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Death Certificate - Coffey, John, Wayne_6/27/2018 11i.x,Y. - - A ' .44:-:•••., `�i` t1�- �111�M14 a4��rM?'4,1 s - �\"`x Cs P a �' + ; INDIANAISTATEyDEFLARTMENT OFsiHEAL,TH 1 ,%( / 1 p # 4.sl -/r� ' r i CERTIFICATE'OF•DEATH �'�II / 11 !` . tfc--, � I �:���y � ,ice, !• fjt l �,I{ �� ' I 1^Local.Noa000c1139 .ai : �tdEDR,No-00000064.HH:1t6 it: r.State No.0291125 v t -0...,,,4 ,n*NU(/%+K )1 1t1/ f k:lm -./ .7-t1,41 ls 1 ./ Natrel -e) / ��0 t l i3 Tla it d!.DX(/ °7(A'wNVL1aYf/ear), i t,JOHN.WAXNEtCOFEEY d. ` t ... `,. . t� i �` • �� I AMA E �O6t091PM 'a O6/08//20,18� C"5.'.SeaaiSearityNateaaa+-Age:Yrs sm+v'UndU 4Yiei1e.<;v"aerL$MOCh'r6°al,Dnae °"!Ta" 1iurei7iDxaoflBut`(MontNDaY/Year)q ®rPSel(GrrnSlatswForetaiCanby) ' 10.'If Dear OrnirM lnA HOSpial v Lpa'Llt Deem OCtvrtM SOmewtere Omx-Than AHOSpitalY p�p��„ -, T r \tp g z Faa , p'DeceOanfs asre�Nat H `\� \` ■ .to ULM'�."•b�e in as i"%anU in°'i`yca°�u m a p'oaae on MIMI p(gat y) ^^� ��( 0 1A / o ymne1_p °lll N l �nil�Ja i ittl1iFasq Namet(lfNa1 atattGive Street and N'Me7Y {111MIC,attlinry 4 s (C cWATERS7OFJPRINCETON,>J`THE�'f1�lkaiA`alSll['/edamllit3 a lY�'t�"attlSP/�e':11j[b��Li® '��.'a'.'`�A111 ietivUHIY.6�Wila5y�dv NI 7 �12'�tC.tyy Or�T�al,,�StY�Sj"AnM LP Code `., \W Y 2s (i3�Cdnty at beam�, 1e M•rital SlatuaNTa',e Of Dear y,� fl�\ l{ �, -at i .. s..,,,,..4.4„_....,"..j.6,2 t ! ` Y \. `1^. J �P aiaMamed 'Mar `ctij i�`�3� F RI CETtOW.I 147 (II y p i I�. 4N c l /i,., .�p xamedp�Mamee a,Ifir,eateaf®aroma "' '�PRI�N''C`'ETONvINI147670✓." IL'Qi i l t ✓/ 1 i IA�I GIBSONL1r i {�/ s11 �rpyv�taavea �OJNeer.Mamea �p urio � ( s.� _ s aa� l��y_ > y \ 9�lsa tat Name Before PVat Marnaaa.� ;;. GIs «,r Usual Gmmavona.,t�1G 'v )(ISSN eusmesrnnaoiayir pi 1�`\'%t it r,r .Is I:` • a-,1\JL�r. � �WI ;Sr•a. SELFMYED. I ` 1{SELFJEMP OYED�I , )` 18:-Resnlence°State r z`J pea Canty 1180 Or TO,m.' - It r 1NDIANAL•, N. \' -.7..-� GIBSON `. ;�•�\ P.RINCETON�\ "e\�. `-`- 1..1112,�� ���\� 4� ) •lac•street And Numbers { �� t � II T• / l /1B01Apl�NO 19e'aLD Code let rsde Gty Lots? "Btt� t i tit 2 i , �/ i eft` ti,>y I i11 $au t v hL 908 NORTH•SEMINARY.,SIRE Pi _ ''•_13 `4 ft i;Ai : . "cy i11 PeS � �E <S Yes O No �fi 47670 1� S19:DecMmrs E9i- .an"� 20 Decea 3 rHUpuvc Ongn"• ^ca t.•'- r 21'Der-tents Race• - - - Z* FilOH1SCHOOL`iGRADUATEOR'GEC (jgptl-' �Wit1, '� �-- • �'' --'4-" h - '}h� 111 ¶r!r- COMPLETEDIU 1:C?4i`":•'1iltnts NOTCHISPANIC EFA 1 �>✓i White 1 1 --*A 1 •'6-Sti l /f-- ' t-c t l 1.t t 1■ ii i22'Paenrs Name`Fnt�tMM dJ last/ r . r p .4•pF C 23• em's Name(FUst�MMdietlasg VITT(j% 723a�Paren s Last Before First Manage !' `'JOHN,LI'ESLIE'.OFEEY i, - 4 ..� i,\,11-.r- rCOEF.E .' . `a e - _�'� `y''. f.,3 MIN.a-Q Ra(b eel F.EY CASTLE{ 'IC' XelnSUrares Name"f Lq . I Qsai1 2Aa;Rela•.ia'tshp TD Dek'udeiu `Tess9 W ess (SSeet Nmber;Gty Sta:e!2iPCOde) s t IeasP?" Ie" W ' iNCYeM `Vs, . , tF .M.f Ft 9O .d?L;F >t tRttil jWt4767O 14 co NANCYsMCCOY'•a'� 1<'re ! ?";11� >. COMPANION - 908NORTFi SEMINARYSTREP.RINCETONINC47670�t 5 � :Cr g art2sQ./1$I�'��`l'%551-n �. ��kFSL2 4,213111 elauti`:+;'r"�®25 Pace in d,sposmm vnr.a.•cncut 4"..sx a `�.`...a.?.F.10Cil i4AA� L25a`MeEadOt est�r 1 Yf 2`ORace Ol Dispos'ton(Name Of CemeteryCrematay'Other Race)?i25c1Lwat CM,TOwnAM Sta:e'Y s• W 1 vu D,aP? a• .'�-�r1{y�1 Ea' D-' F'' e G O_eaw ®Gem` TOO DaItt al.O.emanemam •5 -r .111 ✓ - 7 �.1' / i� CCI,�c 1 �wlnt ;AV Jy c�V� t • �- p� �• t /rU..,O � `/ �4.i �' ��. I]:oa,a.(sPeay) �6� a7 \.- EVANSVIL•CEiCREMATORYb .1%-..t{1 � .r `.��(I7tE'F'V/�ANSV��It{L11L•[/ER'INAh. _> f�`s� �� �.•+25. lr CC/cenaas . > v' .1aneAM C.geteeAAAddr/ms OOf Ftmer FFaaa ttalty1t(tt��� Uftr[{�`J///��7 i iY1C eI `tt yar1Fs,,erall Nana Lame Nirter.: cc ayes ®NO 5 l 4 �Ilp (gl{N1l-✓�r,l❑t��epy,1 \I�r�a '�. 0 9 4 it j l ll• It�t�//a5.''�y' W Nt� COLVIN.EUNERAL.HOME INCi425,N MAIN.ST.,.PRINCETON�IN 47670 `sS. - - Eli83005674w-ls J 127b71sgnaae Cf IMana F,mal Serve Lreraee:lb•St' M3F I�M��M�Ey{���\ly�,pth�eil a: inc.IrenseNaneer of Licensee)):� .rIM { � MARK Rr•WALTER;'BYELECTRONICi SIGNATURE{All ,4 Lty�i�llU1dY64at7'i EDO:10130.10l°i ..2iFlllll "d'aU1n lltlUTi Q I Lf p �u f1 p�� Oa.e abeam sae lnsVUCUans`Ana + LL(4 Vi ��4t eland AWA4� °Ur• 2a onwsc�aq�r g. INl t iSta anxe" \28.:Pan l • s s`ryunas Or Canpfvtorls T .o Drealy Caused The Deadt\OO�Not Eraw�Termmal Evenes� \ /� / IrCerva4".Otsset 0 SCSuC,As Car+ - R Prat Art st W F,DNWtnn VJ,d,aa Shv«uq the EDOlogy�DO 7JOt Abbrav,atlEikar,Onty Ors Cruse On ' �q>�1\\ \\fr,sail, ALenppPtld 1 7 ;MCC! 1 v ° ,{ '1�R l ,,_ fir y�/� O ,kt U11 T Y ai i trr ''ail ;M C 9 1' . i tl�lltllll�2�1 li �l rr:4�}\/ /LIL l2 5 We e' . a,( !s .G.�1 " ,In Dean)'l• A/DYSPHAGIA a e 1 U 1�/-Y-A I i . 111 2 WEEKS r• v1 7 - 1- '� t •• •• • y r' �,��� ��- a, w�ta.. i.. m. "a�iV -01 ✓ '` 1L `fie a - z„,,,,41_,, .l �N'a. cE BRA�LWAS L-AR EN*"~ t:N. ..'��i.;.� 0.1°'A�1. wEEK �` 9.'✓ §equeanuy Lni c y; To The carnet tad on., .12 ti (/ Ln`eA Er,rer The Or That Wti�eC 1 1' �� I S.ITNa E`ve/rit;RestC.vgilriDeaV,)last rS�Y ALCr 11-AMI/LJ IItI1�JQ8fl U�u 1 1= 11Utl1 L�' !Ill Cc`1t S1'Sr NOWT. 1�t r a.mta.,..r..ro- o ` 1 I ---- . ".. �rr°�111aaa111aaa../� s ,. ti D;t `��,a3, `+a�'�� �./`, isa'-.4.4 -.'.- ......,.{�.. 11 Pat IL ErpayWn_.•rmu ` s-4\-- 0 But Nd Renlang ln;he•UMxtyinp Cause amnia Part'��IIloC»OO V 1�3L�1p Yes i PNOtIVE21.11 L/L� ps, yRUCT d tsl us. r'i d Jd ov '.1��A uTb-.Ccn,*te em ova nz Yea9.p No�C�' I� CHRONIC OBSTRUCTIVE PULMONARY DISEASE-6.- U' I tC› 31,Darndaco,u:eco.r4teTopari2 .; t32tNFwe�,twe..� ���7, �' s. 33;.N y°p°°m= c�\�� � �3U. �e74��'T ,]:(t� +�i i l Ell r,.r•.vener • ❑'rry u ao,c a ea A.a,.sve..a a.r.cure, ®Naaral'ID'HOmoY O'AmaerS•El Pentng lrnesdg is / ®Yee O Probably No ❑Unknown - it rii�dquterYi ,aOtn�'e/%4 11 0,_ 1>are..veonmar/r 1�sct--001 `!YI:,Li> °t I/�t%salir3Li� 1.611Uiete n1 r1V ❑ir!a TP°te%!A!w!bm-�1.e.t..o.sa no,nve,rar.srr. .e s. Cold Na Oe Dea`mvrcd tj 44.34`Date Of Irwy(Ma,m'DayfYeer) i 35 ere Of Injury- .,:m r36 Race Of lryay(EGUDeceaei,ts HomezConsmicuon Site7Resmvant'Wboded Area) 37'kjtay Al Work? )n.N�N� L ' l 'C y�e.�4 t'.7`•\ .♦% > ``:. -��' `1\❑Yes EN-o` �� fl���'. Tom. •_�` wati .4. � J• ' 7 \\.,. \\\�V�/J xr' 36.SLovton Ofa;�N�y:Sak �/ • 38a Gty O�r�T�Omn' )r t "3abnSbeat 8Nanba• 1 1 rL r 385--We No �❑Sad?TUPCMe kra �/3� De ��H3alrl;t`•a�m adr� `N `�•. '� \i T� 17f 4tli o o t al a-ago+% (SP� �'.1I11C�S" �LaJll`klariGl�l a N' 1 T e ��re�1 L F f ��•.4.A../el l flro I.Wri Iainf�fti..i..l llpQ ^C-...4 :}����{j IYf j• 5spmture:Df P,tsceryegcause Of D eamtlfl trnror iltk p� ffs.,,,'���rypp a2:Ceter2(Cna gvi'aiej17 lilt alltiit},�e�©�11A >�MICHELLE LEEtSNYDER`'BYdELECTRONIC,SIGNATURE9r/�ArUIIC/�d`•:"`� .6�t al'1111 yZ!CerdyirgPrryscantttllp,C«a,ar. ODHeen,Orsmr (.C\•a3.`.Name Adaresa AM Zip code Of Parson Certhina Cane Of bea ;, b' .. {sums« a,Number �a a 0aam Ceriled Af��II#A ll 1 -+,-, 113 /: mss r 0l[l f.�.2t),i� 7111IL � MICHELLEILEEtSNYDER PO BOXl948t328;Nr2.ND STQSUITE41O2,VINCENNES,'IN-47591,i 1 4� 02001984th +.. < 06412/20.18 aS"Adaaaw Fa,xa se r. er.•-i•N I t✓ V ✓ `i• 1 a I ' a q•;ekes- - t-C SsPivir INK JR VW ELECTRONIC raATURE a9. Fgil strarONy-Dace s(M��a�ry!sw >y YY t I . �� � �1{a.y��[ ��° °UFJUNA22018 3� )+ (/x5.91.11 35tAtccF.`i\1-11:•- ULV,� a�U ENOMENTjTO CERTIFICATE 0E DEATH'(ENTRY,OR ORIGINALIL`11 Me.rradani ∎al•a ALT/✓�([�!p{a7"v i 1 r t ( t e I� / VIII ( , I � 1�1 � I / II/ t I ��I I c: ,,,,,� ' 1d1 � ',l /, � ��,n `�.. / It 4,� � > /. l j /' / �' �1,� t v ti-.�_f. / w r L/State Face 53395 ATTENTION ESTATE The Swul`Sewnt #u Deng requestaE ty ws state gyve, y m artier to Wrsue respa,v ay..Disobs,ae n votntaY aM mere w1T be nb penalty r rehsszL a/g� 's°fir♦ n --� LOS:-tom d o-✓ EL l• mr FATEO D(A1&&CNB �I 11{'�} r{Y J V Y - N I NG'T JRNS L OM O A NG TO A MULTICOLORED BACKGROUND ON SP,Ec'Ar' S iDDEN VOID ON FNO THE,GR-'A PEA`R OF EN PHATE w,1EO CON BACK THAT '' -����r�--,--•N��OMt�CvTO�YELLOW�ENYRUBBED.�ORIGINAL3DOClIMENT.HAS 0.HIDDEN VOID ON's ONF lT:r1PPEARSA ..®E~.....00UREO'y_.a&& a ,as-