Death Certificate - Debord, Ralph_1/30/2018 ........• ' .-
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c•-.- - - • - INDIANA STATE DEPARTMENT 01 HtAL III
• CERTIFICATE,OF,DEATH
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‘.r Loc.:31.Na 000024 EDR-No 000000622331 state No 003036:1C...4:c C:
1.Decedent's Legs Name(flit,Mktdle,Last) 1a.Maiden Name'Of female) 2.Sex , 3.Time Of Death - -'4..t Date Of Death(Marth/Day/yeen
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RALPH B DEBORD .-:.:...-.2., .• .MALE'. 02:58 AM . - 01/18/2018
. 86 Ma-41;r::41' Days Han „Mines :_ct •'...r
-.7:0 1/13/1932 .
FRANCISCO, IN
9. Ever ii U.S.Armed Forces? 10.If Death Occurred In A Hosatat •alta..if Coats Occum3,1 Somewhere Other Than A Hosprtal
l .. 0'gamic*F•otty 0 Decedents Horne 0 Nursing Home/Long-term Care-Fealty
0 Yes 0 No-0 Unknown 0 Moe:tient 0 Emergency Department arpnent 0 Dead on Antnil;•0 Other(Specify)
11, Fealty Name,Of Not tratorson.GP,'Street and Number) - :-.-,,-
GIBSON1GENEFtAL HOSPITAL . - 4...,...7 ..: •
12.Cay Or Town.State,And Zip Code 1). Ccanty Of Dant, r„ 14. Mantel Stela At Tune Of Dean
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Manisa 0 Manied,But Seoarated.ci Civerced
PRINCETON, IN 47670 ..../. '" . GIBSON s' ' LI woond 0 Never Msmied RI.InkniWat
15. Striking Spouse's Name '',"'". 15a.Last Name Before First Manisa.4,5,0--." 15.Decedents Usual Occupation .., 17. Km]Of esisMess(Mdustry
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OWNER OPEFtATOROF'41-:,7.
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SYLVIA•DEBORD WALKER1 GREENHOUSE g, - ..% RETAIL GREENHOUSE
18.•Residence-&a 18a. Catty 1825. Crty Or Town
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INDIANA -. GIBSON "C"-- PRINCETON - ,
'Sc. Seeet And Number e..!... ,,..? 18d. Apt No. lee. Zip Cede let Inside Qty Linea?
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213 EAST WARNOCK STREET
ee:r3-,..- 47670 , r''••••••••`!-;'
19.Decedents Edv5non ,.. .. . 20. Decedent Of Hispanic Ofigin I
5.-:. 21. Decedents Race ".'..-
HIGH SCHOOL GRADUATE OR GED
COMPLETED - NOT HISPANIC .1- White •-•._ ----!"=""
Z2.Parents Name(Fit.Middle.last) 23 Parents Name(Fat,Mone.Last) 23a.Parent's Last Name Befae Fit Manage
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FRED R. DEBORD ' ' VEDA B. DEBORD GOODSON
24.Irdonnerts Name 24e.Rtnitionship To Deoadent 2‘b.MaWrg Address(Street And Winter.Crty.State,liCoieEl fri;
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SYLVIA DEBORD .-.. '-. -`, VVIFE 213 EAST.4ARNOCK STREET, PRI C 4
I •. a.. 25.Fiat*Cf Clin-o-nbbn'
25a.Method Of Disposmon 253.Place Of Moos:Pan(Name Of Crematory.Omer Place) 254.Locator•Cat Town,And JAN
0 Baial'0 Cnsmnon 0 DoraSon 0 Enmentment 4..41 --'1 :: •36' 2018
0 ReirtovalFrom State
0 ige+e;(Specify): COLUMBIA:WHITE CHURCH CEMETERY PRINCETON,IN ----. .x-
25.Was Coroner CataaeS7 P.:Name And Complete Address OtE wend FaciLly . .. - t.: / . 27a ome License Number
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. 5'..5a CI Er.1*
0 Yes 0 No _,, - •-
....• : COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 GIBSON COUN A$S1686f9R .; •
275. Signature Of Miana antral Service Licensee: „„?.4-4.7.,--.:rs 27c. 1_65ense Number(Of Licensee):
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MARK R.WALTER-;:BY-ELECTRONIC SIGNATURE -... . Al-11 h 158 FD01013010 -.
-• • Cause Of Death (See Instructions And Examples) ,., N '-• -P- Approximate
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218-Pert I.Enter The Chain Of Events -Diseases Injuries.Or Complications That Directly Caused The Death.Do Not Etter Terminal Events -.-,- '5 t' Interval Onset
' Such As Cardiac Arrest Respiratory Arrest,Or Vertrioular Ffterillation Wthart Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On ..- t- _•• To Death
A Line. Add Addisonal Lthes tf Necessary. ,8 P.5.5
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Immediate Cause(Final Disease Or Con:Rion Resttting In Der,h)-.7. A. ACUTE RESPIRATORY FAR.URE ...... . ., 24 HOURS
ex.•ro*#xcana-xx or;
B. HYPERSENSITIVITY PNEUMONFTIS 30 YEARS '•
Sequertiaey List Ordaions. If My,Leading TO The Cause listed On • onm,..•cn#,,,..to my
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
The Events ResuRing In Death)Last 1.,:.: ••\1.5?
C. BRONCHIAL ASTHMA h r-2 '
30 YEARS
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.,•, drin(OrA.s.Canere•Org
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Paul Enter Other cidrrru CarsI*0nt Cattsflc In Death Bo Not Result";I./De Ur4erlying Cause aven In Part I
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LEFT VENTRICULAR DYSFUNCTION,CHRONIC KIDNEY DISEASE, (1"?..trr4 29.was An AltopSY Pertained?1.4-Stc-r 0 Yes 0 NO
30.Were AuMpsy Finthig Amiable To Complete The Cause Of De8117
trin--- 0 Yes D No
31.Did Totheoco Use Oat:pan To Death?5.7,- 37_If Female: 33. Mamer of Death
0 OT'PorinnIATTinPw'T*. 0 Ono.".111not,Denk 0 Iblrar.riluenj.:v&Nna omoronch 0 Neutral 0 Homicide 0 Alp:Went 0 Penang Invesegabon
0 Yes 0 Probably 0 No 0 Unknoom
0 Ak A.,.+.e.•P.m..o c.,..ze,'yew:now, 0 usnewl 4 ine.eie bee.m.rye y... 0 Sunda 0 Could Not Be Detem■Med
34.Data Of Inary(Morrn/Day(ear) I 35. Tyne Of Marry 38. Place Of Inkry(EG.,Decedent's Home,Censtrstion Ste,Res..lexant Wooded Area) 37.Injury At Wale?
Dyes 0 No
38.locators Of Irnry-Starve 84. City Or Town -, -.1., 38b. Steel 8.Number , • : 38c. Apt No. 38d. Zip Coos
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39, Describe new Intury°cored -
. --- --V--- 40.i•If Transportatcr Injury,Speaf,y:
0 Dmacsern. Clouem:.°thalami.OCam,rawer)
41. Sig-Oraa Of POOSOOC•CNYICC4=5 Of Dent ."41.tf.r, 42 Gartner(Check
KRISHNA MURTHY, BYELECTRONIC SIGNATURE • 0 Ceittep Ptysidan 0 Coroner 0 Ha:SO:beef;
43. Name,Address And Zip Cede Of Person Cerayrc Cause Of Dent --:'-::: 44.License Number 45.DateeM5ed
KRISHNA MURTHY ,685 VAIL STREET, PRINCETON,IN:47670 01031888A 01/22/2018
I 48.Addrtional Furerof Service Provider . , ,,- •.-•-• I 47. itIcas:
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BRUCE BRINK JR,VIA'ELECTRONIC SIGNATURE
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JAN 22 2018
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR C11214:INFAorLR)"Istrar Only -Dale Fled(Urff'jp3Y/Yet°
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State Rim 53395 ATTENTION ESTATE:The Social Searky#3 Wittig requested by this state agency in order to pupate respensbley. Discbsure is,vokrataty and there will be no penalty fa refusals.
WARNING: TR INAIThOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE‘SEOLHRITYr PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK. '
TURNS FROM ORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUMENTHAS X HIDDEN VOID ON FRONT;HAT APPEARS WHEN-PHOTOCO-PlIED. -2.-11X.-- T