PERFORMED? NO'ki: 1 • . DiTEj0F:SURPG1ERY: • = •epe • RE;;;SON,FOR SURGERY:v ke .•" . . k , ,, - --'AUTOPSY(FINOINGS AVAILABLE:10 COMPLETE CAUSE OF DEATH?- .• - -4;.- ' . ;7-1.2, DIECTOBACCOUSE-CoNTRIBUTE TO,DEA.TH? NO '-' 4,k• 1L _ -.:0•-1 -. . " • -..., , . 1FEELMALE;Noi:APRLICABLE t. ' ' . , ... ... fri„,. DATE OF INJURY. NOT APPLICABLE , .4,,T....c1ME:OF-IN:litURY:2:1‘nr).i..,: ),...,..... - INJURY AT • 1-'•-' ' ' '' . L00ATIOiN OF4N1ORY.-- 20. s•-•••• .-- ' c/ • ag PT: DESCRIBE-HOW INJURY.00CUR;50 ,.an 0 „ - Nt )1, •?'• ,. 2 , • =22;22 o,P & - 0 ' 1 , 0 Twig . (.1 oi •03 ° e.,, . . PLACE OF INJURY a......*--i i f g 7-,s.. °c2 ,-;":„ e " - . , -5-AF TRANSPORTATION INJURY,Statue'of-becedent: • -4;1;1%."'_ - - : ,• : • •. •• T2' 1 -'-!, ' ' ' CgCl- -C)1 r? do ibl 0 , ,)''t c,,_•.e-.4 Type of Vehicle: \ '- ' •••.14 l• " '• / •3 v • , t ; ,/ .. 4--) ' In et'y • le ' ••,!. 0 ° / •• '1/2‘i d; W4 .e.-0 ' ! '"c•°. o Cr. 0 ,':' .. .0 •C kik r14. ' 4•64/ ' .r /„.c, . 'tr....le;.:(<1;11-. . O• 0 0 c+ "c a .• -nt-: 0 ..:- ± ; ... : 4- ,..,0 ° . ° i'S.‘ 1 2 ' --/_ •„-. . . , ' • ,,----itl © ;State Registrar •0 • 0 0 °' . 0,. "'RECO 2015354094 -0 . . - ,.. .. --,,,--viz-,--' • . -, .- , , - - 0-.0. 40 9 °,5 410t joi[44- V 01,0 ° •.••0 -5*? 7, ' t s - 1- /. - .. - i • - -0 ,a--- • ..151 •0'%4•L' 4:24iP , THE AB0yE SieNATURE CaRTIDESYHAT TIOS IdA TRUE AND OF OFFICIAL RECORD ON,FILE IN THISOF4E.° 0 re.,,-(--c-a-T? ; ... 0 - 0,THIS DOCU(A&T,IS PRINTEDOh PHOTOCOPIED ON SECURITY PAPER IMTHMATERMARKS OF THEIGREAT0„..,,/ ,'" ; k . , .....E .. i ,N Jr 6915 3144-• •WARNING: 0 .SEAL OF THE STATE OF0FLORIDA_EDO_NOT ACCENT WITHOUT VERIFYING THE PRESENCEOF.,7NE WATER- se , Y r 4 • •1-- •1, 0. i:', - • "• °MARKS.THE DOCUMENT-FACE CONTAINS AIMULTICOLORED BACKGROUND.GOLD EMBOSSED SEAL.AND4-.4r1\ -. 4 . ..• •{ - 4-.- % sey, , ...• . ... .THERMOCHROMIC EL,THEBACK CONTAINS SPECIAL LINES W111-ITEXT0 THIS DSCUtAct:TWIU,NOT,PRODUCE,dX; •• - , 0 "0 i•,110..• 5.- :0,c"-•.• '• 0;4, . "ft? o ''' >23 0/1,ja 1' i " 2-.'. E1/4 1 a./7---■-.-°° E I ° 0 DH FORM 1947(C9-13)• 0 0 ' o o tr:i3• •A•-•,t-- ••%Va•Lxzt=u•,sozmva1 .. ..:74" ••••••‘.., .1,-,CERTIFICATION OF VITAL RECOR1. 1-',...;FOrid:i. •••\ • ,kk,,,,..2410 ..".,..,:, HEALTH . . ' :4 _.... * 5 3 3 9 9 1 2 0 * .