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Death Certificate - McGillem, Jerry L_5/25/2016 4. ip--- — • -,..vcre,-,,Iiir-- ,,,,vuir...-: ,- 1-IND[ANAATeitE,Dthe- Li tvitrAc,OFftlEA , etry..,,,lir.rr.--1 h 4, ......pi „,jpgr,<,..hr-F.;,..s.i.,re2;;...9.1 % F i„,„..- -, ...,...-•-"f ..-# ° '`. ;--Y I 4,,, - :- 'fle; --;.% . --(Cr --%bElktil(141fttltrljtAYA 1 '.<... i.%•••%. L.'''.II "cl 1, l it--;--1-1t,- , ,-; iin ■ - \'Lle2i.:17.SKI I tL1431Cal I r"C21;4110111/010 lieirta?CfCY;;;-'4,LII:441L:,.;?-a:11rPt'/CL.CillE6C;d:Nri I 1P-07.010T6OrritrlliS511.1101C84, .1f:0-1 .24,11Siarie!IA 2 3 23 3:12.1 . 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R Z. , ..-:.,;-,.. .=. r...Z..'■:■...Z.:: .0 12;BS2 a Taw'',swami°z1P ct.'I < •' -.. ! '.. a i 7'.. 13:.:54",91.-99e ;,.!t-t.::;■..:.,c. 1:,C, :7":",......:.:1::"-..:'.. '' :,,,,,;":., :::- • -'1,,,..;:!.. t%:',,.: f:r.)_).,,-) '-i,f77...,.:....41"„ ',.:. .' „.4.. .4'1 e. :-,.. : .- --- 1' ?r,'3'mr°1e?Pt" . 7rSi ,•;:-' 4 ' I - 0 imniedo,Line<1.6itseacLe.;,&.,-. .,..i.. " PRINCETON.;;IN41670: ' ,.; . --S.', -, \:::--C.. . :. .,',:-..... 1::::::" ;--7.- GIBSON '.:;;•Erf.-'-:,-.;..:/' . ;P'fieitt :13,": 54m,71":1:j52P91 --pj y.15. surviyog spouses Name', r. , -, •- - , - ;. „„.... 15a.-(11Wife)Give MaidenLast Name •Y, #ff...„. 7. '16.Decedents Usual Oecummn:f• --; 17r Kind Of gesinessflegusay;;;;;thi --'• - " ' ; - c „ „ ; KATHLEEN A . : LAMAR ELEbTRICIAN ...,., :, ELECTRICAL - / : • ".-.--'rh-919‘.:11 > INDIANA-..-.Z:— ' -.2- - • . -:- . GIBSON .,--• :::-:.. --.'"1- . PRINCETON .,;4'.-.... ai.3.4... .;'.--, - -.. ..' ' -:,,-,./.1 .;2'..% C Inside City Limits?- C, f - • 803 SOUTHBACE STREET , n/•-•. ,:: :. t , -47670: -‘...::::-:•:Tztit:,.. ..,-... ':-.•.; :.-- .., HIGH SCHOOL GRADUATE OR GED '%. ::. -' • Z. ,4 --: -.' ' -g.J.-14 9114114;' );1?;--' ....:- ' ' . ' .Z' • ' ' ' - .. 'i.;(.. ' V ‘.... ...7 22.Faders Name(First Mekra.Last) ) ,. - F -'V-- - - 23 MflCs Name(Fill.Male Last) - 23a Mothers Maden Last Name 4t . - JOHN THOMAS MCGILLEM . , - .-../ : 32. :s ,••:. 1, c MARJORIEFLORENCE MCGILLEM :. ?= ; ; :•; ---;:fi.,-.3;'-_:;:: _.,: 24;Intormanrs Name••• 3 . • ".,. ' . Me pelationshp To Decedent 1,,,.., 24b:Maihig Address.(Sneet AM Number,City Mete Zip Code): f" •. - .,.. ',i 17 ''tal.."."Tt,t2V`t..t i' : - ‘ - „.,. .,„ , . 2 ,,r -"..--- . z."..:,‘-%;„i "713-in'.''-7-77-.`..?`.7‘Y.-:# :.'":-.:. , '7' -; • .4 c.; . .:: KATHLEEN A MCGILLEM - WIFE I"-t- ,--*---.:. ., -:`:•:. 803'SOUTH•RACESTREET;PRINCETO 4 7 >41::: 1 'Ptftf-e c. • .....,. tr^-.-':V.Ce.- "'..";.• .•:., -•-''' '' . , ' ' ...'"'-. 't 'f -7&1•2eRadebitileproieiirry f ii;77.7,7.it--ird'a.ifs" 'dir.,<#7..' . '-• - -,-...: .., f.".. -7 i'77:5--se hi.-.1:::. ,... I; 25a Method Of Dispasmcn% , • - ' u 25b place Of Disposexer(Naine Of Cemetery.Csernaimy;Other Race) -'25c.Lecaten-City,loan,AM State .• - , : •:‘. b N :0 grew:El orernatte 0 Dornmti Erexcp;ment . . - „ 4;......." C.'=" c t; ..; : 4-r 4 , ,... 7 i: ?, • . . . MAY 26 2016 --1 :. ! . - - <,:. , --V.,--S :1'...,: 7: 0 Other(Specify):f I„,-c ..„. OVVENSVILLE CEMETERY. ., •t.:1. .:' OVVEN8VILLE, IN , . ; :. .. : . .:- .N:..-: I --'26 Was Comer Contemea? , 27 Name And Complete Address Of Rmeral Fealty, 7/'•'..., erf-i• -as,i f, •.ft -.''- ' ..-'...• ..-',,,f• .- iiii, 27,.„,,,,,,...tens.Nu„ber,,„.< ,, HOLDERS FIAERALHOME,OF GIBSON COUNTY INC:-:319 SOUTH MAIN STREET, - .1-c-ti.!;-i 5.,f.fhf.; ;.);,?-f-if'' ': 0 ires 0 No - ' • OVVENSVICLE IN 47665 ' : ) IP.ttif• i t' '3 f ') ' t lila' GIBSON C(949,360021,612,b--. 2 'a? 27eySignanse Of Indians Fuleral Service Licensee: '2--• 'r..." : - t, .. 2 s 2 1: ft. - • :.i.,,.:2, 27e License Number(Of Licensee): -, ' • ' ' - 7-22.7..Y. ; RANDALL*DIKE, BY.ELECTRONIC SIONATURE„ I .i _ :::: '... ,-- .,11: .;•.; -:,-. ':.• ..' 13 F001010177. • - :' 7 - -Z:-. .;;;;;,--41-,3-..:1 f' ..- ; . .. -Amc.91,P.ate!. 'f'. : - 28.Part I.Enter The ClEtnVEyS -Diseases.Injuries,OiCompticiddGis eThaiDit"-ecthaiCiuSe'd Tlie'-eiesih.Do Not E7de fiCringIii Events': Such As Cardiac Arrest,Ranee:pry Arrest,Or Ventricular Fibrillation Without Shriwing The Etiology.05 Not Abbreviate:Eider Only One Came On .- i To Oath'? -2 'A Line7Add Additional Lines tf Necessary , . . ' ::„ ) L'. i. t. gCC..-„CLI•k- 2 i(... I - t -:::,). f` ."..f: trnmediate Cause(Fetal Disease Or Condition Resulting In Death) - A7 .COMPLICATIONS OF BRONCHOSCOPY-DUE TO LARGE PULMONARY NEOPLASM • - - ..MilINUTE.jr--z:..m+1sil.-1"'- 1- ; ,. ; 2 - .:-.,-- . -... 1, . . , •:,..., . ,. 2'. ....Seg-uentmOy List ocoddions, If Any,Leadhg To The Cause Lisled On:, -B• ' . Y• "# . -..,,,, iii,' 'f ji -..lineOr Enter The Underlying Cause(Disease Or Iretry That Initiated ,,, i 1..2''"--7''''-r; r--!, -',:.--::.,, , L-. -.- . -,, 'The Events'Reeuaing In Death)Last '.. , ' -'" 'C. t. -:-: c'''' ‘', .t- i: ; .1!7' ..-'''ff.. ,t , ' ' , . . : .: . ..' ,,:tr- ' ''14)% 11 ;, : .<:-:: ...4 • N. rr'Part II,E,I,0,1?&9MYri3DI- g.atCb Bi.4 N°1 Re4,9b^9 in The....Vr'4•6111!CIus Given'",„..Bi!)1; ::: -29•'!Al#tYA'''D'Alvf,ernecr? . ', 0 Yets . tiii ..7 i :?,- 1"S...; BILATERAL PkEUMOTHORAOES,LARGE NEOPLASTIC MASS is X 18 CM IN RIGHT LUNG WITH POSTERIOR < 1.4. -1rof ' 0"..;irataire, '0,.*.a.1.,a2L-rmaaa&13:fir.te:rittrniiireyjimera?...er.offosee 0 24...2410Hornaae j 0 AcciMrit 0 Pri...+;iniesogatim-.)::...'; ■,) ',..;• D Yes yor Probably 0 No 0 Unknown 0 cep . et r■-emet:Orr;Ts,irr Barn Deer,.; ID trurr,444.0..e;rarr1i.R..you 3..... ' : (tSteaide 0 Could Not Be cie;Yeened?Y.: :t ,7-1:cd,`Z: 34. Data Of Injury(MattirDay/Year) ; 35. Tam Of INury ,..• ...7 7 7.-:: 36 Place Of InVy(E.G.:Dr.:nit?km.Cc:cynic:Jon Site ixestttsant wcoolect Anse): ' .37. Irian/AO/Vo9 fr ;.7 :S-: '..., • . , , - 0'les e",-,.16 Ne -: .., ' M. iccaton Of Initrl-Sloss . - , , 39,hesenbe,,,,,,„jury occurred t ,fr., ,• 2! ,...- r 2. ,, ..: , 42 it Transpo Irtry. >saty : t ; C , / c - ? J “11 , LM M0 ) .... ./II 41. Striature,'OlPerson Cr:L.4.N Cause Of Death: --,'ii T .11./ Sr'...f.” t-1,-.if--..-;?..`-'" ' '''' 421 beitifier(Check Cnly One) • BARRETT W. DOYLE, BY•ELECTRONIC SIGNATURE':.:- :.:- ;- ;-. : - L. Y.-kr' .,*.--. -0 Certifying PhYsmme • 0 Came, 0 Hietfrnaer.' . [ :. ".. Yi. .es Name Address the Dp Code Of PenonCertherg Case Of Dead): : 1. . I , , i r . • e ..,f-5? ' - ' 44 License Nzrb 45 Date Certied .. . - ; . ---- •t27 i < i --'i-... i'; : T . -. : • • BARRETT W..DOYLE , 520 SOUTH MAIN ST, PRINCETON,IN 47670 ..-;:a-.: .....;-: -;:;;;■:., - .1 , . - : 05/17/2016 46 Aai4FtawalSe0dePrOb'der. -:: : - t;f:..7 ::14:;•[5:: !l,%) '‘---.5:.x• - ',....„„r ;,,,,..,; 5,, 47.:Akar ."..44§.. l,::1::::-.411.1„:"::" 2.... ■ ' •-- . '•. .,-....8,?;44Ye 4414C,HeR541f: %C - ' "- 5. .'; :.-347 ; ; .H"-.",-' .. .7-. . --; , #.;4 -- -,..[..‘.'"c:" : FL'i e r..R:o:g..isf7570mY 7,ye,1,01:.r.R,ov.P,C9 p,'„2.5I BRUCEBAINKJR:VIA ELECTRONIC SIGNATURE?i i911 :;1 i •k:;,. , ; : :-; MAY17:2016 s , Ei „,- -..-;:.:zs,:e2,5s.-...;.z 7..2,,; ..:".;;;',-;:2 AMENDMENT TO CERIIFICATE.OF DEATH(ENTRYOR ORIGINAL)C,""Sir -•7.,, 7--...7:77._:i......":?...lf‘..7427yee72127.)r.,-(2-2.Mi 2,.. .ii), ....^ .r- ; 4.1:2: --' : c;#7Y,': -7.:7,2"-".%;....1:7•ThinZ.-7-Pc;cny •'7 ti ,e''' IfIWIY: ';:Ir7'-. 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WARNING -:-... . iFfONGINIALOOMMEMt,t1AS A MUCUCOLORE0 SACROROUty ON SPECIAL WHITE SECURfrf.PAPERAND:THE GREAT SEAL OF2THE STATE OF INDIANA ON BACK THAL. • TURNS FROM ORANGE,TOYELLOW WHEN RUBEED.10MGINALCDOCUMENT HAS HIDDEN" •DON-.0,a STAPP -- WHEN PHOTO COPIED,Dr.-7.11;27)e%ffit9'2:R. .. . . .. _