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Death Certificate - Wise, Fred_7/7/2017
A c., ,-..„ Cu dall-P---.173L-C. ..eLf...CLP.... ../.4._---,. s.t.f..0`...---121, ----- 3.../.. - .--„,..„-CL__.-. .%... ./ a _ S I ' • C..---,-v.cr*-7-7.•;: .----();..(1e--7.ar.---a(Lo-r,----7r.--,- .--,-).; 1 .3" _ 1/4:‘,..„..--:„..-,., -„,,,,,:•„„,-..c.-.„,-;‘,-.1/4 .w.2..tc• •-•••:: .?„,- _‘7,-,Vit.Par-ere--‘7,-,e-''-' ;s.g.`e-sas-',-"Ne----1,•.--,-"'-‘, rr; ii •;;;ivit-.;;',,N.CN,;.;d\- -1)v'ct\---\...; %',:prW,-t.'d--;-;.,I 6-2 -R*707.7.4%....„-z- . i;t--t"-,C, _..;2..1,1,1DIANASIT4TEIP,El?ARTMENT1105,PEALTH, '1c. {',..5acitic-- - r-.' ''. 4 11),;,n. ,,rk\In EitViflat Elora/it-1 c __ , k 1 O'iit64-.V " . -;- q_jc -, ../ . 4- \...,- ..r-5---..FAle/0:' , 4>_,-C.'cet\ik■ = t. ,.<.... :, :--....... , Le-"'`i.„._ \Lc,'d,-.....„ ass-..--,.., . "--''. ....7 I'-'"I'l,....'!":'-'"•--HIC''''''' `Th.'".."----d13 ULt --"W .1..--. 1.-(;•k7''''' r-..‘' -.< :Loda I Nez0001 A' _ ..c.m::.S2,EDR:Nb;00000057,84180. ...,-,,, ,,state N 0:025390•- .,71:-,-;,... 4 _ ... _,,, y--ii li:DecciletsLegat Name„.(Fea.Middle:Last)r.111'11 il mi." „,,V,tp,1 r cr-- ---ins la.,Maiden Name;Sy remade) t A Perc.deff. Tcf r t.,2-Sex,0'‘f1C:tr.DineOf Deeds:,1 4,Date 01 Death(Manta/Day/Year)p 'er. ..„(t' 'It .74,;,11,1W ;57; ' , 1,IL%;,,k,11 ,C'T.,,,;<SIII/li'cr,fir;;;419' 'ii"W;-'''.I' L; 'till,4,"::Cr?,ZIN\Ci",,,,I1 • k\ I Q-...ck ekEDvvist,. • ..::-•'5,4 V, . 1..1,1,,s.„`r1-...cA '‘.'..c.-k'zzIC":.\;k: !..! - .*,-1‘,II..r., "1 :..7-;,- ,-,2" ..:'i MALE"-A 4(1:09:35 All: ..,P1,6‹.05/17/2017..-,a-N.114 I 1 • ,z... ti -81 i v'1 ,1‘4005z; wItemil:9Y!:, iii. i'cf. 11:9;:tEs:‘II II C,(4%-; 01/02/1936..'111ii.ii ..PRINGE I OWIN tthc--.."-.4-",---#1■111,1110::-__.7 t.`?..■11 9Evet in 0 S Armed Forces? ii• 117iir Death occurved in A Hospitai:P1. 11111 :,..-% "7-...,11'1I-%;A.; 10a;:t Death Ctcurred Soenen.tere Other Than A Hosieta11K,:er ;s-J-iIIIIM.,%-5,1;/ ,341-ZW:-/- !"'''r:7>N.',"-k--- 2-: -S:;:e.Nt ;-TN I, Yee'0 do 0 tini..1,..;n'l 0 lalia..;ene.,0 i'margency Deiiartment Otticatierrila Dead P'er'Arrit.al ,oraei.""--"-c,,,_''' c---'rl T`t■V"'"ec,'Ir_I-et;<,"‘",-":51-1..."'Ics''A,21:c""i tic "--C\I rr''‘..,S. ,I. p.4 Ali •, e: •.;i • --7"; i r it C%-id2iuilill ti c./..i11%1t It it ii-(7.--r./lule. .... r4...,.._.., „,h7,711u),--4" . .......,- .. ..A.CIA ., CIft ,.: 7:ad 1:Faulty Narne(If Net Instate"Give Street and temnber),..%„11111,Ir,,irr •1 14 p .....•s 's p p,c-c.-c--.. ,If f 11,11c,'' I' ' l sr" I.I 1 "rt■ 1 i1 it 11G; r"" 1101k k;trCQr'''''Z...- \\rr- t'i- tm•4 GOOD SAMARITAN HOSPITAL -' kril•ir<,'J 1'c'T-2.--/1/4-''.1'1V --"I're.----"-,,..!41 V - -,' 1 ---"'" " • "<- ----k-,,1'1 c.' --144 ',..‘: 11 .....--... i .....- I --......--&-,(41.-4.,,.. ..i ......--.-_- , ...<4...'',',.-- t . -,... , ....-._,..^... 1,..,.- --...- . - N., • I '6 s: 12'City Or Tcwp State And Zrp Cede -■ws,..----ri 13,c0,aaj of Death,: e t-■-,--,,,,-..-9...- -tcso it MaMal States At lane CI(Nadi e 'Na lc- I ...,...--( •• ,--,,,,,,,,,- -..•-•,,,,,-0,,-..-31, -; . ,4‘4:•--__ ;4-2 i --•,-,;:.--,....s. , --"--->((-•S',•-•,..-s-- r, .4.: N, /1;-.‘..',,'''-.)-,c-F f.-- se"-7'11 7.Wr-w-'74:0":/-7"taWcit% ' ,3''a'n - I -:-.---111'\ ,= r4.,11% L.:4----cr"-!il','f, --.--e---.4"'.;: ■ .'.1"" 'I IL illy,-5,---it it c ,..-- -.-ii A '.,;..--„,-,.r,..1,-,...<, f2\IVtil r,.4-,-.0 yprfied0'marbeS„,.th.r.§..!Paraltd 0•Pm1rred VINCENNES;IN 47591 e, ' it-..-,-71 ,t,iii,c-cd%„it a is i‘ A.-tilt it IIIKC-i-c.i121 KNOX,. ., -;,.:-.1--1‘ 1.; P, r', 15t.Streerg SpoNse's Name!' - I "I-,--,.;,--..."-*. ,,I ,„<t . r1 y.5..a:'Last11arne Be FirstMarnageK -.C2 ";;;-tt;;'16. Deeepents Usual OcapaPan St':Illy;r-.‘esod,Of BustresaMdestrye4t-ce '• '';';`,.., c-.7-‘2`;"•'''''- ';--': '';--''';' `-1'.'--._->";11:z;;;. -:-->dt_tr,_'(;',,,',„..'--;; Lc-c.,...„ 7-k.,.:. 111cW.Ii.'') .„, „--,"-AA' AA: --„,->d,I.-.'% .'%"-C-„,'"Il.-,"‘„, 'SI" A.Its,s.„ '`'N....,LI 's,..., -,,I%13,6_, I rd6?..d.-#0-i- '' . ' - s, '--.:,.`s`,..-t-, '''-:".;.."-.t.c.?(1,,1.--k:;.;o3'2_,.. I"'..., • •"'", .>>2" ,11-F.-...---.....V-5---" ' ,- -.-PiCsk-.. ......."?...isi"-.;......„,, .7..,....ss 10,, .... .. ' ".; - '.-,2;..."<",,,,-...,:t.1 - C.--%-ss.,-1,,{1!1,; :‘,. 1. '. :::, ■2:11111;..no.92..s.??.s.co rre,--1,pi't''.! TOOLAND,DIEIMAKER -,-,. .4I MANUEACTURINGSB',P,-;. 1 ti „ I ▪ . ,,..-r. „„•,...„., ,. „.2-,- 0,, . = , 1, 1 da...kl, - •,,,m, 1' i cCie 4: ] ; c%- ''14\II ;"; .,-% 1 11 ..-41\,t k/1)ItI\ ,,,ri-;‘ .,! . ..., . :11k1 .-. . :,<.--- ,,.,,... .,".---•,--1••;t:th.---i--••:.•-•:‘,'“ ,-,,.1.--•:::: ,-..4.•••;•: ..„•••Y ._6_ t - • - i- .•••••-•_ INDIANA ,'-- .- ,- N --".I .. ' ,-,,,..<, ' GIBSON Z- ..„..4.-:.,-,:,.'",.-„,'--;.:,"-...,i HAZLETON'-'---,:>-,., ..?-,- -‘,1:1,e,',-.,-..--.--.'s..-,-",.-----.... _ .1-:,:-::.-...'t•--., ...‘,.; '-..:-. 2_1 SseetAJtNwnDer ' .- WIP. -2c--1; --'[..."--"Illicii<&•isl'.t ''' ":., t 6 /. '''. • '''''' 1 ,V 0' "r:..--"<:4<" 1,(tyin-:„-.-----,-1',f ,..i- If., i >:, .,.c., „---., - ,... , „,, , .;,,, -1 - -.7...„ .‘c,,..1,c--1.". itt 1.,V4 ..7 1,--;.--A--";. 1,''s 4, ''',.. 1•* -!, ' • : t".5. ' ' .", :•,‘‘'kltr.cf:ti411,:i''' A.,,l-0 1' lallor.rr-f. li„!!. 708EPT P,I5 -g-- )1 ..:1.:), l'I.i:K-t:1thiireAill ii,------- -N.z!F.11V---"---YS )..'‘, ',....-i',.•=,!-I4-,-.4.1..)-;..-X:4-,..: 1. ...:1-<:,-3-4,.. ,,-.57 -‹<J.1 :47640N-Tqw ,"-i.:--.CZ.:.1i1,,:"1/4„.`: tiii,-",,-19- Decedent's Educed:es , '' -''kJ,-..4‘,".dd.„.`dp_I-do 20;:Decedent Of Hispanic Ongcr;O:----L,.„Ck_---,'' I .21:'...11ecepenrs Race 'vez,-",-te,'AN'e, ,, '-‘:?;'" 5; 17...„ -;;...- ,.. ...,.„`:1 is HIGHSCHOOL bRADUATE OR GEllfc-e, 5-11;r.%s:.:"c"I -<':"i'-',..? i'n-7.',-,....--.* =4- "?'"1- \ -T.".."--' " "s,'-II*- '' ,......:."- .‘"1:;-,-- ...2...:X:1. ' ■'." 1 ,.., J COMPLETED -. • I ..:9'..,'.112.,.' -.., NOT.HISPANICI152., Dr.".".r.s.MI VVhite.,' ',' :,--' :. .Th ..; '.' ,...4.24 ■il ri rirc",':".A:2 A ti,1,1AP'r-A-P'tin!,. [4•:22:Parents Name(Fest lamate.Lest)I ,--..„, : . " f-----Li; , f i "kJ.): 5%--„,-,c,--AAJI r 1 '23 parents Name First,Middle Last), .'",-..., I . "`,,Cl' {'M.73arParenrs last Name Before First Marnage' i ' 't C;":''' 4'2'-;";::; '?T.:.'"• ;;;;; C. , ";,-„;>i--- F -Tht;II"; ' '""%:-.-N'' c";\;<"-N,,,•`;1/4- (1":'I;-""\-`;'''‘'; I',', ' ;-;, c';'''''*;;.; ' - '''`'•-e-I.; -"""; iCi k1'bN,•.,''''T- ' • .s 'I' d, .L--.'I L-A'fr:'-..'..<.. •• JERAULD THOMAS WISE- i 11i n - .---31,'P'!:"T d■..s`s„-,L..7'-,%"-.-i- 1."t-''-r'-i"..,.,- V' :LS'1EON.S A--•_I.MA,'c R'"".I E WSfE-i Kc'>Pt■.,.;...;';-'.--s "'.l,iN.'"''-'-A-L7,'s._•<SI%3._R O,....B--..i---L_:--I-?"N a5-.d"■ ii, :-TIc---"I-‘P,“,I-I,,;>,.•.-,,„ z)- _-_.,.,0-. ( . 24 Intonnanis Name, • s. ,, " !, , 24a ieerosrin To Decedent 16- - 24p l pang Address I(streettne NuberON:State Zip Coae)%11.1r 11 11.54initr.ry 1V ' - - I '' %=2:?: 1 it 7.-- iril„ % , u tc - _ , -,JAtw- }-, , - u,,, s RICHARD LWSE . 1 ,? Lz SON : 1/4&.. ',?T .708,EASTSR,56:-HAZLETON„IN47640: 21; 4C( L.- :-.......k-_;-.” ,..'--.--.....--'2_0 ..--......s...\,:::.-72.1 -::,,-?-±J,15: L. 'ff-t'..-45Cr2VPIat'aitispc'sMe034-1 ,Ict\--;:%:,-,4”,1 i>_"::-.5"Ii 20_1i-in-''s--. .sur -).-----": -...•,:-,.---,_'..ieil .„.1/4:5 1 • Ci• '?51 l'ArtIld oi D'sPiston-":".1c" t.-.1--- ‘,iy,■ 25p:Place Of Osoossooni(Name Of Ceneteiyiriemsery,Otter Race)%_25c.l_ccaptcnI,Sity;;;Ion:And State 1 ,,, _..,a- t v ' te ...,•3 ;#,b,B4airadel;izeon:IlOenaPOn QEntointiment `: .=Yti .; 41,-----%,,J1-kqc It' ‘' 4.<!;. --:- I I;It; :r'-i 1 .4.,....., • -‹ b:R • IF .' S I'\Ge< '-' :-q'-f(`-‘ ,,,-''''' Z',, ','C'C',. • ';:%-• '''S'A-- `,... 1; 4.,Id ‘'*,' eA'skC'Vi'l -.. sc., :...senov...s rom Este, .:„. ....1, .„,.......„, ,.,..s.,....., -..., , ...... -...ts. - s,- .- . ,.......,„„ ......`... .1 sz....*-...,.. c..,‘. s.. • s. 0 other-:(srimt: . ':'-'N=,:s:, •-=-0-r.r.n.,:: COLUMBIA VVHITSCHURCH:CEMETERY.ilk-;.- PRINCETON:1N',...",-',*..t.::-...:-'1,',;■•._- 17,-.N... ...." Al!:-.,--%'-'1... .,...-2.1 a .25,Was Coroner coyeacted? % % 27.Name Aral CornMete Address Of Raster Fariftg?'In\recdr,11111,,,d---' I: -,-tc...7,4%, is‘f..Ad„,,d;;;`,.,r;i A eli-sdi"1 11 0 -27a I FtnertRunie License Numbers C.---.1%1 I I . 2% ‘' • : • . ' `.. ' , ` '"<cdVt\i.jjtcri j\d'jr,. WL‘",' ,-,%.1ijjIl '■ il <7; '11' ' ' ' % "11(171'-1, 111,L' I'de;' IlIVII{,,' J.1 I I si -0 Yes:0 No- - -At •,- ' 'I' "..- ' :se ;.%-d.,--,-,--s-o- :LS-LA-% ,,•-.... : A.' COLVIN FUNERALHOMEINC425,N•MAIN:STO PRINCETON,.IN 47670.-,..:ill:N....A_il<<"■5.:...7-1-,..:1_ EH8300567 I: .6-1,...t.L. • .?..".27bSOature CM Indiana Funeral Service Licenseeit .. ..711,1,71,...„,-; _„/..11,7.--cis.,,, te,,,Ri. it --,. .b ; ,I,37tt:j.ec.,-.-jdt'27c7LiceriseNumper(Ot Licensee), .. --e;%1\t"ltec.'- `7 ,71.k..,-;F .. d'.5= RICHARD DEAN-HICKROD:;),BY!ELECTRONIC SIGNATURE"---(eiriBlity>1 --'- ',,i‘ci....- All. --72,--- ED0101215V.L/i. initle(--.: -...k, 11.,,r(icr.....9.11110, 5.40 i in .;-„,:--,. t;.., ,...-: ! ,1,(•;,,,,-,;:e.,‘• I,\(,,,-.....22._vlstrdf\Cause Of Dealliree Instruclion And Ea/lints)'-jsr.:-->„L.III• ij'(- 0. 4, I--a-srcK,Iiii-- LIVIamecAraginlII, L. 'I,213,Pf;liEnier Lim Chit?'oi El'e¢n14-"DiStalinS!17-400e‘,':Or Coln plicatigns:fhatiiicifillcaluise9,iceDtals.DOXI Enter Terminal •-:* I' 'I E.ents-41•L.--r-- c 0' - '11 • 'InleivecOaseta kl , ‘;; '„c-Sucti As Cardiac Anest,Respiratory ArreeL OgVeraricutaiFitiriffetion Wdlotit4sitmeig pie Etie@giy.Do'elot4bbre4ti:Etef,pity.One,Caisse„On .1‘ <sic_ , To Der `...J j.l .g!'%'"1 rc.`"L",,..,..,.-i---- 4.... la • 41 12.:„Ii5- '59,k1,1999-13-11".", ii--lic-,ciseelSligi*T, ri -'4,11,';r,,, ' .\' I•P ''-el,thb3W/Atir0 ...a 11};:_ !Int tA--" ,....\\.1 k&,.,- Ry'PLIUtflr Gins:A-Sate Cause(Final Disease Reuling In Death), , j\,A.-,,ACUTE URINARY TRACT INFECTION'WITH SEPSIS u d-i-.--S, i a//Li c.------/I i ..------' 1 .5 _,-,7.1WEEK , ,....-s? syl▪ I tl 44X 1 -‘L.:,1`1','',' . ,..-1 S'Isequent,'"C"'"t-aly;L'ist"-Cdond"' "1/4-is''`'. if An'I C'ea`dingsTOLN-The cause jr`iss"zedin„ .,,,Hf-d-PRO_STATE-CANCER I-, .....-Ii",:p`I'l A '„?.--.. -'-CILL.,;k`-‘,""As."Ster.......C...W..-Tt-C,..."s-adds`a.„i3pLENGTHYLe. j Iq•%.,i, '1,Liii&A:-,Enter The Undo-lying Cease(Disease Or InfuCjiThailluthilid •'t,re,,- lure, -...„.., 111-„,....,-,..p.,7t.-(45.)..!...-71..-... ..--Atiti.,,,,„- all,i....?-t--...,4,-,,,12-:;-.A;,r“,ii ,„ c: ,...(11ILTIPLeMETASTASES LS/di BONE-ANOLI.ING _.--'‘i l' ',Ac./..-- j1,If WI A iltlitil f--;2-:-- A LENGintl I LII,j ._, ,...„„%kt. C . ..< . ' ''-'%::::,, CI fi*C.?-..,„1".-,,II Ai''-ft".„.-..,S''.,,L4cr.„.,''f_ 23,"e•-,..C.. . Zr -Skj,'''■.r.... 3(..<•,*-1171 %c<17a-"ilz`,9*:Il'''<cCcitil - '''‘NIC;lAts....-;;;Cti`.-,_ 1 ,,.-".t..:„,''.,::„..--..::;,`.-24;-;..."-:,:-.7.- -:,?,--- --7.„-_..,--=-_,_. ir fl- Fart U.Enter Octet Sicrerrant Conti' Pons foreavbereno to Death Etra Not Reading In Updating Cause Given In Partl-cdls- III ,29:Was AnArscpsy Performed?. Is-_cit. -1L-g-tr"int 7",'.../ 5'111111 A-'6,- ,I if/25 Mush 7 .(ipoi„7----"' • 0 I.( Ad-,siulsisc ----,-----ds s' -1 it....---011:1Yese,g-113 No,r, ,,,..-...pimill0 ,,,o, 7/jj minTis;(6yEm(5,'161N FAlilliggk::v 1 .."5,.-< 'i'l il alc&1_,11'-' 't`L■ li I :-/C4i- :-s' iri ! : ... ,3P,'Y.-stkeC■st arP2:11??-2t.2:31t7i!!-StrritZts kite-rike,TSIrd,yesIlia No EF. 1 ., ....„ 3,1;;;;Did Tobacco Use Contedute To Death?. . -ii.:32dIfFemaIe. -A,Pli.:ki .2,...., ...: ‹,...s.n ,n ,:), ' it;„ . : :„.-,.....„---. ,-..-;. :ay:manner 9)De. -...,. .,.._ -.......-... ••-k>,-... - (:,,...". ••.... '„--;.s."I'-' , 's s_F s%a.'fi... .. ' ..' . , z...b,„..-;„=, .,p., ., - t.,. ,,,i. , I I ' - , • niuSiletsenesf/isnot..., I(EjNatisral,(9'1-icnads1:2-15. Accident...D.Penang Insestiat,on I ,E,i,a i-0, .,iff,t,bm,n_rcs?utet,----.> 1 ',E -viuIzcc- lo-,...,-;.... .,....,\.h0 ,-.gg,-cc,i,:::::47:::::- .21..t icdemhzei".tc4.-- twilsvi ,34 ,.:;.Of by(Mcnth/Deyryear) ' 'v.- --0 5 '35-T Of t "''' ',-.0:It 011<-34' I 36 I Place Of mon'(EG:Deceeent a Home,Cense-action Sae;Restaurant,Wooded Area)11.re 37:Llury At,,„t„,n-cc .. .1. - &--.. , — ^in-- , :-/..., ,-, hi. .--.‹.......-. •-,130 ......._ ml 1 ig:''''' '''. ::(:1"j="C<TI'A‘-.7T1-`:1 ",- <>I'll.".. ....''',...-L ---''''''''41.- -‘,. .)."."-=i,.x.:\,."1"...LJULL■7-9..---rge)2131.c.. ..-•- •..."`...-"s'SS-S"%\''''s>"'-';‘''-"'" ‘'-s.---I 'c''-'.:::'. *--,k24 0 ISi Logsdon ce IN's rsaie ':,..4,,,,,r;.j is,-,--„,... NM.CtrOf„Towri:I 1 1 N.._-.- Ill I i-13,:tr,;s IfurnciSr):).1};1■C t''-'4-----"' ... ' '''-':-:Ai )i ir .i1T\CIIA 1PeAg91 .,•%;.-trri, ''';',','. '--c.- \ti .-%: 11c43.. I. 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