Death Certificate - Haley, Larry_4/17/2017 !.Sl:"JYbYU-^JL3l..&t,' •/L.14 JY.eYL.V'Jf.lt-.::Y.IVL°JL -444 1C.�9L'-YJd1=.:�4..tla :. .'.W[: . ._1l'.�y`
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< CERTIFICATE.OF DEATH a 1( cIS
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Local No;000078 i a EDR No 000000569960-: : s/ Nc 016532 �1'(%�
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LARRY T HALEY. . : : °" - _ - E • < ^MALE ,&02:00 PM .;04/01!2017
, 1011 Death OasTSln A Hospital '" , 7,104. If Death Occurred Somewhere Other TIm1 AHOepeal"'"I '-•r r r •
x .•� --C - Tie ❑HOfpa Far%y ®Deada[sHVro ❑NUavg Han.atlm1y rive' ty � ' .••
❑Tel®;NO��lkdw*n ❑Irct ra 0 Ent9 rrY OeL StneN aymaY 0-1/419;4442 on Nrivtl';0Oew(Spicy'); , "
II:Fealty Name(II Not Instlaat Give Snot aM Mate); f
200 SOUTH VINE STREET ': - - - i
12'Day Or Twn&s Are Zip Ca: 11 Carty of Dean '14:MaNM Status Nits a Dean F -7 '
: HAUIISTADT'IN,47639 . . - GIBSON .,-•• it Nsecwie . la Ner.rMiniid.,O'U*r.n.:
15.Saveing Spow'e Nana 1Se.Lest Name Baba Fist Manage . 16.Decedents Uaml Ompmin 17:1&e a B rtn1Si y N
) SHIRLEY HALEY. . . . BREIVOGEL . OWNER r . _ . . ` RESTAURANT
•m.Rnseem-5144, . ; - 18a Larry , •1W.Cry Or Tom .. ' X S b'
INDIANA . - GIBSON HAUBSTADT - .. stir -
z 18c So-eelAN NaMer - . - tad.Apt Ha's, : lac I9 Cods 381-•331349:7 hit?
't i ' - ®.Yes.(]No•• 200 SOUTH VINE STREET =. ; I. _ : 47639. - .
19.•Decade#a Earaton s, '• .' . 20.Derr eft Htypa4c Orlo 21. Deciders Rao r:' ' t I
' HIGH SCHOOL.GRADUATE OR GED"_A
3h COMPLETED'"- ''°` NOTHISPANIC
22 Genets Wane(FM Mtlfe,tarp - . 21.Paste Nam(Fat Midme,lmp t 23a Pups last Name+Barbra Fte Menage
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THOMAS HALEY . . : . . - EDNA HALEY: t ' HIRSCH. !
:24 Wrovfs Name - 24a RNa4vutip To Deader 24a.MaP,g MQSSS(sNSM AM Melba Cdy T�(�l >.
SHIRLEY HALEY WIFE °' PO-BOX 410, HAUBSTADT.IN 7 3, ` .. R' / .I .,. - :.
Rawer.Miern - •'I .
25a Method a DBposaal . 25C Rae a Dispovan(Nero aCwnemy.Grammy,Oder Ram) "25c Ireton City.Tam,Are Sub•5 ) x? ` ` `
0 CIO ,o Gratin o Earl m: • r A1D,R 172011.
o Dew(Speitm STS PETER AND PAUL CEMETERY ' HAUBSTADT,IN
28 Ms Carer Caga n 27. Nene Anil Carpets Aderees Of Fees Faulty .� [ •:•� 4.r Pa Hans llmaahAarder
0 Y'e ®N° . '• WADE FUNERAL HOME INC,.119 S.VINE STREET, HAUBSTADT,IN�g77f.Q�pigN " R�''{QJ 90 '•
270.Scrum a Incline Mara Series theme: :. 2c ^se+°e UI'"
ALAN J.WADE;BY:ELECTRONIC'SIGNATURE . .IFD01017080s - -' i ? \ - - ,
'. ..h` -...-. ;: came a Deal Ism batTUCUau ArM Eaa'w ) •., v .� _ " 'Appra6lele_
ti 28.Pat L Ewer The Oren a Events'=Diseases.thither.Or Canpbmtiorts-That Died'Cawed The Death.Do Not Etta Termiel Evans. "'IV, Mrea'at Greet",.
Such As Cant =meth;Respiatay Arrest,Or Vertriara Matron WAhat Stowing The Etiology.Do Na Abbreviate.Enter Oriy One Cure On ''. ...;i�;, To DeC 1 r...:, i
A Lie. Add Additional Liles U Necessary. x
i . - 10 MONTHS
ha'reo¢r Cause(Fi1al Oeeasa a.Galdain Resit();In Death) A METASTATIC CARCINOMA WITH ABDOMINAL AND LIVER METASTASES
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340;319;29Y'Era rah Ct+edve..D IVs.Leaddge, The Case Listed On a rmm hr _ •
'TieEv Era This ng In Deat Care fur', '. : That 4atar'
The Evers Resulting N Death)lag C.
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pal IL EAer OOerESO --e a, Isattbtb Deus But Na Radtng In The UMelyvq Cane Given In Peal 29.NbMAtmpsy Peiomedl- - -:.,D Yes ®Nd"'•i ?
3°.Aare& . FitgAVaia°MTO COropMl•IT.?c8.°1•9'9°4-74 .Ayes OrN°`i. •
31 Did Tobacco Use Catete To Death t. " 32. UFeale: 33.:Marla O!DeaiM1 ` , :4;-7", \3 4.4 5- :.
. - 0 44.14411•,M1e tea 0 wets Mi"cN„w 0 wweG.(mmantry a cv:eon ®Nand 0 rialto, ,0 AGdded 0 Pendvq losstgebm •
Ovens P PmIt ONO.®tlnpelwr i •0 wwvt"er wveaom T, ninSt.o.e, 0 reuo.:ewy.svm IT.yr r 0 Shrine O Card Na Be OaartNnsd . . . c _<
31:Dee a N}ry(MaaYDa?YSef) • 35.The Dl hear . 36. Rea hen(EG..Decedent's HOne.Constrain Site,Resrra&Wooded Aro) i 37 [ritzy NNbrt?
. 1:' 1. Ores ONo
36.lnrfama err)'-Sea 38a City a Two "380. SbMta Neaten; 3M AtNO :'- i Lp COde 7i
at Deote MTwtOry Owned ' _ m.Uiretscombar ON41839cur : I
41.Slgatre..a Pena Gestfip Caen a Death ' 42 Caches(CMdr arJ One) - '~ '
` MAQBOOLAHMED,BY.ELECTRONIC SIGNATURE - - ' -123 Gthin0FnICS" 4 OCaonaes` flneeoace-
', 43.Name.Ardesa And Z.fade a Perim Carding CauseaOeath - 44.Llama Naree/ i 45. Cass Gear s -
MAQBOOL AHMED?,421 CHESTNUT ST,EVANSVILLE,IN 47713 • , 01054343A-.f - :04/03/2017
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i it BRUCE BRINK JR VIA'ELECTRONIC SIGNATURE - .- - -. •. ..,. - : ° - : '1.%APR 03 2017
+ . . , t AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) x I. c <
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