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Death Certificate_Smith P"FF rt,1n let Ilrin rtn/rn!+E rynn r a i Y V.m , II'LVt'1.M T , e , .,1 - - ATTENT*IDN STATE The Social` Sec�un a y't r ��v- `'tea •�-''` `` -- ,3Boonvllle•-�N,- N• ,t,., y '' re ue.„.,,fed ;ttJs pwsia erlcy In Di t, ,D A S g `�"' k t` , 'Ir v, \ �` pu(SB I(Qs sla(uiory.responsblggty Dls<ID 8.,5 INDIANikaTATE DEPARTMENT7OF4HEALTH �' T`` '``'SEP 1 8a207�, s volun ary and this WJI be no Penalty IDr reh.re l - z tr».a �' ISsued '- 1' S..rxy :Ivy, s NN Local ND W. OERTIFICATE`OF,DEATH State No �-: . +1 5lI W�.` T,.. REGARDS IN THIS SERI.S ARE CONFIDE-AE, P;ER IC i-Mtl0 f• ,fttr .Ln ce y __t i r, •'I DECEASED NaYERtF .4M.oul..0 V �'�? i 1 SEs \' \\ TAII YPE/PRINT4 0 ED IAUSIa , N .4 1 fs 5. L,MEO DEaM se oarEOFDEA-L o anti k a"=1Ns`` 4. jrMJames Leonard Sm(th " < 4,-,-_ '"_ 04 ]OrPM ,Sep _mtier 1 O. ' ii t17< � PERMANENT '' ;,� f g 'tea. i l�+:s"3�"�'Fs^.�'�: -'-al kA W.S DECED NT 1 $b.YEaa LAST SERVED W Ct[`i Lt �'-"t-9. PU 5.. ..esmw)tG9 td .a"'-,, F-F EI �,� }A VS YfTEMNI r �t VS aF1.,ED FOPGE57 6� `� -1 `�x ry� .Y,�12�`"-- •"l�'.1,!S z�i�Tt. iC'Y-� HOSFiPLa�}}I,wnMa ;��G(K 'E� iCE;TTE4EAfiTti;„;;;. ...r } �O OWN(SW Ij�� 1 y+�ti r_3. YESR.J.)T vr a l .. ; . r, 5 :-""' A 'i _ x- Q E_,. «n ❑Doe _ ATI fl.w < a a 9e FACALIrY.NAME(/rot ew,m p+y,0'M.V runDrl K Sc•CITY TOWN Ofl IOCAiION OF DEATH 9E COUNTY Of DEATH ? �DECEDE:N\T.�s'S co c to,. &,".ltal -���~ l,�; lewbur 11_ om, `ID AUgiAL SLAWS i I- vL'.G SPOVSE I<'+"d II EDECEDFNTSLISU.L000Uv,LilOnlGwwd.o.t. I]YKWDOF2 S+NESSryTOUSEa9B a `i\ti ` I `\(Sa(h) �G - (v+A.T mNoe.+ I , wv an'ro ud ro+.'q YFwrcr o-MN V`F e' i f'`+, 4i ,Iiarcted y'"� i\7ar�arei'Gach t '� I:Bus(nessYlanater - --; Co�,n�emenceStore' W ESIOENCEr ST.TE rr I I3c CnrioWNOB LOCATION 'i I SC_sT1EET ANp NUMeEaAbat t5 i ,� _. y+- 1£ �. ° x 1� 'Indt na T" � s Gibson�k ern I ,.pr Y, 3 ;I.T4,1 e. , . ,- ,Pnnceton g 9"_il South-Deerhaven,Dr'� ,o. ," > `� hir(`< yNy t1II�--I-,O.-1-, --1+6.1NSIOf C1'YLWir5y I ECIi2Er.OF C IS W.SDECED TOFM1$DAMCOa1Gl - 4' t6 MCE en✓ IMur �5 l,7 [IFCEDEniS fDl,CarpN-:' }.'• i. '�kSda.. 5 W Ng6YLC 4W ` AhDI.v. a i N, No ra :N.•IN Y 4 y Gn. �V.`- r "I.:4SY iW«5f o-r lv.a. jE:i::�.n '� -4l670 "o ON A FAP l'tQ U S�.A•-'- - ae:-E�`@•,�-t1'�`. '_ � ',�s'*v(sc,Nr/ --'•a~ii Y/ oro., I•)HI c s s'v� a.c ' r(0. ._ Vhite- - I2 1- x -.� n ' cam : v- ❑w,O.Yn-s �. .-:;_'�_ _..,. .ir. ,. - � ,<; _ ` PARENTS L' IE FATNEaS NAME(F n A4Ed.!aN 3 S - • < r< 19 MOiMRS NAME(F N Mgd..M.-•.n Slrn✓vl ti "'p .5 e \ Y`S'L��- .'T*:rMRc l", huts rr x..a. {�., ,E.. dN�L�onardIr,�mSmlll _ _��� Velma PearlDati ti� - `>L INFORMANT � b' wF05urwi5Ne4E(fYa./or.J ` -" ]e I.u2wC.ODPESS(S& vMrer Rwi&ci N Crya.% sji,z Coal ]4c haxn'.r saw t:C \.g M'�31'a f(�i1Elt"Ir P2e_ S�i�th �- i r9 _� c c: x4r 'tt. l% tut iztr " ate g, �,,,_ b} =941 SouttisDeerhavemDr Princeton In 47670�,_ fe r'F - �' • }I ME TFODOFOISPOSITk3ii Q!E,NNnbn. _s�-. IID-OAFE AND P5dEOFDISPOSIlION fNr»d ..-.vryc ,.. c i1< LDCA&,n Cy i $ui W"Gg G h S L.:".: v ,�-r_.` .,, p.� "xr-f" --�eE.r" _ r� - Y " dis., ' -•�. m a.�N g•^O�uN,veD ❑,a NI s.w-- ,?,:f4.F i Sep-1-4�007 4r- 'v f -: , t ❑� -. s tr Kerr*, tenor BnncecEA IN r _ � O onN(sP.Dyy, 1 �5[i�Jose h Cemetery ,c � 1,� r - of l_ DISPDSITIOY II'1MSAZ rF-Y;T " -T'� � EY1If E URcER5 UCENSF NOr t, ]11 .S DEAT PEDOaiED i0 CDa0`IEa+ � 8iar.5 R 10'alier,� -..-, a7`Cys- „^ �LED01013o10_ K n x(7 '._ o Ew 1 i-• 1�.`$Ni•4iUPE DF FUh£PAL pPECFOP' '� 1. ' tzS ] e LICENSE NUMBER -- i5 NAME ADORE55 AND 11DENSi UMBE OF FUNFNI NOME-'rs� i < rf r �� F e �i'4 , !� �` a h rtil( 'L.ozi(e €i�`w� '`2. 7� �:.n c„ .:I =, z.l ttit � .,y -,,t.,. Coh�nPuneral Home IncFH8300461 f°s ' F a'' (�(%�/ r , FDO1013010�\.�4 ---� k P--Iq r- a3 ` , (� ,C� • �„�,ri , a�i4< 42�tNorth Mam Street Princeton, 1N 47670 s -''F - }Z`-L `. _ �i4 IFS'lt- '!i\i`l. ;1\i\\ �1t\ x1 �� :-. 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'�pi +cY2` -_y �` � k4 `v*-., 'A `- L t-rs1-" +• 4 wr wr .DDPFSSOf faiT__nO COM. .,3-CR 5E Of _..(ITE4l6i(i-."-p 4,`� . �t��x C \ �`` .t '-i a Thomas�Va(rs c0in:6 :11Ea a Suite I110 ETa svElle E7y1,/�7i1 4,' \ _.- g i s 4 t:11 -.--N OfFICEP55KJ1AiUaE�q•-C ]c C f / X - t- 81SDAiEFRED(Mmci'or Y ) '� 4 HEALTH "y' -s a- U ys wg is �. n }, M s .Fr OFFICER F"il aS `r''Py.` t�,+` .0cs �kL;z r v y _ t - x ./ ' SEP 1'8y2�01 - ^` t\ Sl2 MANNEa OF dEA]M ). 4D Of LNNPV $ -1i�\iWf Of Ss.c aJURY ei , 141 D BE it''' -RY OCCUPoEOJ i �' r `AW ( hLi+. )j.,''>s �,,. ut lww''w/v n -yPlA!({Y ` lr o.a), n\4 'V 5.. \'t 'fit `�. \i`A:S \ 13 Fc`ncF l S- 1,eEt\v ;-' 4v : t!, ; •ui' ''-- `3<••• • i\l t I. IY�N. . y0 Pv2C.4 ___, ,- l is t - ', p. 1 s' rD S �.,ys° �' 5 PLACE O<e.,VPr I nom r v ll ,ar en Nr 4(8 LJ^J'O aw IPNI wine«Cry r S,n) 'ft 3,y, A. �``~ �` \4L -.,0,n m++w kE`-3� t om -- �\ - ti �v j � ale � ,� J,�0-'7 DPOI:WnCEDOEep(Mvw alyWaJ }.�M°rOa vENICLE.CCi°ENir lv i7. r arr h �' '\�:� -- hv"f- -� �rC-sx Y,.r- �a Y,. - 'a� t em r F- F,x . - x^_^ �:- u �� r s : r s t GIBBON COUNTY AUDITOR -:s .tip 4:- .`._,., •a-i ,,, vh---Y- -c 4 r^ v^ - 'ib- L.". ..2i to& - -Tar 3` e'--sue Shier. >ar, ; siisen '; _ 4i:SOHo6,004 St ).0)FOrm 107 10(R5/1.99)`�(2 -. I,,,l. _ ... . ' �'�-'$"_ - - ='�f - VOID IF ALTERED OH ERASED•NOT VALID UNLESS CERTIFIED BY HEALTH DEPAR4lENT • -L—E0 — q 16-z s t —ZI— 9 • -Lz 0 - oZ • 00o-- o0\ - � '� L NOlIan AlNf100 NOSBI�J 610Z 8 Z NV1 UWild