Death Certificate - Beadles, Samuel E_10/17/2016 .e.a.eresers V I n e c 4acrnn I men I ,Jr ncnu n ' v v 1 v v v
CERTIFICATE OF DEATH
` ). Local No 000042 EDR No 000000309966 State•te No 010336
1.DewdnM1 Legal Name(Fiat Wee Last) la. Malden Name(dam) - 2.Sea 1 Time Of Death 4. Data Of Der(MonttfmyA'ear)
SAMUEL EARL BEADLES MALE 01:14 PM 02/23/2013
73 Moes Days Haws Ie,utn 04/15/1939 ELLERY, IL
9. Ever n U.S.Armed Force? 10.1f Death Oaoned In A Kaagkr 10a d Death Oeamec Sm+nnae pear Than A Hospital
❑Yes 0 No ❑Unknown ❑kpmrn❑En' anCy De arorent Oulpan.e 0 Dead n Acme! ❑thha( Peseta ®DeadueS Home ❑Mash;tkanrL.drq-mnn Care Facisb
❑orw(sprd)
11. Fatty Name(If Nor tirstiSnYm,die Street ad Number)
110 PENNSYLVANIA STREET
12.Cay Ow Tom.Sane MO Zip COOe 13 Canty Of Den, 14.Mama)Stan At lane Of Dees,
®Merkel❑Marled.But Separated ❑Divorced
PRINCETON, IN,47670 V� GIBSON ❑Widowed ❑NewrMania ❑Unknown
15.Semen;Spousal Name 15a(it ,)GNe Maiden LAa Name 16.Decedent,Usual Ocapatin 17.lens Of&stmsknWany .
RITA BEADLES . PARKE SET UP MAN MAUNFACTURING
M. Retipe- .Stae 18a.Carob _ It Gay Or Tam
INDIANA GIBSON PRINCETON
18c Street And Raney 184.APL No. 18e. Zip Code 181.Made Coy Linz?
110 PENNSYLVANIA STREET 47670 121 Yes ❑No
19.Decedents FAvfai= 20. Decedent Or R apa,c Ongn 21. De edr,(a Rem
SOME COLLEGE CREDIT,BUT NOT A
DEGREE NOT HISPANIC White
22.Father's Name(Fist facie,Lae) 21 Mothers Nana(F a.kiddie.Last) 23a.MoO,CS Malden Last Name
JOSEPH BEADLES EDITH PEARL BEADLES DEARING
24.Wormers s Name 24a.Readonshro To Decedent 240.MaY,Address(Strut And Numbs.My.Stan.Zip Cole)
RITA BEADLES WIFE 110 PENNSYLVANIA STREET, PRINCETON, IN 47670
25.Race Cf Lbposen
25e.Menai Of Dbpendrt -25G Rae Of Dlsp sear(Nana Of Cemetery,Crematory,Other Race) 25o.Loom-City,Town,And Sloe
®Irma ❑Onion ❑Donation O Entombment
❑Removal Fun Sine
O Oew(SpedryT NEW LIBERTY CHURCH CEMETERY VELPEN(PIKE CO), IN
26.We Coroner CattacteT 27. None And Camden Adores Of Funeral FaC'ly 27a. Funend Hone Licence Numte:
®Yee ❑No DOYLE FUNERAL HOME, 520 S MAIN ST, PRINCETON, IN 47670 FH10400010
276 Swann Of mane Funeral Server.Lmnee: 27c I. (d Utensil.*Utensil.*BARRETT W-DOYLE,BY ELECTRONIC SIGNATURE Iiam Nm
FD29500009
Case Of Death (See Instructions And Examples) Apparndmate
28.Part I.Enter The Chaff+Of Evenly -Diseases,injures,Or Complications-That Daaty Caused The Death.Do Not Erb Terminal Evens Interval:Onset
Sam Al Cardiac Merest Respratory Arrest Or Ventricular Fmrillabon Without Slowing The Etiology.Do Not Abbreviate.Ens Only One Cause On To Death
A Lune.Add Addtnal lanes B Necessary.
L•rrnedlte Cause(Final Disease Or Contdn Results-1g n Death) A. METASTATIC PROSTATE CANCER WfTH ABDOMINAL AND BONE METASTASES 8 MONTHS
• 0..eta w♦nom 0e
Sequstaly List Conditions. If Any.Leading To The Cease Listed On B.
Line A. Enter The Underlying Case(Meese Or Mary That Metaed o..la r+.Y1/am
The Evens Resulting In Death)Last
C.
a.ero..nr.,.em
D.
Pan O.Enna One Sar,dunt Gto9gekns Cam MgM d DuT Sul Na ReWOnp In The undabkq Came Gran In Pan I 29.Was M Mn om Performed? 0 Yes 0 No
30.Wee Autopsy Paine AvaLOle To Complete The Came 01 Death? ❑Yes 0 FNo
31. De Totem*Use Canaan To Dee,? 32.If Permata 33. Marne Of Omen
❑Yes ❑Prmmy®Ns tlnkn,Oarn 0 e.Fwd. wrase. 0.rem,en..s wee 0...Prawn.ea neon.. von..area. 0 antral❑Hamada ❑Accident ❑P«,On9 InvesePtm
❑la rwa vat Pman a pas Ts r ow flan ore ❑use.•awasarm,err Per y. 0 Suet/.0 Cam Nal Be Deeemnel
31. Dan Of ty,ry(Lleamv rye 35.Tea Of Intl 38. Place Of Injury(E.G..Oece/eOY Hone Ca,s.mm Site Restate Woofed Anna) 37.Inlay At Work?
. ❑Yes ❑No
38.Looabm Of Iryvry-S� J 38a.Cay Or Tam 3811. Star B Number 38c Apt.No. ' 380. De Code
39.Depabe Haw Injury Occurred - - 40. 1?Tmepertoa,IryvY.•
-- � ov Oce.1>R.0
41.Scuba.Of Penn Cendwq Cause Of Deers - . - ' 42-Crtde(Check Only Ora
MAQBOOL AHMED,BY ELECTRONIC SIGNATURE _• ®Carrara Redden O wars ❑Here 03Qr
43.Name.AOaess AM re Code Of Person Cetlyeq Came Of Death: ,- 44.Lcerue Norte" 45. Date Coifed
MAQBOOL AHMED 421 CHESTNUT ST, EVAN VILLE,IN 47713 - - 01054343A 03/01/2013
Malone el one Funeral Saga Roeder Roeder ' - .. . . . -_. 47. was:
48.S¢.a se d Loci Herat,Oman ` 49. Fr Raplatry Only -Oar Mal (MnNDeyfY.s
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE,. -. . = MAR 04 2013-.AMENDWENT TO CERTIFICATE-OF DEATH(ENTRY OR ORIGINAL)
•
it o Porter 53395 ATTENTIO I ESTATE:The DOOM Seasity a e being squealed by IHs state agency n ear to pasue rapaeatty. Octlmao a voknsry end Isere we/be m petty hr refusal
17/05)
I IU4E;_ALTERE CTITEERASED NOT VALIB UNLESS ERTIHED BYtNEALTH1.DEPARTMENT