Death Certificate - Ice, James W_12/5/2016 ,,Ae4 , ., INDIANA STATE-DE RTMENT OF'HEALTHry' ' Lie" ry =t.4' ' f • `'•
' 10ERTIFICATE OF DEATH' ' r+; l `ti
\�♦ ; r Local No 000446 EDR No 000000542608>-' ::-state No'053466&I'I _ : L �..-t;
I.Decedents Legal Name(Forst Made,Last) _ o1a Maf19nName Oljemae) i;c aSeer 3TineODeath '4. DaleOf DelhlMarriDayrcear) 1
/ 3 A _ i. /, _ S.i / v•
JAMES WESLEY ICE - :. MALE ' 0641 PM -a 4., I '',11/12/2016; ,
Hospil - '.,
pottinc FaWy -.�DeGmYa Hare. ONUavg Haatllapbm Can rya Yy•0 Ve5 13 No ❑UldalOwn ®IrpaSal❑Emergency Department&+Casa& ❑ .. oArMl• Q Ogre(SpaplY) ,
11. Fadey Name(If NN lsenden,Give Street and Nbnbet) - -
GOOD SAMARITAN HOSPITAL - - j -
12-City Or Tow.Stale,AM/g Code 13:Comfy 01 Dot,; - 14.Marital Steer AlT,e IX Dear
.
p Mandel❑Mane&Butsessamo O()bon??? '
VINCENNES, IN,47591 NOX " ®_`,e&aead.
❑-Neva MZmeO:,❑tMlsndw&
15. Su vi g Spade's Name 154 last Name Before Fit Manage' 16; Decedents Usual Occupant.' - :17,:Kind Of Buren/Mau, ....,
, ` EMGE PACKING AND
PACKER AND FARMING i • FARMING t
10.Readerce-Sate 18a. Coney 180.Coy OTaan _ i
INDIANA GIBSON HAZLETON - 'i `C-
18c.Street And Minter - ,18E APL Na \1St Tg CMe_•'1 �`1St 4a0e CfyIitS
5101 EAST 1075 NORTH • ' . 47640 D Yes ®`r D Jr.
19. Decedents Edivbon 20. Decedent a Hispanic Origin ' 2t. DeGdaruraRae t: I A
'r
T a'
8TH GRADE OR LESS NOT HISPANIC •• , . ' .. White.'- . . . .
22-Paw a t) Mka9
Parents Nara(Fiat Me,Lo '23.Prate Nene(First a.L - 23a -.-
aate Ito Nave Before Fiat Marriage
JOHN WESLEY ICE - EVAMAE ICE • -: . POTTS.
24.Informers Nara 24a Rlabosnp TO 24b.Main❑Address.($IM And ehnubv,City.Stale,Zw Code/. .`
RONALD ALAN ICE SON 10797 NORTH SALEM LANE ROAD,:HAZLETON,.IN 47640 : - -
25.PaGaOepeai5o
?Sac Meted ai tan 150.Fla®a DSpcstnKane Of Cemetery,Cre�my,OMrP e) 25c Laaan-COY.TwnAM Sorb. I e
123 Burial D Cremation
❑Donation❑Entombment ,
p Removal Fran State . •' -
❑Dauer(swam: - MOUNT OLYMPUS,-IN ' -
21.Was Came Contacted? 27. Name And Cowles Address Of Fuuaal Fealty ; 27a Fuleal Hans Imnse NInNa
0 Yes 10 No
COLVIN FUNERAL HOME INC,425 N MAIN:ST.,:PRINCETON, IN-47670: : FH83005671 '. .
27h Swabia Of Indiana Fingal SMMce Licensee: ',,• /;
,RICHARD DEAN HICKROD, BY ELECTRONIC SIGNATURE - - FD01012153 t. .- y
-- Cause a Deatn'.ISee Iatuction.And Examples) '...' Approauipte
28.Pan I.Elver The Chain Of Events -Diseases,%retries,Or Compleatva-That D.entty Caused The Death.Do Not Enter Terminal Everts- ' I - ' bvevat Offset')
Sin As Cardiac Arrest,Respiratory AnesL Or Ventricular Fibrillation VNhad Showing The Etiology.,Do Not Abbreriae Enter Orly One Cane On - -To Death
A Line.Add Additional Item d Necessary. j .
Immediate Case(Foal Disease Or Candum Re&A WITH .ltrg in Dean) A. PNEUMONIA WI SEPSIS - - - : 5 DAYS
fit
e
Sequentially List Dondaiais, If Any,Leading To The Caine Listed On
B. LEFT LUNG MASS PRESUMED MALIGNANT'- •r-.a•/ -
o.eRr.wmgtr :11
Lite A. Elver The Umeryrg Case(Disease Or Ijuy That Iodised
The Events Resulting In Death)Last C. CORONARY HEART DISEASE t - I . •LENGTHY 3
m.wln : .-
. D. ATRIAL FIBRILLATION. -. . .. . , , - ` A. °: .. . . l LENGTHY: p
Pan II.Error Other aGDOODL.Q als CaSt$I 1O mDeam 4l Na ReSlalg In The UMayirg Cause Gina)In Past` - 29.V43MANepsy Pertained?::
.. •..p Yes ®.Npa 1 -,(
.30.V,We At5o yFfll g Avaiaee TO CdrnlleeT eCW OtDeaSl? '
MULTISYSTEM ORGAN FAILURE
31.Dd Tobacco Use CMMIEe To Death? 32. If Femde: 33 MerarerOfDeln -
D rear p Probate>O No ®IMImPan D we i�p r; ❑- rvrrsre:a pw:.a aP o..ml ®Normal O Nortaode ❑into.n,❑Perabq l`mesEpalmn -
❑w jf{�'m, pur�snsv er::Re rvv p$1tAe p Call Not Be PabrtnvM} ,E
34,Deb Of InixY(Matlpy%Sa) 35.Tine trail n' -Of nun(E.G..Decedent's Home Cauindlon Sete Restafat Wooded Ann) ' I37 Whey Al MiA?. S
C.,O Yes.:; ❑No j
38.Location Oflr{My-Sbb 38a Lily OrTO.a,DEr 38b. StraaaNUnber \ 3Bc ApLNO '38d.�Cade
l� .
39-Desodie How lam'Ommed • - - ,- a. Il TraapaVm lady M- -
�p� : pmi..woa p..�ve pnP+.M Odmersra+ 'red
41.Sigasrs,Of Person CMlyig Case CC Dealt /`^"" �R - 4
GERRY M. HIPPENSTEEL. BY ELECT (�y1�ISY AUDI\ 42.Cetera.(Cheaany ore)
R9f8S0�+IrlFii tllfC ®uitiMno PM�al. .0 Coroner : p.Heara,orscer
43.Mn,Address AM/geode Of Pwaon CeUyeg Came a Death: - - _ M lawns&Numbs I45 tin l:eCiea
•GERRY M. HIPPENSTEEL ,406 NORTH FIRST STREET,VINCENNES IN 47591 - --, ' 01025674A `• - .i171/15%2016---.
46.Addpa'S Funeral Sawa Provider: . 47 AYns ....(' - ✓- ,a
48. $ag,et e of I 1 Nears 014r - T - ea For Replan Only Data Fen MaasioerrY•at•RALPH'JACQMAIN,VIA ELECTRONIC SIGNATURE`_ , _ - •_ NOV.15+2016( 'a t - i- E
- - AMENDMENTTOCERTIFlCATE OF DEATH(ENTRY OROWG1NAL) ;,-ya - -
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cx '\\'i ` ' c s i '`t;< <. "-,. �yt 4� iii.
Stet Form 53395 ATTENTION ESTATE The Social Securest S is being(equated oj3Ss stale agency n to praiue respoinbey ,,astlowe a vomday R!1S1&I re rm be in penalty for Mosel% i 24.1
,
WAR N I NG�ORIGINAL DOCUMEM HAS A MULTICOLORED BAG(GROUaD ON SFECNL SECUfUTYPAPER'ANDTlEGREAT SEAL OF THE STATE QF'IND1ALfA ON B4p�Ti�AT°'` :
. TURNS FROM ORANGE A YELLOW COHORrtuat :ORIGINAL 5s e gti IIA.4 HIDDEN-T ID'ON FRONT THAT EF WIFTHE 0T0 ere'N6 - 1
FILED
DEC 5 2016
26- oa - / 7 - Co a - 000 a59 0/7
- oa -` 7 coo acrd 0.5 1a/ 7 GIBSON COUNTY AUDITOR
60 Gal 06a Coo 355 6/7
a oa I7 o63 coo l/ 9 01 -7