Death Certificate - Harper Jr, Walter L_11/10/2016 r,,." �Nlr ll til /j 111-�i 1NDIANA�STATE DEP TyMENT�OFIHEACTH +� - __,.•I� ;; S� c 9ER`fIFICATE�OF�DEATfI
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,mac _'- 000431.. . 00000054,0233 . 'state'No 051711 C
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WALTER:L HARPER J �v" F`e`e :.�Y4r .'\.>,:. ;:-.• �` +,r7S 3MALE '07:02 AM 10/28/2016
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9'Eva in U S Armed Forces? f -10 II Dean Cmnepn ANmpeal'. ;;;v //i r// tl 102'if Death Dmmd SaaMa+e Other Than A Hospital
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1 GENTLECARE`OE:VINCENNES ? - .
d^12'_City or TOwn•SMa AM Zy20de - .t:f. 13 Cwfty Dl Daattl 14. Marital Status At Una Of 191211
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'j VINCENNES IN;.47591.. - " : r,, KNOX .s , OAdowed O Ness Maned 0 Unknown
a ,`SUVutg 3 h N 152 last Name Relate Frst Manage _ 18'Deuaays Usri Oaspxan 17. Kvtl a Bus ess/niust y
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'• BRENDA.HARPER . EVANS=. RECEIVING MANAGER HOSPITAL
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INDIANA . ..:-' a .'-'•
G+IBSON ``, ~c` , PRINCETON r-`''
1fN. Apt Ng. 1Be.Zip COde t& Inside Caymz7 8a„ tl e .
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301 HARDING AVENUE \ 47670 0 Yes 0 No
1 I DecedmY L-dnaam:f� - ;:v 20 Decedent Of H;spavc agi 21 Dea.Nm[ R
i HIGH.SCHOOL GRADUATE OR GED ' . tr cam` ' `; -a ` '
t, COMPLETEDr,:% >y� NOT:HISPANIC r White.. 1 '
6 22'Pamir N (Ens.Mdde mew, \I 23 PaaVS Name(FVSL`Mimle'lasD' 23a.Parents Last Name Before Fist Marriage
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- I WALTER HARPER SR r: r r - JOSEPHINE HARPERS TWITTY
1'tea reri 's Name \ 24a Rpam4tp T DecedM 2191'Maiq Address(Sae:And Nunber.Coy:Slate,Zq('pipj T T
I.1.ti4:btut i▪ �Z.\?_ latsoc.'' w < C 2491 M -.gA&ass'!,(Street ., ,pp-I,M,•9.r■gp N'
BRENDA HARPER WIFE'' ' " i. -a Il 301;HARDING AVENUE?PRINCETO 6
m t v, \ef-\�_r. , , si y ..C.2s -R.-Df OUposbon`
252.Means,Of.Oyspo :1T. 250.Place CPI Diwosam(Name?Cemetery,Crerna'ay'OOIa Place) 25c:Loatm.City To.m.And State
a ID aaml 0 Ciemaran O Damian 0 Eaamman f::. } .115 '•Rey te:; --- >;< NOV 1 0 2016
D D`aee.(Speoty .4."-. - MEMORIAL'PARK CEMETERY 1,-i, -`k' VINCENNES, IN
I 6 2s Was Coroner Cataoedl . 27. Name And Calpefe Address Of Funeral Faaary !E -!. \ n -". - \ t - 272. F ... licerae NUnbdr
!k.tsA..\• ....._L < GOODWIN FAMILY FUNERAL•HOMECINC 524BROADWAY,VINCENNES IN 47591 �j icjl @a•• _1_ -
5 DAVID GOODWIN B'EEC ONIC:SIGNA URE ,r ' . --; r�,� U� - `. FD08600424 •••a•a
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w vE��se C >.. 1 \ tries OrC '•r.::Cayae recsty m(S n`traidns And Ezampesl_.. Aterrat On
I i 28 PI;I-ardor The Clem Of Events - a pr V t,cs s,Or fato-i Atua Thal r Caused The of A Do Nte Ernte Orinnal Cause Toavat Onset
A Li-let-mid As Cardiac AfTel Lea If Necessaryt,Q'Ventriaflar FmbnBalpn rAthola SfZ'''.... .The Ecology'Do Not Ahbrevete. ." Orly Ore Cate On To Death
1 :r-. '-jddtlsr lsl- Qy eassary. - s \ ,`.`• ''
m . i nknn date Cause(Fnal Disease Or_-atliion Resulting In Death) - A CARDIOPULMONARY FAILURE BRIEF
i $y fN- i < _ /`tl_,:c\`AC :�N. o. .o, a,_w.o a
rYw i ,-,B CORONARY ARTERY DISEAS to - LONGSTANDING
1 SineArEnI rate Unduly If Ain, (Diseae meCate Lsted On •
%L!eEv EnrrTMUgb,DS )Cae(-¢_ease Q'bpay That legated ..: Im j`._ rf-.l, =ill .la `°�"-, m
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i Pat II:_Eger DervS mCnma Cafl .ceiq gb Qr�O al Na Resaitng n The Ca G 41 Pettl ( /I 29 Was An AUaasy Performed?
/+ IC v D Yes 0 No
s.. HYPERTENSION STAGE 5 CHRONIC KIDNEY DISEASE,ATRIAL FIBRILLATION OIABLTES MELLITUS CHRONIC*' 30 Were Autopsy Fr n°Available To Compete The Cause Of Death?
aF LUNG DISEASE UseCor tt ToD -`?-. \-., -::m' e \-l \Y*`; \1F\�\-.R - \ ID Yes 0 No
) 311041 TcOaan Use Contribute To Dean?• 32. If Female.,.!}ii t4-- _lLgl - ..lT� 33. Mature Of Dean:
S' LI I/: 'tF -.2%.,' c 0,qq,, '.0 YY 1 0 ca r 'a:uia Dan 0 Naaaal 0 Haniode 0 Acadea 0 Pending investgawn
0 Yes`0 Prcbaaly 0 No.0 Unknown " -XC \ is\ a . -:343-3-.33:3-:13.‘- -� ` C,.Yr.: \e".'.
?,;} .�'.1 .a`"i r.lt> ,v 0 tq•e•'A bne-wi oar, rdB _ ,..1:1 on.", A`P"' :-- O Swale 0 Could Not Be Determined
+` 3a Dale Of,May(MatDayttm)- • 35 Tine DI ritzy '%,Place Of aquy(EG Docede,t I-brie:Cantruam Ste,ReslatsaLL V d Area) 37. Ir tsy At VAmk?
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38.'La�v.Of`r(tzy Stag 392 City OrTavn- ; +3891 'SiestA NUnber 38c. Apt No. 38d.Zip Code
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PMeean O Coroner O Hearn
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63.Mane Address And Zit Gate p Pusan Candyap Cane Of Deem - - era. Lame Noma a5. Dam Gems,
t 3 I. CHAR ES CLARK HEDDE,;5207TH STREET VINCENNES IIN_47591>- '
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lei Ifn3IWT::- .:, 5.(�1�%"� ;- It:l;?;AMENDMENT;TO.CERTIFICATE OF,DEATH(ENTRY OR ORIGINAL) ` ,
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t %Stale FO031533A5 LATTENiION ESTATE;.111e SooakSeaidy R a ba g iesuASted byte state agent'n o*r fo P�ii reapwsmd¢Y,i Oarbvna is vokslay and there re be m perery for refusal.
/�. sCORIGINAL DOCUMENT IIASA MULTICOLORED BACKGROUND ON SBEC(AL WHITESECURTTYPAPER AND-THE-GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT
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