Death Certificate - Muncy, Karen_2/15/2019 INDIANA STATE DEPARTMENT OF HEALTH 1 0 0 0 C O U
(rI CERTIFICATE OF DEATH
`� � Local No 000250 EDR No 000000679524 State No 059326
1.Dradrts Leer Name(Fray Mae,Last) I 1a. Maden Name(If Tenet) 2.Sex 3. Time Of Death A. Date Of Death PAndstaytrear)
KAREN J MUNCY J MCCALLISTER FEMALE 03:15 PM 12/03/2018
5. Scci Stony Nuaaer Ba.Age-Yrs Ea.Under 1 Year Sc.Under 1 Mae ed.Urat 1 Day Se.Uhler 1 Has 7. Data of Brn(MaWDayfear) I @ntdaca(Cry era State a Foreign Catty)
73 Marta Days I Han minutes
Has.al
❑Hoaoce FMuy D D,mderls Mn 13 Nurvp Hemelmp.e in Cam Fadsry
0 Yes ®No 0 UNvwn 0 noCra Em•�vlcy Depsnwr Qrhawm 0 God CO Nmal ❑ yl y,)
I
It. swan Hems(If Na ImW-pry Give Seed an,Number)
RIVEROAKS HEALTH CAMPUS
12.Cry Cc Tosv Suit An to Code 13.Cum DI Deem If.Mental Status At inns Of Death
ID Manned 0 Maned.Ba Separates 0 DAarad
PRINCETON,IN,47670 GIBSON 0%Meowed D Never Married 0 Une,w.m
15.Srnewp 5paae's Name 1Sa.Last Name Bete Fat Manage 18.Decnaas Usual Oawabon I7. Krt 01 Duressbcsry
JOE W.MUNCY FARMING AGRICULTURE
15.ResgalCa-Sx• lad Catty Ito.Cate y Twat
INDIANA IGIBSON FRANCISCO
IBc Sall Ara to nLnet 19e. Apt No. IBe.Zn Code 1B1.1mb.Cry Lands?
5540 EAST 175 SOUTH D Yes D No
I9.Decedents S .caoa, A. OrMetl LYHispairagn 21. Decedents Race
HIGH SCHOOL GRADUATE OR GED L�^
COMPLETED NOT HISPANIC White ^ -�
22.Peels Name(Fat Mack.tarp 23.Parses Nan West,Made,last) 23a.Parent's LestManage t Na,.Be •Fret Panay
BERNARD MCCALLISTER MARTHALENE MCCALLISTER I 5 2019
24.VNmaKs Name 24 Reletats1p To Dereeeer 240 Warp AOdwas(Steel And Mond.Cry.Stab.Zt Cod)
JOE W MUNCY HUSBAND 5540 EAST 175 SOUTH, FRANCISCO,IN 4764 - , bet
25.Place Of Dspos ten w ,.'a'A'�'/Yf'
25a.Whoa 01 Cupoaia 250.Rabe Of Ds00siaon(Name a Cemetery.C.m.eaey,One Race) 25c.Locaa,-Cry.Tast.Aid slas.V IBSON COUNTY AUDITOR
❑Bo re ul 0 Ceds D De aSa D Em monMne
❑Ramat Fron Sib
❑Ober(so«eyt EVANSVILLE CREMATORY EVANSVILLE,IN
25.Was Cana Catatedi 27.Mn An Cando Address Of Fin a Fatly Pa FM,ral Mere Lin.Naar.
Yes ®No COLVIN FUNERAL HOME INC,425 N MAIN ST.,PRINCETON,IN 47670 FH83005671
27b.Sprcue Of Insane Final Sarwce Licensee: 27c.Lane Nunn(CI Ltenne):
RICHARD DEAN HICKROD, BY ELECTRONIC SIGNATURE FD01012153
Cause Of Death (See Instructions And Examples) Approximate
28.Part I.End The Plan Of Fvewe -Deeuas.Injuries.Or Conpecatiov-Thet Direay Caused The DesUt Do Not Eras,Teoni e'Events Irtenzt Croat
Suet As Cardiac AiresL Respiratory Arrest,Or Vert/tube Firilatim W;Pout Shoeing The Etiology.Do Not Abbreviate.Enter Only One Cause On - To Death
A Line.Add Addanl Liles d Necessary.
Immediate Cause(Fatal Disease Or Caddon Re tti,p an Death) A HEART FAILURE WITH REDUCED EJECTION FRACTION
Me a roan reuses--en
Sepuer ten List Candela-fa (My.Leadng To The Cause Listed On B. LARGE CELL LYMPHOMA
Lire A. Enter The tIde n lyip Cause(Disease Or 4pay That Initiated o"•ra`•r'..""aoe
The Events Reacttsg In Death)Last C.
we s la Si A ra-e.-ore.
D.
Pan 5.Enter OM Sanemn Gemstone Cmtnto v-to nen Ba Net Restore In It.udertr;Case Given In Pet I 29.Was An A.ttsy Pefame27
❑Yes ®No
NONE 30.VMmA 9aay FtWSAUameief Complete in CalupDu:m> 0 Vas 0 No
31.DO Tobacco Use Case,To Deem? 32.If Ferrate: 33. Maas Ce Dean:
❑vat ®Pmpaay❑to ❑umnp+n ®"'N•re"wr"•••'•" ❑...r..At to..apante. D ma pant la..es-.wen am. Ono oe ®Nasal 0 HandPenanga e• 0 Adert 0 Penang Inveary n
0...men as"....a we Ti'l-sus.doe Chase•...re.Yen.P.P..M. 0 Stem.0 Cored Na Be o.rem:md
1 3e.Date Of Iteury(MWVDry/ysar) 15.Tine Of Injury 38. Race Or Lryvy(EG.Decedents Han.cansnabn Sat.ResaaTt l,tO eo Area) 137.Irryy Al Work?
D yes ❑No
38.Larado Of ltjay-Sure 38a.Cry Or Town 38b.Street&Number 38c.Apt.No. Set Zen Cods
39.Desooe Hoe Itpty Ocned 40.If Trnspeta'a,b tsy.�SccmY:
A1.Songs.Of Peer CetMPg Cause Of Dealt - C.Cotter(CheckOnly Coe)
PIERCE D.ARNOLD BY ELECTRONIC SIGNATURE - ®canning Rrysaan D Corer .D Heath Oboe
43.Want Matra And Ln Case at Parson Crying Case Of Dent - . at.License N1n er 45.Dab(T•e
PIERCE D.ARNOLD ,685 VAIL STREET,PRINCETON.IN 47670 01076381A 12/042018
46.Ad:0TL Funal Grote P.avar l7.'Alias:
AS.Signals,of Local Haiti Ors. a9. Fee Registrar Dray -Ors Feed Ia tDayfYee7:
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE DEC 05 2018.
I AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
b6-\S-\°- Wo-oo\ : n11-+ - o oar e
State Form 5 ATTENTION ESTATE The Social Seaaity e M hang requested by this state agent/in add to pnue responsb6ty. Disdossre is vohartary and there will he rd gently la Mina
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