Death Certificate - Campbell, Doris J_3/4/2019 sirs„.,r:nwf-cur..:rn,..'s�..rt_v'�rn.?: n.A,er�:moisNimavr,gr -.-.e.. ._.an.-.e-.-.-alas*-=Crr yerr--,•...esermiS.T'.M rcrn.aseri rc:=Y'.nx.�.c.mm•n,.
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"t 'a% ' INDIANA STATE DEPARTMENT OF HEALTH /-----\
(stI CERTIFICATE OF_DEATH- / i
'' = Local No 000205 EDR No 000000665980 state No 047659 \--_)
_
Decedents Legal Name(Flu.MMCM.Last) Ia. Maiden Name (It female) 2.Su 3 Tme Of beam 4 Dauer Deem IMaewernear)
DORIS JEAN CAMPBELL _ BESING FEMALE 01:40 AM 09/18/2018
5. Social Security Number 6a.Ape.Yrs Bo. Unoer 1 Yea 16c Under 1 Minds 6d. Under 1 Day 6e. Unoer I Hour 7. Date of Birth(MomfOayfYeaf B BkoWCe(City ad State a Foreign Caaoy)
Forces', IC It Dean Occurred In A Hospital. 1 a If Dean Occurred Somewhere Omer Then A Hospital
0 Hospice FaWty 0 Decedents Hare 0!:wing Ha elLonptem Can Faokty
❑Yes 0 No 0 Unknown 0 heaven 0 Emergency DeoaMere Outpater4 0 Dead a Astral ❑Deer(R.ey)
11. Faciy Name(If Not InstMon,Gne Sweet and Number) •
RIVEROAKS HEALTH CAMPUS
12. Car Or Teem Sate,Am Zip Cooed 13 Canny Of Dean :a. Mental Stalin At Tim*Of Dun
0 manioc❑Maned.But Separated ❑RaWGed
PRINCETON, IN,47670 GIBSON -®Wiodw.p -❑.Never Marna: 0 Unknown
15 Sunning Spouses Name- 15a.Last Name Before First Manager 16. Decedents Usual Ortiwamon 17. Kind Ot(iuswulnouswy
OFFICE WORKER MANUFACTURING
IS Rtti cat-SW'S 1 IS. Cam te0 City Orion
INDIANA GIBSON PRINCETON
I 'Sc. Sweet And Numoer tad Apt No tali LC Code tat. L-see Gay Laar-sir
11244 SOUTH VAIL STREET 47670 ❑Yes ❑No
19.Decedents Educaton 20. Decadent Of Hispanic Oran 21 Decedents Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Paints Name(First.Mode.Last) • 23.Parents Name(First.Middle.Lind 23a Parents Last Name Bete First Marriage
NORMAN BESING ',THELMA BESING GRIMMW000
24.1.teals Name 2:a Relauonslsp To Decedent 24o Mats Mass (Sweat And Ntanoer.City.State,Sig Coot)
IVICKY CAMPBELL DAUGHTER 2715 NORTHWEST 48TH PLACE. GAINESVILLE, FL 32605
25.Pace Of aspectco
25e.Menoi Of Disposed-on 25a Place Of Disposition(Name Of Cemetery,Crematory,Other Race) 25c.Location•City.Tony And State
0 Baal 0 Cremation 0 Donation 0 Erecenoment
❑Remora.From Sam
I❑Daly(Sheaf') ST JOHNS CEMETERY BUCKSKIN, IN
26 Was Clam✓Caealeed 27. .Name And Complete Andress Of Ftneel Facile, 27a. Funeral Home License Nwnben
❑Yes ®No CORN-COLVIN FUNERAL HOME. INC.,323 N. MAIN ST. PO BOX 278, OAKLAND CITY, IN
47660-0278 FH19400002
27b. Syrian
Of(it Feral Senn,ce Licensee 27c License Nunbee(Of Licensee).
I MARK R WALTER, BY ELECTRONIC SIGNATURE I FD01013010
Cause Of Death (See Instrucdcns And Examples) Appro.irate
29 Part I.Enter The Crean Of Evens -Diseases.Irqunes,Or Complications•Tnat Directly Caused The Dean Do Not Enter Terminal Events Interval: Onset
Such As Cardiac Arrest.Respiratory Arrest,Or Vervcfar FimBatim Weer,Ssrowig The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Lin. Add Addittioral Limes 8 Necessary
Immediate Cause(Final Disease Or Cordltron Rest9mg In Death) A RESPIRATORY FAILURE HOURS
o.n.o..,ce...aaw Of,
Saaxrpaty LW Corddixn. If Any.Leading To The Cause Listed On B. CHRONIC OBSTRUCTIVE PULMONARY DISEASE EXACERBATION DAYS
Y Ow aide Y.ww a;
Lne A Enter The ee Cause(Disease Or In/LayThat In.tiated
Tn.Events Retuning
g In In D Dean)Last C
.p.•up'...cosine•on
D.
IPan II.Enter Omer Sn -ant far inns rdnlnW^rep to Dern Sul Na Reedong In The Urdr:yi n;Cause Given In Pan I 29.Was An Aunpsy Pettamed' ❑Yea ®No
I
PULMONARY FIBROSIS AND LUNG CANCER 33 Were Avoosy Finding Available To Compete The Cause Of Death? 0 Yes 0 No
131. Dd Tobacco Use Cw.move To Deam7 32 It Female 33. Mama Of Death
❑ ® IWaNy❑ ❑ 0 r^.ern sts,Psa.u' 0 e .er•. ,rn ...aoe ❑ a n e. ew as a a0 AA..0^r,.0.a.. 5 oet Nas:se]0 Hirice 0 Amara 0 Pending lmeswyaocn
Yes P Nd tfnMwwn ❑,u erne as.eviler a an.:.t n..,ens.o... 0 yea-,,n...inert.,n.c.a ie, 0 Suode❑Colic Not Be Deampned
13a. Dam O Ilyury(Mciti Osyrvear) 35 Tine Of',bury 36. Mace Or(Rug(E.G..Decodes s Home.CaumAdcn Ste,Rostawart.Wooded Area) 37. Iryw At Vices,
❑Yes ❑No
38 Lcor.cn Of Vaunt-State 3aa City Dr Town II 3ea0 $tri NtS ' 10 38c Apt.No. MC Zip Ccoe
39. Desalt*How/mir°corned 1 40. It TrauparatW(ray,S�Wty ❑
ep�9 �❑o..n,o� ❑....e. e.aoan ' IY4df
I41. Sgvdue,OL9enm Cer rang Cause O(Dear AK O "' 42 CeitSer(Check Only One)
RAMESHBHAI P PATEL. BY ELECTRONIC SIGNATURE M - / 0 Ceryirg Prysciat ❑Canner . 0 Hums Mar
A3 Name.Airless A.x ZioPerson Code Of P Conti g Ceara Of Dirt.^. - mi. License Na er 45 Dal Cer_5ed
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IRAMESH0HA1 PATEL . 685 VAIL ST-. PRINCETON. IN 47670 'n - nR
I' 01040266A 09/20/2018
A6 etdnFransAaFrans � ovi SX, Prder. - ON C' n N 147. 'A:aa
Ia6. Sgnatxe of Local Heat Ottcet - Gtds 49 For Registrar Only .Da Ftlee (MmoUDaylYea):
BRUCE BRINK JR.VIA ELECTRONIC SIGNATURE OCT 01 2018
I AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) I
AMENDMENT
- ,,A-000 %fig - 004_ '
State Form 53395 ATTENTION ESTATE:The Social Security a is toeg reguestec ty this state agency in order to pursue resoons:bAty. Disclosure is voluntary arc mere will oe no pena.tg for refusal
SAIA n A 1 a A 1 et- ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT