Death Certificate - Hix, Fannie_3/2/2018 �v• ri�ia:!;'izS:.."..�.�aC A-�.'.)-:`.T,�.!�:�: ) CERTIFICATE OF DEATH L�.:._iG `��.rvTi_:'7i:�. r` :i_re
`INDIANA:STATE-DEP �-TMENT-OF'HEALTH'c - - = 1�,
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CERTIFICATE OF DEATH
'6 Local No 000115 , :. EDRN0'000000580099`: �,�°State No 026833 1 �_ ,'
it 1.Decedent's Legs Name(F(*Mime.IS) 1a:MndSO Nam.(If female) 2.Sex 3. Tme Of Dear 4. Dae Ot DeaQh(4oitiO R&r) 41
P FANNIE E HIX 1 , : , HAYS '%o_ -� FEMALE --_12:14 AM `-05/28/2017 '
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89. _� -
C Months Dan Han Mautss/ PRINCETON;IN )1
�i 9. Ever in U.S.Armed Faas? 10.If Death OattWmAHcsp . .i�-10a. If Deatm
Occurred Other ThanAHasp= ••
a \� F�V p! e Fnty p p oemear.Hare O Ntn g HOm6 cn94ac n Cn tSO'ily `d
( ❑Yas ®NO ❑Urbnown ❑ItpEM O Emerpercy Dammma auLeterf ❑Oeeaen Anral p.Cd;er(Spapl)?/' - \ ��'. -1
11. Faeity Name Of NalmtLaxL Give Street and Name) j••' ' •O' _
'1. GIBSON GENERAL HOSPITAL _ %'? /i - - Di
Ps' 12.pay Or Toed Srr,AM Zq Cede - _� 13:CaS OfDean� 11.Moral Stm*Al TVU 01GS1
/ _ j \ �� " ❑Mama p Maroa.'But sepaaxd p Drama 'J
' PRINCETON, IN 47670 - GIBSON ® dviie p natu d p Dn"n -
r ba
15.&nie s Spouse's Name 15e.Last Name Before Fat Mamap. 1e Decedents Uswl Ompmon 17-Kre CI Business/Industry s)
�SSTA: - :----- • SECRETARY _ MEDICAL OFFICE )
/ 18. R -State tBL Cgny -� •lee. Cdy err Town„ ,Y _ %) �
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\ INDIANA - GIBSON - �� PRINCETON
1ec Sr=AM Hunter �� C led Apt NO 1a 2V Code ) 181.Itel0e C1T!lialb? �Tr
`E 804 NORTH HART STREET -�- l 47670-. ®Yes O No Di
19.DeredetaEduzenon 20 De09Ee910fHitpeucOnan,,, � A 21.Decedents Rase
SOME COLLEGE CREDIT, BUT NOT A - ' \ i,' . , �^
(� DEGREE NOT HISPANIC , ,! White
Syr 22.Parents Nave(Fist Middle.last) 23 Pat is Nth(Frq Mid9e.luy - 235.Parent's s Last Nane Bebn Fist Manage °
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`E EDDIEHAYS _ FLORA�HAY3,� F', WHITE' _ �}
r 24.Informant's Name 24a.Relatrurp To Decede f 241.Mai'p Mtreas(Street AM Natter.Coy,Stn,Zip Code) 1 I :��I
MICKEY HIX SON -A 804NORTH:HART STREET,PRINCETON,IN 47670_'".1 :- ' - °
a °
• ' 25a Medea Of Cesposson 251.Fla*Of Dispopea,(Nam OI Cemaay,CmMtay.Omer Rau)
- 25c.Lost=-Coy Toes AM Stn
®Duel O Crematan O Donation p EnmmMnal
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(r 0 RermyS From Star /� ) _ .
• p aura(Spetlyy MAPLE HILL CEMETERY V� �. �A ' PRINCETON,IN - - - -
• 29.Was Cormier Calacted? 27.Name AM Cardin Address Of Ftneral Faulty <--� -- ! - .I -.27a. Ftnxal Homo L Number.
a 0 Yes 0 No • COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670. FH83005671 . r
/ 271. Sonata Of mama Funeral Sense Lansaw VA, - •.= FTD0 09940 (a acetate) e
JOHN W WELLS, BY ELECTRONIC SIGNATURE
- .---cause Of Deem (Sae Instructions Arid Example) ,`` - I - 7 • Approximate
.2e.Pan 1.Enter The Chan Of Fvaas -Dames,mutes,Or Campfraliaer-TTat Deady Caused The Death Do Not Enter Term4W Event • ) ilenzt Onset a
Such As Cardiac Arrest,Respiaory Arrest,Or Ventrkidar FLraation W ithota Stwsq The Etrbey.Do Not Abbreviate.Enter Only One Cause On a A Lie. Add Addtmal Lines if Necessery. �, � - ,
o Immediate Cause(Final Disease Or Ca jition Reading m Death) A EXSANGUINATION - ., �� IMMEDIATE
Wepvwaa•w•aoe , C
Sequentially Condors. B Any,Leafing To The Cause Listed On B• - AA -
Lie A. Enter The Underlying Cause(Disease Ortyuy That Initiated .- 1 wep,ra��y.>m
1,. The Events Resulting In Death)Last C.
LC/ oew e N•••CAY••ot J Imo. v�1
-.
Pale.Er Omerc :: +v,a .alt •^^b em Ba Na Resl:np In The Undeceive Care can ii m Pat I .. 29 Was M Armpsy PaNmM?
❑Yes ®No
/� 30.oar Ally Fndnp Ava4W To Ca pI to The Cause Of Death? o Yea LI No
ebb GASTROINTESTINAL BLEED - ,1/
31.Dp TaW®Ua CormL,u TODmm? 32.UF"-e V°�� 0 Mather Ol Hat `1
`� p Yes p Probably®No 0 erdmo n 0 rnwrr*.,r.- 0..........A.,4-..---6-1,,3/421 p eaeyweenInenwa•••••∎ one 0 Mete 0 Ca=N Be Aaiaal❑Pending t!vestgmen• ❑rrna-aun.e.woor.n,r�ri.o.m pnne.�uw:a:++na•.wi� ,:` ❑DYIa❑Code Na e DexmurG '
v.- 34. Drs CI hew/(MccitNIDaylY ear) - 35. line Of lr*n , c' 36. Place Of tjisy(EG:.Demirea Hone.Car*mrmn Sts.Repeat Wooded Areal . 37, thaw At YbcT
i 38:'Wratm 011Hay-Strz 3Ba Ciy Or TOVn �39D 6ueaetenlDar 1� �' h 38c pt,NO 380 $DOGS l*.
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_;^v -Ds Tr•,wrbwn Lary `j.
Hl 39.Dnmb Hose Wary Occur= 1 e�,.�.rV� •-r. p°`n4+ p•w LJ^°ea°p°"'�°!, -�
•/2.. 41.Slane,p PononCeat t Came Cl Dealt - =
C 1 LID',11-ti O a ,=
i c DEBORAH K. BORCHELT, BY ELECTRONIC SIGNATURE , - .A.!!"[ � c ®c�
-p Hem" %?'
•( 43 Name.Auras And bp Coda Of Person Certifying Case Cl Death: - ,. ,. 44 License Mncer - 45.Dew Carte= ._
�. ��
t; DEBORAH K. BORCHELT , 203 S. PRINCE STREET,:PRINCETONIIIN 47670.'
'^e"S- : 05/302017 y�
.**urns Funeral Servce Povider 1, f 57 -.%,-- n." i i 46 - Ica
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�(( 4e. Signature of Loud Health OIScer. �� M� 49 Fx PplatrarDM'_Dn FWe M yNM , : �,
€4 BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE --"';) -;?::::.- MAY 31 2017
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) .
oa 8
.14 o a_ 00 y• 3 80=,DDB 367- ab7 (C4-C O4CQ .�•,aC State Farm 53395 ATTENTION ESTATE:The Social Seas*s is beoe requested by this,state agency, alder to pursue. =cons_ billy. Disclosure is voluntary and mere re be no penally for fot sal. .•
WARNING•TURNS FROM ORANGE TO YELLOW MULTICOLORED OR�IGNALL DOCUMENT HAS A SECURITY
IDDEN VOID ON FRONT THAT OF THE STATE OF
PHOTOCOPIED.�AON& 1: `T 5
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