Death Certificate - Buckler, James J_9/1/2016 ISSUED BY MARION COUNTY PUBLIC HEALTH DEPARTMENT
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�' t INDIANA STATE DEPARTMENT OF HEALTH
!= =;� CERTIFICATE OF DEATH
\;." / . Local No 005762 EDR No 000000269766 State No
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LDeriOmYS Legal Nbn[IFn:W.Oe Last) .a Medea None lY female) 2 Sea 3. Tune IX Death 4 Date 01 Dap(MmNOeyXar)
JAMES JEROME BUCKLER j MALE 07.40 AM 07/112012
z? 10.II Death Oceved MA HD`p.at ICe. Ii Deans O¢tr:d SVi menet OTC Then A HosSal
❑Yes 0 No Urinwn bptml E—.CgCry DmC:nen Matm ❑Omc on knm' ❑❑C TH ae s peaFamyy 0 Decedents Hone ❑NCV:g Hoo•Lpng-tam Care`acley
I. FerL-.Name(E tea Y.LYAs.Grre Steel and Na-R'1
INDIANA UNIVERSITY MEDICAL CENTER
2 Ole Q'iMil.Sin e.A'n'W Code 13 Cast]O'DdT Id. Merle SDMS A:isle Dl Deals
0 keened0 Korea.8A:Sepaaec ❑Dena
INDIANAPOLIS,IN,46202 MARION ❑WaaMd 0 Neva Mamd 0 amnt.n
I15 Sninrc Sma+ses Name 15a.11:•:edejGree Marem Lan Name tfi Ceeaaa-s'_4v ORUCaos: 17. 'Inc Of BI.wrmYSisry
KAROLYN BUCKLER MOORE OFFICE MANAGER GOVERNMENT
le. Res[md State 1m Carty tt.c}aTwn
'INDIANA FAYETTE CONNERSVILLE
1&.Ereel4:G tltlGe IS.Am.Na tee.Zit Cone :9.Inset Cc eras?
0 Yes O No
2W REGENCY PLACE 47331
19 Decedent's Etuatan 20 Cececm;Of Hsoamc Ogr. 21. Decedenrs Race
BACHELOR'S DEGREE(BA,AB. BS) NOT HISPANIC Write
22 FCnes tenetFist Nadu.real 23 Manes to(Ftst.Mane.Lae) 23a.'Knees Minden Last Name""1
JEROME BUCKLER HELEN BUCKLER SCHI♦d�l H e I
2.Me nen:5 Name 2da.Relatmvup T3 Decedent' 2o.ELENg ACCre55(S:rel And timtec it).State La Code) 1
:CAROL YN BUCKLER WEE 2W REGENCY PLACE. CONNERSVILLE. IN 47331
I 25 Race CI Oi stm e mp_1 _zp c_
25a.Meted O:a9os:41 =:E Place CeaDOSt'T(Name 01 Cannery. e e:cy.Claflag) 25c.lmln-C::.Town.Ara Sate
0 Bona 0 Cm-mason 0 xramtn 0 brim mean
❑Remover From Soo 1
0 ober(specify) ST MARY'S CEMETERY RICHMOND.IN ////1//��
26 Was Coroner Cmaceda 27. [lame Ant Cam-Vex Ataess 01 Funeral racier 127a�FIN ter.
0 Yes '0 No MILLER 1:10STER BOBBINS FUNERAL HOME INC., 1704 N GRAND AVENUE, GIBSO 998U�1TY AUDITOR
CONNERSVILLE,eee IN 47331 IEn c
Izl: Segment[Olean,F rl Sema Licensee. 'c. License Number la licensee)
STEPHEN A. ROBBINS .BY ELECTRONIC SIGNATURE I FDO1007061
Cause Of Death (See lnseuctions And Examples) AOD 0.2x
29.Par I.Enter ne Chain Of Evers .Diseases.Injures.Or Coao8atms-That Dinner Cause°The ean.Do Not Enter Terminal Evers In:esal Onset
Sin As Cer:ac Artes,Resosa:are Ames.Or entouat Fnella:co':laout Snorting The EDobgy_Do Not Abbreviate.Sac'Only One Cause On To Dan
A Lee. Add Amerman Lines It Necessary.
Inveda:e Cause(Fivl Disease Or Condi:ion Res:Mang In Deana) A MASSVE INTRAPERITONEAL HEMORRHAGE x .n E HOURS
Sequel-Maly Lis:Commons, If Any,L eao'ng To Toe Cause Used On R AORTIC PSEUDOANEL'RYS'a ..e torn. ` wart 2 DAYS
Lee A. Enter The Underlying Cause(aseese Or Injury T N:Intend
The Evens Resucng In Dean/Lam C.
D
IRar:II.Enter Omer 9Crasar3 Crn^_:tens Centmes<to Dean But Into Rea:ang N ire'Lnnsteng Cause Gann N Peel 129 VnsMAU:yry Pelondn fJ Yes 0 tic
MULiI`.'ISCE'v AL TRANSPLANT 130 Wee Amovsy Fln¢g Available To CooTete toe Cause C Dean? OYes 0 No
31. Dd:oasca Use Combo[To Deana 2 IlFe ale. _ 33. Mena ODeen
❑yes ❑?xdy 0 Na ❑Unknown
`0'- 1[tune . 0:..rte-'---O.c. 0 ua:c eaa as s.,..tre..r:GA 0•C-or 0 Nava 0 Hence, 0:ceen: 0 Penang ln.es:a:o:
0.� - �c.-n.eee'e 0 t,.. .re:iice.•.. 0 Swx 0 Cann No Be Enennec
134 Dee C:hire?lMonttCsvtteerl ( 35 Tent 0lRtzy `•36 Place 01 InyIE.G.recedes-5 Home.COa:utsn Six.Restaurant.Wooded keel 37. misty A:wow?
❑Yes ❑No
36 Loon=C r ry-Sax =a.Oar Or inn 33n. Stee:&N';nba Sac Act No 38c.10 Coce
1 39 Cesaoe now s%ay Ocean 'o I'T2n9ona3tn I utY S •ne Iz.v-n
I1. Sgeve.a Peso,CatI5r. Cause a Dean-. 42 Coiner(Creek avy Orel
ASHESH P. SHAH, FY ELECTRONIC SIGNATURE 0[dying Aysom 0 Cavr 0 ner.atein
(£3. Name. And LO Coce Prison CeIIMInT Cause Of Lea:: 44 'Ucese[rose =5 Cane Cerc?e.
ASHESH P. SHAH .550 UNIVERSITY HOSPITAL, INDIANAPOLIS, IN 46202 010623564 08/10/2012
146. A'ldloal Antral Se'ae L,a13ed. I 17. 'Antes:
!aH 9getre d Taal Heat'.CSS. 49 For Regsuar Ony -Jae Fled(Mten/DaytteaI.
VIRGINIA A CAINE,VIA ELECTRONIC SIGNATURE AUG 14 2012
I AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
1 -o"/—2 5 - - 16o• ow X58.5 - 0c0
Sax Form 53395 ATTENTION ESTATE ice Social Secuny a E being requested>y4.issa:a agency in order to pursae resporslbilry. Disclosure is:oluMary and here well be no penalty for refusal.