Death Certificate - Nelson, Darwin J_6/14/2017 Sg /,tea}, INDIANA STATEID TMENT-OFTIEALTH ,
sVA�> CERTIFICATE OF DEATH a ° L VMi
`., 1 Local No 000052 EDR No 000000564628 Sta. te No 011367 .
'� 1a.Marten Name Qlfetnae) ,s Z Sea 3 TurepDecn 4 Data Dean(MaOVDay
1 Decedent Legal Nme(Fes;Middle Last), •
DARWIN J NELSON - : is -J ,r .."' MALE" 16'-.39-i. ,-` . -0 3/0 312 0 1 7
10.If Deem Occurred In A Hospital: s`
❑Hospice FamEty ❑Daecems Hone ❑Nursing HaiWlatgam Care Facility Q
r 0 Yes 0 N 0 Ur4novtl 0 Iraat'em 0 Emergency Departmert Ouav^ent 0Deed at Anal o Omet(Speay)
G 11. FaoTty Name (It Na Ins:]P dn.Gee Sleet me Number) i
GIBSON GENERAL HOSPITAL c
r. 12.City Or Town,Sate,Art Zq Code 13. CaunyOf Death 1d. Mantel Status At Time Of Deem
0 MamedO Matted.But Separated D Divorced ki
PRINCETON, IN.47670
GIBSON ❑Widowed Nest Maud ❑Unknown I
1
15. Surviving Spouse's Name 15x.Last Name set ae Furst Manage 16.Decedent's Usual OaWtian 11. Kee p 9rsz><tvtndtary 0
ti MARIETTA NELSON WELT REALTOR REAL ESTATE
19. Resbarra-State IBa. County tea City Or Town ,
��`L INDIANA GIBBON PRINCETON n
`'j 18c. Steel Ana Number 1ed. Apt No. 1Be. Zip Code 191. ImceCry Limo?K�1 47670 0 Yes 0 No E
dill 3271 EAST 50 SOUTH
@Tal9 19. Decedent's Edira?on 20. Decedent Of Hispanic Ongn 21. Dec°aef3 Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Parents Name(Fes.MiaJe,Last) 23.Parenrs Name(First MiGla,Last) 23a.Parents Last Name Bebre First Manage
r
DARWIN W NELSON NAOMI NELSON PAVEY
R 2a.Ii-dcn ant's Name 24a.Reasnstip To Decadent 245.hewing Address (Street And Warmer.City.State,Zip Code)
I▪ IMARIETTA NELSON WIFE 3271 EAST 50 SOUTH. PRINCETON, IN 47670
I 25.Pace Of Osposton
_ -25a.Memo°Of Drepostm 250.Place Of Onposiaon(Name Of Cemetery.Crematory,Other Race) 25c.Locaam-Cay,Tam.And Stay
0 Basal 0 Cremation 0 Damson 0 Entombment
0 Removal From State
D me(Spear): WALNUT HILL CEMETERY FORT BRANCH, IN
• 25.Was Coroner Ceetemed? 22- Name And Canplete Address 05 Funeral Feotty 2 7a. Funeral Herne license Number.
❑yes 0 No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON,IN 47670 FH83005671
220. Signature Of Inaara Etnenl Service Licensee: 27c. license Nancer t (Of Licensee)'.
JOHN W WELLS. BY ELECTRONIC SIGNATURE I FD01009940
Cause Of Death (See Instructions And Examples) Approximate
22.Part L Enter The Crain.Of Events -Diseases,Lryunes,Or Campecaiorts-That DieCJy Causec The Dealt Do Not Etter Terminal Events Interval: Onset
Sue,As Cardiac Arrest,Respiratory krest Or VemtaWlar Fibrillation W:tsM Showing The Etiology.Do Not Abbreviate.Etter Only One Cause On To Death
A Line. Add Adaeanal Ludes If Necessary.
•
Immediate Cause(Final Disease Or Condition Resulting In Death) A. LIVER METASTATIC CHOLANGIOCARCINOMA 6 MTHS
• o..e to 4.rre.o•-.
Sequentially List Condrlms, H Any.Leading To The Cause Listed On B-
a..m...:e...aA a,
O The Ev Enter tResulting Underhill;n D )Lase(Disease Or Injury Tnat Irria:ed
eG,t1i Tne Events ResW:4g L-.Deal'.J last C.
OW into...Ce.eaaiv M
_J D- e`6
Part II.Enter OTer$[n:.::arc Conti tons Cpnsa.'nc to Dear:But Not Read�y.� Cause Given In Pant 29. Was An Autopsy Performed? D Yes El No
TYPE II DIABETES MELLITUS,STAGE III CHRONIC RENAL DISEASE, O. .R RtgTE 30.Were Arsxsv`idmg Avatade To Complete the Cane f Dead? O Yea 0 No f
HYPERTENSION 1 z
q.,, 31. Diu Tobacco Use CmsuU.e To Dear? 32. If Female: 33.Mama p Desk'.
N
0 mnp.nve..er urn: 0.+.a.+u n,e a omit. ...tort out n.w+ abrna>., 0 Natural 0 Hone 0 Accident 0 Pettey lmesyrsn
P9DYes ❑Probably 0 No 0 unl,to..n D,„,m>.rtwmwe°JUIt- momma ❑a,..-,em.eray..e.,r,,, ❑5rioae0 Gated No Be Determned
• i3.Date Of Iv ry(N.m YOry.Yeag 5 T eOfIryry l 1 � eO INa (E.G.Decedents Hone.Construction Ste.Restaurant 1booed Area) rya AtW ?
DYes D No
C38. loosen 03 Witty.State 38a City OrTwm 3BD 6 N r der 38 API No 38o a Code
19 GIgcON COUNTY AUDITOR do. ItTantpaaamlrmay 5pec�y
39. Desmx How lryury Om+rec I Do....00m.•v D•.�e..'p>.�.+• Om-nand
a;. Signature,01 Pena.Ce n g Cause Of Dean 42.Gf.Sa (Check Only One)
p. WILLIAM R.WELLS. BY ELECTRONIC SIGNATURE I ®Cert irq Ptysidan 0 Coroner 0 HeSttOser
AI Name,Address And to Code Of Person Certfri5 Cause Of Death. 44 license Natter 45.Dab Ce Sed
•
hi
WILLIAM R.WELLS ,510 NORTH MAIN STREET, PRINCETON, IN 47670 01017790A .03/07/2017
di. A'W S'
a6- Atonal Furtna Service Ppvger.
48. Sytamrte or Local Health pacer . a3. For Registrar Orly -Dab Fled(MaNDayll'eay:
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE : -0 MAR 07 2017
YI .
a°etais aeo oo� 443 - 0
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• '.Sts:eFOnh 53395 ATTENTION ESTATE The Social Seruny#is beig requested by this state agency in onderto pursue respons Wray.Diubsure rs oNntary and there wit:be no penalty.fa Ye:usel
ORIGINAL'DOCUMENT HAS A MULTICOLORED BACKGROUaO ON SPECIAL WHILE SECURITYPAOCR AND THE GREAT RFM OF THE STATE OFTN•DLA.AON SACI'T)AT'"` :r
-- .WA R N I N G m .TU}RRNN.SFROM ORANGE-TOYELLOWWHELA RUBBED:ORIGINALDOCUMELAT HAS HIDDEN VOID ON FRONT THAT.APPEARS WHEN PHOTO COPIED
•L l lL =L' STATE OF INDIANA v v'�1'