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Death Certificate - Kolb, James H_8/5/2019 ,iWia� [� ��rT n ice. V»l/ ra�+InY. 4 raW�Nw��llhVT-- !/��� gfGa .. -; . iI �� �o'o�/ ~�\ii \ / INDIANA STATE2D'EPA RTMENT OF HEALTH? �'� '� ' / '>� I� 4 t Ott /t ; % f •C jGCERTIFICATEjOE DEATH%� ) ' �" . 1-" - • . '/C�. ; I /tom . G< lil�\ tl•ltwA�`�II � '. .. ^Ct� � \Local•No 000524 .0 EDR No 0000007-23305 \ :037237'. - `� h /5 �,`St 3-Time >.u �, Ii1 DeseeeKS Legal Ham 'lam Warta.La U ;', Il ;, ' 1 � i ,1�IOenName( aleh �11 ,\ '1 3 Tme01Deat , <)OTeOfDeath(Month/Day/Year)�-._<9 i l/ ‘:1-...:, / 1 1./ JAMES:HERTIS KOLA\ a v • �t_� -�.. 1 w 'oi /K ALES 05 48 PM` '. 07/eQ1Coi County) C \Sa al SosnryN bar •Se Age Yn 6b UMerll Year Sc UM t\mb 80 Urber.`Day ffe UMer,iw 7 Daeof Br. (MalMJaylYear) B.Etnplxi.,e (Gry and Staea oteig Carnty)S (ti 1 s '/ qal4 1 / - / AI VT,' C11 t 1,A�� ��� V AA. A�� . VA��A V�� p sospce Faeati> p�DttelenYS Hon ;p N nvg Hometonptem:C reFaoary n ;2 V p Yea`a Nol p'Unknown ®Inpeveni.0 Emergency Department aWavent p D ae Aniv 9 \ \. l 1/ ❑Omerh) 1` A� �/ fs ( �� 11 G� l G11;Fa yName(IfNotInsttsbo.GlueSweetaONumbed I�/ r (1 I , ' v// / • , • . e %` I -;� DEACONESS GATEWAYi %� . .. '; -C • 1• /t'� ' t // • vv t , , c vv fs[�` )its s 4 CityOri Su A�:1,?,p,Cod A_ A' V A`' A , 13•CanryOfD th� A 14,Martin Stars At Fore a Dam I 1 ),t. / / , %i t i 11 1, 11 l //% /', "B1'wieotBO .0 N erEiy Samara eE 1c1 l.ni wn d NEWBURGH�.I N,.47630/` � % /1� .:. WARRICK� / i. p.NavetM �-e,❑ant nomi, t l 15 SVNwsg Spouse's Name / t `(, .„ / \ 15,Last Neale Before First Menage:, -. 1s DBCMenrs Usual net,A .Me. - 17_ KIM Or 9euysairdus'vy. til iii G i�.� 1A � I G v --, 1 / ` / . /�1i A.,I /�, COUNTY TREASURER /' GOVERNMENT%r�N� ' e Resicerce Stae l' 1w'/ s Baf County 1 1B0 GryO Twm ; e. Gt-�Ller,�/�� �iG%l� •�f�� w ,t'�: .. ` % !1t,� 1 ' �V'.,I�/ 1 . i 1 � i Ilj 'A. , INDIANAAA a\v � �� GIBSON v v vA��t c PATOKA`� ��`vA�o'. -. . ▪ `vt • L 1ec•Sweet And Number 1 \i 1,• / i ',// l j/ �',, , n o j I , /� lea Apt.No 6e 2p code to ImberoCdy Lme7 P. 4 I ,0�1 : I // // 1, ill,// 1 a' // i 1 ` / 1 -j I • "11nN/� 1 /` l �I It V p0�1� 1 > /� 300PEAST 400 NORTH / �� 1 ��Ji47 6 • 1) ❑Yesll plNo 1 ( t9 Decedents Educedon • -N., 20. Decedenta Hi marvc Qi9n � \\ - 22 Decea (s Rai! \ � \� • �iI \ ' MASTER",SDEGREE(A MS MENG / �IYt�-' � ; �j / l I� %r L MEDIMSWIM BA)•._ lTl I /,01 it NOTSPANIC I 1llli% ;l ti Whie▪ lll , rod/ - ▪ ,!�9 (1`),r. `G 22 Parents Name(First,Mladla Las v ) a /' /- I '23:Parent's Name(arm;Middle lasU 23a Parents LastN Before FirstMenaget ! •/ V /< V �"`h A ��y ,� � v i V c/<� N./ v A AAw • � HERDIS CLEMENTS KOLB P.r: , 11Z\." {�✓: VIOLETISABEL KOLB „: CRECELIUS - .T5 ,24:INormanf Name,„-- / l / • 24a Relatonsnip To Decedent,.✓ , tab Maine Address(Street And NAnd Manner,City.State.Zip Ceder• l \ e }t1"J ' I"- JILL EMBREE ""_Is-----, _�s ts 0,-_,I DAUGHTER- :-N 3001.EAST 400.NORTH PATOKA IN 47666t40-, 1 'CS -.�' Tom\fi e v -z%� NAvV - s : - -. / ,-'i125:nce of u.w xn - IAA // 1: mien �_..Yit-' �� LG 25a method Of Dispoti one/ 250 Race Of D.sposibon (Name Oft' eery,Crematory.Other Race) 25c.LocatonCity.Town.And State I , yt V Vf ❑1&raL a Crcmabm p'D«,aoon❑EMo/bfneni c I ///, �/ // i' 1 I�y lI'i l • -/ / ' G \ p Ref:Mal\s t lt� �, ,�1/..\\'iN I \\ \�\C . \\' • ` 'C \ A., T�I C p awispeery) 1u \\ o �- / EVANSVILLE CREMATORY, .1 \\\\�iiu\ EVANSVILLE IN \ l' t 26 Was Coroner Cwrtactedi'i 27 Name Andcomge:l AM OfF alF try %/ 27a�Funeral home License Number: 11 G'i / /1 I I// +1 U/ / I t ° , / 1 �/i t .// nu l II Desl®No \ % COLVI FUNERAL HOME INC 425 oil N�,AIN ST `iPRINCETON N 7670C� .: 0� j H83005671▪ It y---\ n 270 Sgnatue Of Indiana Funeral Service Licensee: A V,i� A Q. A�///q� / 27.,License Minter(a lse see) O > A: 1 A , rif.0 ARKIR WALTER:;aBY ELECTRONIC SIGNATURE•// �i G h, G//.�l I -� FD01013010 , -- �-s/ • 1I 1 pp - d '„Oause OI Death S e Insirucbpna A a la 1 / �p0 ill%ul II/ill n�%t , /,� A G . - r1 1/l. /t A J"av`°'rae(��)C r28 Part L-Ente.Tbe st RespE Events Diseases IM s Or Complications That Deeay Caused The Death:,Do me Te nalE C' d\ \ \- Inetvat Onsel \S(L.n As CardiacWrest•RespeaOry Arres.,:Or VerWwl2r FitinOatlon LMthotil'Snowing The Etiology Do Not Abbiev e..Ent O Or user) . ` To Dea:ti „ •\ 'A I:at Add AGdddnrallLnes L Necessary��� 1 � I �/ ` i%�,lt 1• ." �iGi •' 1•f� ��/ ,:mA l : -.1 e / y � /-c ' ')Iclmmediate CeuselFinal Disease Or Condition ResWurg In DeaN)/ if.�- CEREBROVASCULAR ACCIDENT t1�0 :_/JI �s I1 lH /� 3DAVSes U.%// � ar ,1/ 1 �„)? i/\\ . ".� ', /▪ c ill11)/ 1)',% ' , I` Ai '� tl4 lI (\ \\_Q ‘ \\\ ��t \\�`' \��D.�HYPDXICRESPIRATORY FAILURE\ �� \ \ '\• \ t OAYrN\ '� ( - lbekft Ent LstCUnd erlyi I Pats LDiae TOThery Th tIsteded w.eiaa oo b , G ILne Event; rTheing In DeatCaush) sei Or' 1„<-That'1 Initiated,' , ti/�^'PN E''��UI ' 1-,,,,,-"" •1 / ' / , / -�'+ `i S, - (The Eveennte\es\ting1In i // '' 1 Q ASPIftA\ION UMON \ i111 l �/ 1 DAYo`�n ll It 11 j N 1 G. 1, II��\ r � \\ i1 � 61t�SON S9UNTY AUDITAP � \ `��� I`j 1Pffi II-Fste;Omerswni Corc Lo Du' D m- But Not Re ;'''',l_ ne UMertydq Cese Gienln Part'/ , 129 Was AnAuropsy Per•onned'1 ;Ipves%piNo / ',Mir-4 '``�I / / 1/ 1 t,l i � 1 I t/ i I t 30 WererdmvFinding,A - T Complete CauseOf Damn t 1 , tr+�--�•- .•n^"'crl . ->- -t n �Ye:ip Not(• ��' C• 31 DM T�o V Comntexe To Death7 32 If Female VGA�` V� ��AA J Q ��`V 33. M a Death�1., V '.A ��", 401.4 V� I }��{ 1 I z' CS',..,Peru p A•o� ao. p •w•.eu .w+ �(I t 'a Natvnl p Horrvaa 0 Accident):p Penng Investgabonn C p14es. p P; lrabab®jpUnknwm /!I p -..:vna4 �.unn /. a 1V. I I❑amewwi-rm.e.▪ e`. 1 r m-y/,rOI ti ,/� 4 / it ❑Sudd ❑Casd No:Be Date rod _G' i� 34 Date Of, hyury(Mon.NOaylYearl , ri V,35 T ahyury iV '36 %acealryary.(EG Oeeaents Hom Consmction Sie Resaurmtt Nboded Area) 37 L^I "Rt4Wrt? hr. . u�•. _• rt \> • , /.\� ,▪ / , �rQ ,in� - .. c \. .\p Yes .�,pNo 1 , 38 Loea,onalrury Svro ; / 38a-Cirya Tvm / i 3Bb Sbeet3Numeer _ 38eaApt No 3ed Lp CodeXQ 1 /i/ :' / 1t / t / l 1,A0 /y _ l t �/ /i I ' / 1' / % 1 / o .. n1� lei 1 i 4 fl /-tV ( \iro/C ▪ 1 i /av I/� �� Si!\A `c� n: . CU Pt. 3B Desclbe How ireury Ocand - ' v O vA VA y r .A l - ,40. Il T s00ta ltwy eoty V A` 1 \tee II' '"j r _ ▪ \�',•\�/ \�,O \\// 'po« - 'px..'swwia4 ''. < 41 Ssp r,rc Of Peron certfprg C se Of death.l /.> I /i i I i g it % / I t' 42 Cer'Ser(Check Only On)/ ,e. (11 ;�/�),,{IY k JAYBOBBY OBEROI BY,ELEGTRONIC SIGNATURE\I) ,- � :h l.��,i i) ©D Nlying Pbyscian\ ,•0 Coroner, --0 H athoter, \1".1.4 , ba3�erA v�Lp�OfPersono� Cause a.Dea)� �AAv/ �A'\ 1AA\ / ����AA��'':. 44 ileense Number,,,,„ . _as Da cm:see�Vi C hat it /i a:.r // % l /� ( . ',4\ ��h n 4,1, 1JAY BOBBY OBEROI 1600 MARY STREET;EVANSVILLE IN147.74701'I } G%11 ,1I Il� l�% 01082388AiLII11 C. • 1 i 07/31/2019 1,42 LY Ade:yoga!ktirgral Service Roeder (' / \ ( /` 1R`"/� \I/ \,)/��III%�\\` / 47 Akas^.`\\` /q 1/� ce Sinaure d Local heaan OE.� v ��1' � ' OCR/ p • • W F Re9 stra O 1y Da a Feed(M yt ar) J�q �� G RICKY B YEAGERFVIA ELECTRONIC SIGNATURE 1'� 1+.`t) 1 0 .OI7 P'I `E«/)III 11 (,..'...1 'AUG(01 2019� - rr::'Ot i �aa� ,�/<A -- s,1 ttt 2 /.F_' AMENDMENT TOCERTIFICATEOFDEATH(ENTRY ORORIGINAL),c :1 �// { 11'Ye6-A L, iD C vw yvv�� Z vv V� CAS y��� � A ��A v v � e't : Fc-t-/,. ,1,1 /i l l/ `1t 1� IO' i i 1 � V — i- 1 11 i> � •`o o (1��r i1�-e� / V/ 1 / - V l%�� �1�1 v Itl i State Form.53395(ATTENTION ESTATE::The Social Seaaily a is being requested by this state agency en order to purse resp▪ ons b lity ▪ fu Disclosure is voluntary and there ill be no penalty for resal.= t G t ORIGINAUDOCUMENT,HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT II 0I, RN FROM ORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUMENT HAS AHIDDEN VOID ON FROM,•THAT.APPEARS WHEN P+H�JO�'T�,000PIED. - n i',' :KZ?' ,.. • LI ! 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