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Death Certificate - Pickett, Karen S_10/5/2016 "sinl .Y..YL iA.:A19]R..42- no'-JI9L if1M111.AiG 3.9Cte21V.:Y • 1'n .Y:AL'siinx T .lYNt.,ic_ls•- Y.599 .?7n1:.]Ar'NL'-ieox r.u1tiN,`_'$34-, -?nw.nf it -ti vj/,,f 1 - INDIANA STA7 DEP TMENT-OF'REACT. I'� e..r vII :� n I� .;j l r/ N y `` L..♦ l '- \. \CERTIFICATE<OF DEATH C `. . �\ � �'o ai-- 001�82i5 _ � so100000�0533381 � `i s tr r _4S5Er. •1 Decedents Legal Nerve(Felt,M4me Lnt),_- (r/ 'I C-2) / i.. ,6� r1a;Maidenpanre Ntmiarer - DTI 3 f2 Se ;;� } Tame Of Dent ill(,•4-.Da;e Ot Oeth.(Mx DaYA'ear)Y 341 �/cilil '=1.`�✓�ii'R'u:.� 'i'�k: .� I rsd i II%.c(U ..,,,,J.'�¢� ' 4.Itr�C..M/ II>'�;"i�,.; j 4Itij k4-",<-4!l�e ..,E''' KAREN S PICKETT$-.5.i....:.".:::=1.-&6›...-:',--'; `J �: "``v . - M � /2 �`'� RESENBECK� FEMALE u01'40�AM. ^:� 09f23 016'\ � Than A Hosptal��I r- 4 --'2"- I/ /�/I IfE/,i r /•iI r -� .� �•�J. - /',.v` .:'' 4(T f` ®Hoyspice FacsY rD.DeredeAr H etV 0 Nursing HanefLonFhnnC racily"1'`:,‘.‘.:.'4,..':"`k ❑Yes,®No 0 Unknown D trpzaent D Emergeray oepartmeet a:parent D Dead on Fmval '� = -- '> I r:> i✓.1.t':.n. D.od,a(Spe?N) ' ./• i '11.',Faaty Name(If Na Ins:ano.Give Steel and Number) _ Z,<, - l -- : f� CHARLIER HOSPICE.CENTER " - ' ? _ F;-. - 1 • ' 12.'9 y Or Twm,Stax,Am Zip Cdde 13.CanyOf Dean 6 14. Matti Status Vent Of Death '4 ' .,t moo. s G \Y-?-�3 .' S� - -• :©Maned D M med But Separated:D Doomed EVANSVILLEr IN;47713 ' , 4-31--;„ ,; :r1.1%.1, • VANDERBURGH - % '0 Ydaowed O NewMarned tD unknown 15'SUNwq Spouses Name . 15a Last Name Before East Maipage 16 Decedents Usual Occupation 17..Kind Of Busirenlnd sty ' JACK-PICKETT - __ . - < ¢ .. .._ HOMEMAKER . HOME • ;,3 ; 'V... ;Fr-Residence Sta - � ♦ , - INDIANA .-," . - GIBSON _ ` FRANCISCO ' -'-- " _ ♦ 's., S "Sc.Street And Number ♦ - / then AplN tee Lp Cade - tai 4nbe CrtyDmap t$ iI ❑Yes D NO - ri 6612,EAST•475 SOUTH - - `� �.I 09 Decedents Eduraaon' P 20 1Decedent Of Faspank.Ongn 21 Decedenrs R , e• HIGH,SCHOOL'GRADUATE OR GED t.; , <, t ( • ' \ � COMPLETED NOT HISPANIC _f ' Whi e. C.":.---:. '�N •- - • . ?':• = ti' I a `22 Pmenrs Name(Fes.Mime,last) - ,/ 23.Parents Name(First,Middle last) 23a Parent's Last Nat Be breY s Marriage "V WILLIAM'RESENBECK ANITA GENTRY L ' . _ - n . ELDRIDGE •T . . 24 Iu om.:arts Name- ' ' 24a Retatcnslap To Decedent 24b.Mang Andre (Sleet And Number Crry,State,Zip Code) T1 T��:.�f ) -. \\ ti - �. �G JACK'PICKETT HUSBAND - 6612'!.EAST 475 SOUTH, FRANCISCO:1N 47649 T " ;11 a\z"�., =3-: .. -S.d e 2 a a a'a.u.,;VS '• aid=''`. . . _ .-•`,...•♦.0 ,�� 25a Mend Ol Dispo xn 25b.Race Of Piposib:a(Name Of Cemetery.G etrait:Other Race) 25c_Lecatdn City.Tam And Sae © Btaiai 0 Cremat,. 0 Donsson 0 Entombment ' , . • D Removal Fromm .e // b - ♦ _ > 1'.1 ❑Ore;r(Speay) , .: COLUMBIA WHITE CHURCH CEMETERY .. . PRINCETON,IN . . .. ,,T,..!.1 . ; 1 225 Was Carver Contaaeao 27- Name Am Complete Address Of FVfert Faoki `. ✓ 'c, `.":t \ "\ c - \, . 27a7F alHme taeiseN bet.' (0 Yes 0 No COLVIN FUNERAL'HOME INC 425:N MAIN ST "PRINCETON, IN 47670 „ - - , FH83005671 .e L• ; •: 27b.-.S.gla:txe Ot vwana Fu eraf Service LTensee: • _ T .3- 27c.License Nmber(Of Licensee).9...•'JOHN W WELLS- BY ELECTRONIC SIGNATURE ./' - i - FD01009940 .. - ;I' r ::"' > w' ;;,,,('Cause OI Death (See In`tructions And Examples) ' Appro`rimate�1 t 429 Part I Enter The Chain Of Events Diseases,Injuries,Or Complications That Directly Caused The Death Do Not En to Tenurial Events' Interval Onset .' %Sikh As Cardiac Arrest,Respiratory,Arrest,Or Ver ricular Fibrillation Without Shower The Etiology Do Not Abbevfa a Ewer , One Cause On ' t To De'9. ) .+; A Lase. Add Additional Lines II Necessary. \ -.7:9// p\ \ \ r' 1t' " t p.. . y ' N•Immediate Cause(Final Disease Or Condition Resulting In Death) A •ACUTE MYELOID LEUKEMIA - -. ` \Sequentafly List Conditass, If Arty,Leadag To The Cause Listed On B _ - .' Line A En er The Underlying Cause(Disease Or Injury That Initiated ' A. '.j • 1.°-'°"" `°°t°m° "-• 'c. -,The Events R e s a l t n a N Death)Last 7 iy . . _. • 'Pal U.Ente Others ifran Catrn,s Corrbu:aw to Dean,But Not Resuong In The Undertyaq Cause Given In Pat I;II r 29,Was An Autopsy Per:coed? •- 'f ' - •r '.a ti. ' �D,;a4,.... D' No. ,/ i . .,:4 ♦ `.-•\`e, s;�\�.� wN4re AftocsyF dmgAatadeT`Cbmpl\a Tire CawO`oeati ♦rl Yes Dr J 31 Did Tobacco Use Contribute To Death? 32.If Femal ' : : ?ISM "2^ ,' ✓' 33 Manner Of Death / s;-i / ; '%- etwpe Yon 0 - .N at A.Tr'e ssa c ! '0 r D Ptoeaby'0 N D unamwn ❑"°.,.am ❑»i-� o..e I .bar cep: ©Nabial 0`«n:xe nc`a\ ❑Parictq\gaaoii� �.♦,� •O me nv4+s eu n.pw n Dmmrrarson air 6:3'..";©went;[no's'[am"m:..a ,- . O SuWe D Could Na Be Determined a i]4 Da:e Of Injury(Month/Day/Year) %. Tune IX lryury' 36'Ram Of anP+Y(EG.,Decedents Home,Ggnswction S:e Reslauant YJdoOed Area) 37 ritzy At Nbkp ' 4' 3aLoraion IXlrjvy-Sate 3Pa. City Or Town 3Bb:".Snena Nianber - ?ec:Apt.NO i.' 36c Lis Code / I • Sg _ - 39.Desmbe How lrywy Omrred ,/ d0 It Transpauam.my�.9:,;^ / : , .. / d1.i Signature;Of Person Ceryaq Cause Of Death` 42.Cerdter.(Checkian Onel ' JULIE'ICGERHARDT, BY ELECTRONIC SIGNATURE �- � \f 0 Cerby;ry Physician ,D Canner 'D Nealdl OIf,CE e4] name Address And Zip Cone Of Person CeNyang Cause OI Dea.n 44. License Ntattber 45 Date Ca':ed ' =‘,......2.:- } JULIE'K GERHARDT ,.600 MARY ST., EVANSVILLE,IN.47713 i >.,..-" . - . .../' . 01057271A 2. . .0912 3/2 01 6- ..`. 46+Admudrul Fmtfd Savfm RC-der '1 -1 47 Ane ' -_C 1 . I- / i' ��..0 � ' ! e . :: \ ice. a°+.�a.4Ch`��C+ toe.5yylawreofLOWHetm05ce v, �, 'T i d�' y:� �n� Y. / >;-; 49 F Reg,[ Dry DaTRed IMontfDayttea i .. �•- ROBERT KENNETH SPEAF 'VIP' ELECTRONI SIGNATURE ',L Ltt2 ( r r n .fi 4 rF,,aIter+ 1 : .-. :SEP 23.2016/t'1 it e;.;Ff IY/�3 .5 .:1wa .,yw�s- \- - J \'.tA4 'AMENDMENT,TOCER71RCATE OF DEATH(ENTRYORORIGINAL)>�J+'4\\�12� °*,,.* c. st \\ �r i /' f / L1 Il % C� ri ✓ r II I,�N / li - hlr f,ir- a� Ila-o: ".• .000 o 1a ,oa8% i le'. �. ,,.� / y 1I . , /; A r�II �\V/ ;%s \i.. 7y ~ it I■" 1,,,, 1 /iRR',jrl�/�,.% R,,/ 'G� f i 17rt l /I rt.' loss �ioo:.:,.,f„"ol3aoo,� �� - t r , `: - � ;I Sate Fam53..�- ATTENTION ESTATES"The Soc21 Seaaity p is being`equested by the state agency5a ofd[,topyisuprespo ssitS1, IDtwbsure is vDlunary lad mere wIU be nn peralry to re'isaLl ref.: I `TURNS FROM ORANGE HASAMULTICOLORED BED ROUNDONSFECIAL HAS HIDDEN-VOID ONFFRONJHEGRFAT;ARS OFTHESTATE,OEINDWJA ON DACK iliA•`, .�WARNIfVG. .TURNS.FROM OPANGE TOYELLOVf WHEN RUBBED ORICJNAL<DOCUMENT HAS HIDDEN NOIDON FRONT.TYATAPPEARS WHEN PHOTO CORED}s�1'•.3?'�if?VI r.N