Death Certificate - Whitehead, Charles R_4/23/2018 S
30 ' fi. „----,.3', L'... t'', 3 INDIANAESTATEDER• "IMENT OF.,I-IEALTH i i .--:.-#.- '1 :::";:'. c '.>' !. -1,-. '',-`--.-• iir "--,
s-,.-17... -:::_ -C::4 z ':. . ; =...- t '3 ,..!!-• : ',... tERTIFidATE;a1-DEATH -t z t tr- ""•-• ".. n ' 0 g Z x t-`.-; '.
qiiits; fi: i' a:: '‘ ?,, 't : ? , *.: ; Z ' ; ' t ; ' ' ;-'-"ti: P r ': 1 j I ..:. " •": :1 '. ? t g t !.' , ".
if i'Lli:. "...I:, .:,,, ;V" •
LOCal-NO b 0 00 9 0.-. 'N' .‘r N --'ED A N o 000000635732 .----• . -- -stat 'N " 0)9115 \----‘..,:.?
., .:- .: e o • -. • , A
,J Decedents Legal NarQe"(Firsf:Midcrle.4,„-Q.:•:•• •• --,.. .:•;;;;-, -..;Jail Maiden Nano(If fernale),--..,„ "•Js.".. 2 Sea d g3gTene Of Death..-,: ,, 4. Date Of Death(MotDarYea0
ii ., s, s', :,-,t „ ..... ... _.::" ... ;', ' "...„s.,,C .......Th. f•I'..-t ;• ., "c . s t' ...v. 1.: -g ' f: '' ,: 2 •''' ''
CHARLES'RICHARCI:VVHITEHEAD.,:. 1 : :! ; 2- ----: 4.), :_:,.. c . *--, ' .1:. '4:: I: :;-. f'-` , 'MALE: ' • •0660AM :A 03/26/2018
10.If Dean Occured n A Hospta - , . . _ 10a f Death Occurred Somwre OthePun A Hpl" "- ,' -+:
0.,yes' 0 No 0 Unknown 0!mi:tient 0 Emergency Department Outpatient 0 oc.:;ci on Arrival n oiei,e„.,,,-,„,
•-• .-- `-',""--, . ..
4'g:fealty Name(It Na Otstilubon,Give Steel and Number) : ,; , • . . . -
" '
„
961 NORTH US 231'HIGHWAY ... . . . . .
12:City Or Town Stale,AnclZip Code t)3. County 01 Death - • . .14.•Mazital Status Al Time Of Death
S
. „ • 0 MaMed 0 Mimed,But Separated 0 Divorced
SWITZ CITY, IN,47465 ; .. . ...
. GREENE 0 Mowed.. .,0 NeVer M.arried -0 Unknoin ,
,15-Surtng Spouse's Name ' _• 1SkLast Name Berme First Marriage 16. Decedengs Usual Ck3a.pabon 17. 14nd Of Businessindusuy -'.
' ' ..•
. '
COAL MINER- , - MINING
_.
.18.Residence-State - - .. 18a County . . . .lab`City Or Town ,
. .
, . .
INDIANA . - -
GREENE •• SWITZ CITY -
- • . .
.
let.Street Alral Number ')
lad.Apt No.. -, 18a. Zip Code . let inside City Urnas7 -
• .
961'NORTH US 231 HIGHWAY 0 Yes 0 No
47465 -
._ . , . .
.
19.Decedents Educaton ; I'" 20. Decedent Of Hispanic Origin 21:Decedent,Race • - -
HIGH SCHOOL GRADUATE OR GED . • ..
-
COMPLETED • . NOT HISPANIC - VVhite . .
FIT Pare tpfore Fast Marriage-
•22 Parent's Name(Fat,Middle,Last) • 23:Parents Name(First,Middle,tall)
c - ••.• .
• •
VVILLIAM JENNINGS WHITEHEAD EMMA WHITEHEAD • -. BISHOP •
24.Lntormants Name 24a.Retatantip To Decedent • - 24b.Mang Address (Steel And Number,City,State,Zip Oxie)APR:23 2018
- : - -
RETTA F LINDSEY . DAUGHTER ' 961'NORTH"us 231 HIGHWAY SWITZ CITY, IN 47465
_
. . 25.PlaCe Of Olsroillion- , ' • . . .. - - _ .
.
25a Metn:d 0.1Disposigon : - 25b,Place 01Disposition(Name Of Cemetery,Cremthory.Other (ace): 25c.Location,City.Tcwn.And State gragorevi- •
0 Buie] 0 Cternation aDonabon 0 Entombment . . 11177flitinir/IPe
.
-
D.Re'rnoval From State , ,
,
GIBSON COUNTY AUDITOR
c .
.
reme;(spec:4y : . ...
.. MAPLE HILL CEMETERY •--• . PRINCETON, IN.•. • •-•
26 Was Coroner Contacted? 27. Name And Complete Address Of Fulcra Feciihr • - • , , 27a. Pass Nurse license Number
', '•
- -
0 Yes 0 No .
. • COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 . - . FH83005671 • .
-275.-,Signets.01 thine Funeral Semi;licensee: , . . ., ,- -, . , 27c license Number(Of Licensee)-.; -
RICHARD DEAN HICKROD;BY ELECTRONIC SIGNATURE t . -- . . FD01012153. . .
• . - - -
-- • - - , -• ..- - Causer 01.Peeth•(See Instructions And pampfes) • ,- •-
" Approximate - -
28.Part I.Enter The Chat Of Events -Diseases,injtries.Or Canpkations'Thai Direcily Caused The Dealt Do Not Enter terminal Events Intervat Onset. .
Suon'As Cardiad Arrest,Respiratory Arrest,Or Ventriastar Fdanlaticn VVrthout Showidg The ELtolcgi.Do Not AbCracriale.Enter Only One Cause On " . - To Death; '
ALine. Add Additional Lines II Necessary. .
•
. •
. .
mediate Cause(Faal Disease Or Condition ResulCag In ,Death) A MULTIPLE ORGAN FAILURE'.-- . , • • 3 MONTHS
- , weer*c..•on,.Cer - .
,- ..
' .•
-, - , , , •
7, . ...•
,uSecjuentially List Conditions, If My,Leading To The Cause Listed On a ISCHEMIC SYSTOLIC CONGESTIVE HEART FAILURE •
3 MONTHS •
use A. Enter The Undething Cause(Disease Or lnjuy That Initiated . : • I. •
-. • • ,. ..
The Events Resulting In Death)Last - C. END STAGE RENAL DISEASE ' . - ,
3 MONTHS t ,
". '' PaoW As A Cateaae Or
.C. . : . .
. . . '
. .
. ..
.
Pal U.Enter Other as , aco De But Not Resueng in The Ur:retying Cause Given In Pan I - 29 Was An Autopsy Performed? . , a , . ...-
NONE .... ,..
- • • r 3D Were ALtopsy Finding Avaiale To Complete The Cause Of Darla
' 0 Yes 0 No-.. '
-;
31::Did Tofu=Use Contribute To Death? 32. It Female: . ,
33,Manner 01 Death: : -
0 frel l.'s...1nel^Pal vs., 0 lNeawl 4i/iv.CS 0..th 0 kin Pthwo.Su sways varml2 Oar Of awns 0 rtatUral 0 Haidcide 0 Accident 0 Perxrag Investigation
:LI Yei 0 Probably la No 0 Unknown
• • 0 ran...rant ew...Swart P.m To I war Saw owes. 0 uwar•W a nusuu wow tr.rya rt.. -0 Sukide 0 Ccad Not Be Deutmined .
34„Da Of harry(mcpuiDayrYear) - 15.Rae Of Injury 36. Place Of Weary(EG..Decadent:,none,Cr:amp:bon Sae,Reuss-ant Wooded Area) t 37. Mary Ad WOW
.
-, :. .. . . •'', . . • ' -0 Yes - 0 No
• •
.1k Locaton Of Injury•Stew i 3Sa.City Or Tam 335. Song 6 Number 384-At No. . 38a, Zip Code ..
. . , .
. .
39. Describe How Injury Occurred „ 40. If Transponatien Injury. eofy: . . ..
t., . 1:10..mener Oevev;•1 Oevalewt avettlsee.on •
, •
••1:Scutum CI Person Car-Mang Cause Of Deadt . 42.Gerais(CbeckOnly One) "
JOSHUA'EDWARD.CULLISON , BY ELECTRONIC SIGNATURE . 0 Certifying Physkien • '' 0 Canner 0 Ream°Facer •
43.••Name,Address And Zip Code Of Person Cate*);Cause Of Deady ' 44. License Nurser 45. Data Cer4ed . .
A • „
JOSHUA EDWARD CULLISON' , 708 WEST MAIN, SUITE A, BLOOMFIELD,AN 47424 01075649A . • 04/16/2018 - '
... _ -
-- .- • .
: .-....:.•. i I ...- . . . " , .... ._ .,
- _
45,.Sqstn of Local HealOb •. . - , - - . e9. For Registrar Only -Data Filed CMcsnavDayfrear): ' , : , i •:- _'t 's
PETER j:POWERS;VIA ELECTRONIC SIGNATURE .. '.•••.• -: ":.: t. 1- ij::: -: c ::i : - :. . .. '.•APR 162018 : t i• ''. t i :
-;-. ..„. .2 .:. •:. --_ .• .3-.: : • -- : --. ; : ._ AMENDNENT.TO CERTIFICATE OF DEATH(ENTRY OR ORIGNAL) 'I , : i .7 ••• t jt ,, Ir. I. , ;t ..,; I ' •:
. - • ••• - •'.. cr ', '''''' r: .''.. ''''''' 1
'.• , 2 t '', t: I ' t' ,".. .% ...> :t. C .^...: . ": t • ' -- "1, ". - ',••• '' -*--: 1/5 5 1; 1, .-."1' '5 '1. ; Ez; -: '''. 1-:-
. - . . ...
. . . ,
Statepnet53495 ATTENTION ESTATE:The Social Security rr Is being requested by Iniielate:agencl in order to pursue iespOnsibigly..Div:loth:ire-is voluntitty and theta 011 be no penally for refusal 3, g 1.• ,:s-.‘,
l. WA?Pd -.
g ONGINALDOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL Of THE STATE OF INDIANA ON BACK TRAIT'
ORANGE TO YELLOW WHEN RUBBED:ORIGINAL DOCUMENT HAS HIDDEN e•1 ON FRONT THAT APPEARS WHEN PHOTO CAPIED,--". -r.,,-; •I',....-..,'.-;
_ .. _ _ - -
1 ,