Death Certificate - Hull, Alma_10/21/2016 I' �"rF0,; ( 'INDIANA STATE' DEPA , TMENT'OF HEA
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act. • CERTIFICATE OF-DEATH ,
, Local No 00001202 , State No
1 Decedents"Legal Name(First,Middle,Las;) - '1a Maiden Name(If.female) 2 Sex - 3 Time of Geath 4 Date of Death(MathfDay/Year)•
H
ALMA HULL ` - '''' `WESTFALL,' ' ':FEMALE 0:00 AM :'June/29/1991 .
.
.. 71 ' ' ' - ' March/8!{920'1r
9 Ever In U.S.Armed Forces? 101f Death Occurred In A Hospital 108 If Death Occurred Somewhere Other Than A Hospital - -
4N0 - UNDEFINED •
aver(Specify),. .-
11 Fac:My Name(II not Institution,Give Street And Number) - .
ST.MARY'S MEDICAL:CENTER . ..
12 City Or Town,State And Zip Code 13 County of Death 14 Maria)Status At Time Of Deam
Married
.15 Suvivvq Spouse's Name I 15a(If Wife)Give Maiden Last Name :16 Decedent's Usual Occupation 17 Kind of BusinessAndusry
18 Residence Sate 18a County - - 1Sb City Or Town - ' <
INDIANA • PRINCETON
18c Street and Number 15d Apt.No - 18e Zip Code 181 Inside City Limits?
. . NONE
.19 Decedent's Education: 20 Decedent Of Hisparuc Origin • 21 Decedent's Race
White .
22 Parent's Name(First,Middte.Lastl I 23 Parent's Name(FirstMiddle,Last) "" I:23a Parents Last Name Before First Marriage-
24 UEamants Name_, - - I 24a Relationship To Decedent-^^.•' I 24b Maim Address(Street And Number,City.State.Zio Code) -
-
25 Place of Disoosi on • -
25a Method of Disposition 25b Place of.Disposiuon(Name Of Cemetery Crematory,Other Place) ' 25c Location-City,Town And State
I.O.O.F.CEMETERY • ,
25 Was Cotner Castaaed? 27 Name And Complete Address Of Funeral Faalrty 27a Funeral Home License Number
NO - COLVIN FUNERAL-HOME;PRINCETON,IN 47670,
27b Signature Of Indiana Funeral Service Licensee - -- `I 27c License Number(Of Licensee) -—
Cause of Death(See Instructions And Examples) , •
28 Part I Enter The Chain Of Events-Diseases,Injuries Or Complications That Directly Caused The Death.Do Not Enter Terminal Events Approximate
Such As Cardiac Arrest,Resoiatory Arrest Or Ventricular Fibrillation Without Showing The Ebology Do Not Abbreviate Enter Only One Cause On Interval Onset
To DeaN
Immediate Cause(Final Disease Or Condition Resulting In Death) A Cancer-METASTATIC LIVER 8 SPINAL CANCER . • .
.Due To(Or As A Consequence Of) - .
Sequentiafy List Conditions,If Any Leading To The Cause Listed On a ___ _
-Line A Enter The Underlying Cause(Disease Or Injury That Initialed Due To(Or As A Consequence Of)
The Events Resulting In Death)Last C
Due To(Or As A Consequence DO
• D
Part B.Enter Other Significant Conditions Conmbudrlg To Death But Not Resulting In The Underlying Cause Given In Part I 29 Was An Autopsy Performed? NO
' 30 Were Autopsy Findings Available To Complete The Cause of Death? No
31 Did Tobacco Use Contribute To Death? 32 If Female I 33 Manner of Death
NATURAL
34 Date of Injury(Month/Day/Year) 35 Time of Injury . 36 Place of Injury(E.G.Decedent's Home,Construction Site,Restaurant,Wooded Areal 371ryury at Work?
.38 Location Of Injury-Sate 38a City Or Town 381d Street 8 Numcer 38c Apt No 38d Zip Code
39 Desmce How Injury Occurred 40 U Transportation Injury Specify
41 Signature Of Person Certifying Cause of Death 42 Certifier(Check Only One)
JOHN GULETZ, M.D.by electronic signature PHYSICIAN
43 Name,Address And Zip Code OI Person Cerifyi g Cause Of Death 44 license Number 45 Date Cer:i.Sed
' July/9/1 991
'46 Additional Funeral Service Provider 47 AKAS
48 Signature Of Local Health Officer 49 For Registrar Only-Date Filed(MonttDay]Year)
. July/9/1991
AMENDMENT TO CERTIFICATE OF DEATH (ENTRY OR ORIGINAL) __
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=' > ORIGINAL DOCU V ENT HAS A MULpCOWDR�BACKGROUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL OF THE ETATEOF WDIANA ON BACK THAT'-
-�.:..WARNING..TURNS.FROM ORANGE TOYELLOwWHEN RUBBED;ORKaiNAL DOCUMENT1.0S HIDDEN VOID ON FRONT THAT APPEARS WHEN PHOTO COPIED-C_ ••;.-i v. - .