Death Certificate - Belles, Mary J_5/16/2018 !a/ - `, INDIANA STATE DEPARTMENT OF'HEALTH
tor ! CERTIFICATE OF DEATH
Local No 000104 EDR No 000000640508 State No 021131 2
y .Decadent's legal Name(Fest,Middle,Last) 1a.Maiden Name(If female) 2.Sex 3. Tine Of Death 4 Date CM Dean
et IMOrw.3ayn�4
Lf
ID.1f Dear Occurred In A Hosptat 10a. If Death Occurred Somewhere Oche Than A Hospital
L. ❑Yes ®No ❑Unknown 01r et ❑Emergency Department Ouyatier ❑Dead on Amval 0 Hospice Oe(S eciffyH ❑Decedents Horne ®NWtiy HorrolLorgtem Can F tty
It Emery Name(If Na L tt:tm.Give Street and NraMe)
GIBSON GENERAL HOSPITAL-SNF
,` 12.City Or Tows Sale,And Zip Code
13.Canty Of Death 14.Mattel Status Al Time Of Death
7
PRINCETON,IN,47670 GIBSON 0 Married 0 Married.�Separated ❑Divorced
M
❑Never Ma ed ❑Unknown
( 15.Surviving Spouse's Name 15a.last Name Before First Manage 18. Decedent's Usual
Occupation 17. Kind Of BusiessaMUSry
L IB, Residence.Store 18a Canty 180 City Or Tam TEACHER EDUCATION
INDIANA GIBSON PRINCETON
lac. Street Ana Number
180 Apt Na. 18e. Zip Code tea. Inside City Limas?
298 EAST OLD PETERSBURG ROAD D Yes ❑No
a
19. Decedents Eduton 20. Decedent Os Hispanic Origin 21. Decedents Race 47670
ASSOCIATE DEGREE(AA,AS) NOT HISPANIC White
22.Parents Name(Fast Middle.Lest) 23.Parents Name(First.Middle.last) 23a.Parents Last Name Behre Fest Manage
DONALD LANE VIRGINIA MAE LANE KING
24.Informants Name 24a.Relationship To Decedent 240.Mailing Address (Street And Mrnber,City,State,Zip Code)
MARTHA LEE OPRISKO DAUGHTER 316 EAST MONROE STREET, PRINCETON, IN 47670
25a.Method Of Disposition 25.Place Of Dispovbn
®BMe ❑1 O.spo a 25b.Place Of Disposition(Name Of Cemetery,Crematory,Other Place) 25c.Locabm-City,Tam,And State
❑Donlon❑Entombment
0 Removal From State
0 Other(Specify): MAPLE HILL CEMETERY PRINCETON, IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Ramat Faebry -
27a. antral Home License Number:
❑Yes 0 No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670
27b Signature Of lndaa Ftnenl Service licensee: FH83005671
RICHARD DEAN HICKROD, BY ELECTRONIC SIGNATURE D 10162153 (d Licensee):
FD01012153
Cause Of Death (See Instructions And Examples)
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28_Part I.Enter The Chain Of Events 'Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Ape Tatman
Such As Cardiac Mesh Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Onset
A Line. Add Adddlonal Lines It Necessary. To DeaJI
Immediate Cause(Final Disease Or Condition Resulting In Death) A. CARDIAC ARRHYTHMIA
0..cup,„i•caw....on 5 DAYS
Sequeriiaey List Conddiens, B My,Leading To The Cause Listed On B. CORONARY ARTERY DISEASE to YEARS
Line A. Enter The Urde yjeg Cause(Disease Or r'*.y That Initiated e,.•mt.«•C•••••••••••••our
The Events Resusr,g N Death)last C. HYPERTENSION
Di.eid we cams..0,3
10 YEARS
Pan IL Enter Others R- _Btu NIX Result I rid; f el�c
;lying -:11� t Autopsy 29.Was An AtY Po nre
rled?
:�: ❑Yes 0 N
FLUID DEPLETION,CACHEXI A FAILURE TO THRIVE
30.Were AV,dpty Finding AvalaeN To Cowie*The Cause Of Death?
31.lid Tobacco Use Ca-tibiae To Dear? 32. If Female: , ❑Yes ❑No
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33 Maurer Of Death:va ma..vcver Year w.aw.urw.wu.a,� wore.w. .vc. aio.w ao.s ®Napual❑Ham,
de 0 Accident Pan01mesVgaOOn❑Yes ❑Probably 0 N ❑Unkown ❑ pgrfe .4 Pr's'''.a oMAY �q,i IUJ
Uea-e a q■O••N.an n4 M1a.v
34. Data Of iqury(M VitDayfYear) 35. Time Of Injury 38. Place Of spay(E.G..Decedents Home,Construction see,Res 0 Restaurant,Vo Na Be Area)varq'Mtoded Ana) ]T. Im+Y At Work?
❑Yes ❑No
38.Lem'ian Of irery-Stan. 38a. City Or Tam __ �/e5 Vast 6 Mm0er
//((C. (,JVi 30c. Apt No 380. Zip Gant
GIBSON COUNTY AUDITOR
39.Desn:be How Injury Occurred- -
_ Des.sraislsorla:migory,�.5ep ei
LL Sgnat+e,Of Person Ce:.]yirg Caused Death ❑� � ❑e) UM.�cur t E
KRISHNA MURTHY,EY,ELECTRONIC SIGNATURE 42. Center(Check Only CeleD Conner
43.Name.Address Ate Zip Coce Ot Person Cen:tyag Cade CI Dears ®eemyrhg 44 License N Heath� ).
KRISHNA'M`URTHY ,635VAIL STREET,PRINCETON, IN 47670 01031888A 04/25/2018 i
46.Add oil Fuenl Basics Provide - 47. 'Alan: -4
48.Signature el LnalHearhO:teen` !
gl
49. For Registrar Only •Dan.Fled( /Vent 1
BRUCE BRINK JR,VIA ELECTRONIC-SIGNATURE APR 26 26 20 2018 7
1 ' S AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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State Form 53396 ATTENTION ESTATE:The Social Security#is berg requested by this state-3gercy Inorder to pursue responsibility. Dissclossure is vokantary�a wit be no penalty foe refusal. 4
WARNING ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER AHD THE GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT °
TURN$FROM ORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUI.IEtf(HAS A HIDDEN VOID OH FRONT THAT APPEARS W'FN pumnrndicn -
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