Death Certificate_Tackett JU r, -
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1•,}- rt • *S. INDIANA STATE'DEP• -TMENT OF HEALTH'. i
di49� CERTIFICATE�jO EATH �y
.,. f Lora No 000177 EDR No 00000..05'97307 State No 04402141
)/ I.Decderns Legal Ne�i<_';(Fnst Mae,Last �I�Lq�L�� It MaideaNa 'e lineman) 2.Sex 3.Tine Of Deatl. 4 3Da(e:Of OeY.h QAortvOayJflm/
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RAYMOND H TACKETT V MAPLES 07:37 AM 09/06f2017
5.Sada Security Number 9a.Ape-Yn I.
eta: Unties.?fern`e Under 1 Math aG Under 1 Day 9a lh,des I Hot 7. Dab o 1 ry
.�j .. Al w T'
Hospital - v,I
i H . l0 N010.4 Fadty 0 Decedent's Herne 0 Nursing HanMocpbum isav
ta Yea 0No OUnknwm 0 Inpatient 0 EmxpmcyDepartment 07atent ❑ADea± ❑ot,er(Sper+fy) _AL
C . .1,:Ft sty Nana( Nat G• C eSn.o and Name) ®M £]��AP •
GIBSON-GENERAL HOSPITAL .mb. d.SO .Y.A
ill 12.City Or Rem,Stab,And Z•Cab : 13.Canty Of Dents 14. Mental Status At Tam Of De l p�-�y
i ,�,�,• 0 M.anied❑Married,But Separated.❑* iced
PRINCETON, IN,47670 ,ir GIBSONIYi� O Wdowed ❑NeyerMeeied ale/room
is ' 15. Swlynp TSBpa1tati�al Name IN-1- 15e.Last N Be:aa Fast Mantape.4'hy 10. Deaden!,Usual Ompata, 17. Kind Of sa tjx -
C.
1 JOANtTACKETT HOLDERBAUGH DRIVER S RAILROAD
,i �1a-Re :Spin fees.Camt'J � lab.City Or Town �y0
INDIANA40
•
• NumberGIBSON . . . PRINCETON �� e.
- �`�/' sad.Apt No. ,ee. 2N Cab . +N.h�iiEa(]':yLaMe]
s 612 SOUTH GIBBON STREET - - Fir �C4Y�„rea ❑No
' B 47670 .k a S9.4Dradrpe Edt,mbc, a„-q{qy 20. 0eadml Ol Hen cOdph r' 21. Decedents Rea
b 9TH--12TH.GRADE,NODIPLOMA' NOTHISPANIr White . `
22.Pups Name(Fast MIdde,Last ( - s O Yg'� - 23.Payer( Name(Fnt,Mitts Last ` IP 23a Pre,Last Name Belie Fast Manage
• EUGENETACKETT aiF�. ?. .. ANAHTACKEITIC �` CONNINGTON' _,xt ,'
, .. 24.he.,....pa Name 4�.,�t, Ttr 24a.Relatonap To Decedent N0.M*LN 'lil y And Natter,City,Sun.24 Cob) - - Q
JOAN TACKETT u2r6. �' WIFE 612 SOUTH'GIBSON STREET, PRINCETON,IN 47670 . '�i
Mead - �Tn- .� 2S.Pbcepps lion'S
®� poo r, AP 25e.Place Of Oisposilon(Name,OL'eme:ery,Cremabry,Ot,6iPlace) ' 25c.Lecahn-Cry,Tome,Am State QP
A ❑Domaan❑EnameneNap&Ys- 1e- -_/
•
IJHRten. FranStb ���7yy77
,�Dtr5Tspec c ODD FELLOWSCEMETERY , PRINCETON,IN .# .
2eiWY,Caaer Contacted? 27 Name And Crnpbs Address'$u,cal Facility 1IW 27a Funeral Hat Lla
no Hunted
. A COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON,IN 47670 418300567:le
Signature v even¢Fate!Seam iicensee: �� 27c.license Noma(Of Ucreee) t,NZP
MARK R.WALTER CBYIELECTRONIC SIGNATURE d FDO1013010 .. 'g
st.r'e2,,�I `�OifE mi gire yCaeath (Saused he De t DoAnd EnrnT ( .• hteroxt On 1S;Pr11.Enter The Shah,T)I Everu4 -Obsesses,In/tries.Or Compfrationtkece. y Interoxiato
Suxi,As Cardtc Ane Res ' Showing
The
The Not Abbreviate.
Not Enter TerminalnlyOr Events w
„. it P Nay .Acres(Or Ventricular Fibrillation Y, Stww'u,p T},o Etiology.Do AEbevia;e.Enter Only Orre Co {; �` To Death• A Inc. Add Addibtl Lhes If Necessary. .-
ImmediateCause(Final Disease Or Goret..i000 ResudsN In Deat)[5. A CARDIOPULMONARY ARREST _. '. MINUTES
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ib
Sequentially List Conditions, If Any tea iT he Cause Listed On B: MULTISYSTEM ORGAN FAILUREa1. - J AN 2,' j0' YEARs4'�'/
Line A Enter The Underlying Cause(Disease Or hay That Initiated ' '6ar`v�sp.m lot As A�p an: f �The Events Residing h Dexh ylast°.1 C a01�sAq'01� • .�.i .
r})"�,11. a5 - . 'rl awmlaAAf actor(.
,' DEC $, z� aUD1TORh •
Pecs iq ErtW W,rS:n'.rmt Cehdpnl Cotext-ina to Peel But Na Result999999999999 ThaUodalyYN Cause Given In Part l 29..Was AnAutmsy Podamed7e t U
'IABETE '., ,1gi - l[[1sG ToCc Yes ®No
DIABETES MELLITUS .sw 30.Were Acbopsy_FvcicIha�atoRO Comte The Cause Of Death? ❑Yes ❑No
31.OM Tth ¢Use CebbuteT.Deeth? ke - 32 IlF��e r 'e , 33_Maher Of Deal _stAti: ._
❑Y -.❑RolaFAy❑No ®,,UU *' ❑ }" �'❑wa r nil&crave 3❑.w!es.: e�pn ,rvcto mi.aa.,e - ®N axes,❑Haniode ❑' .a ea ❑Pr:1414 stgaoon
•, s9A y. ❑arn.aea e4 nnwo u am wa.e..one :❑60.,„„Dt.r.441a,,,.n:i:.y.., ga " .
34.Dab Of Ir#ry(Morth aylleat'((3 35. Time Of Injury - - '38 Rama�r2� G,Decederte Home,Cauficton S e Rest❑CaW'Lila Ba Detam,4id ' I11.R�'k
VAT
-• Y" ' ,ta�r,t Wooded Amer 37e(ki,sy Ybk7
4 R.4 dO.7 d •
a,+ 1 �OY ❑No
-i''38'Location Oftiay-Stan 38a'City Or Tabuqpl -. 3aC S, et&Nto:er
�`�. � t µ�a VC1.7 Sac.Apt.No. : 391 Zip Coda
It . - t ,u. /
39. Desbibe How kith'Ova¢:ed irk ISp .den ,j9�
4y) i pis ❑an.•xe... pY..•a..�n.ae ef ❑a.aPa)
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41.Sin,Of Pessa,Dvlfys,p Cause 0lOea.Ri I �-, � flier1 '. 42.Chaffer(Checkctry one) �'M"
MISTY G.HOKE,BY ELECTRONIC SIGNATURE , - • tut A tk Ih4': ... . ❑Ceru tc Piryeltlen 0 Once ❑Hea"IaOfier)
43.Name.AddreasAnd Zip Code Of Parson CerttyUN Cana Of Deady - - .•�`{T��r:i - N. Liana Mona 45.-Da%'Crtled
MIST •
Y G.HOOKE 203 S.PRINCE ST., PRINCETON,.IN_47 -. - VJ' _gc,.# • 09/08/2017
�,EC�Otel Fu+eM Service Provider , n )�y[, s;D c .'WV
a8'Sicnaare of Local Heath Osca yam_ aAl,• - .I, -.', .;p 49. For RaplsearONyy t Dab Feed (Maieayffeat
BRUCE BRINK JR,.VIA ELECTRONIC SIGNATURE ,' I:in,tl�d SEP 08 2017 nit.p
allays?.. - AMENDMENT TO CERTIFICATE OFUEAT4(ENTRYORORIGINAL) - _68'Es•'
dAQ a - la O(7= Q - bo 11e# �,� Boa
State Fmn 53395 ATTENTION ESTATE�rihe Sd®I Secaiy#is requested by This state aten i„order to µ n Yrespats3#iry. Discl44 osure vo ry end there will be no penalty for re uses,R.
WARNING: oRIGINAL'n,IMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WtftJEJSSE ,x,pp
ECtlRftt PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ONAft BA .THAT
R.SEROM ORANGE TO YELLOW.WHEN RI MIAFO ^01MM/a Mei a.v.,'. "/Srm •-•••.e........___.____ .___._-.