Loading...
Death Certificate_White %I�I' s- C•iit ` 1 1 'i' 1-1,1�:..""% '�INDIANAA�SATE'DEI RTME▪ QF,,HEAL-T,H' 'I : a ' i'!'� !�ih, .,,,�i, ;-:- k y >�"\ y ���?j�?j CERrT1FIC`ATE•OF D ATI1 � 71 d /---:Lroo i oo`D000195 S�i E R� Oi0000044 58 8 '_ s .C�stat('�No 06945. � ti� di,,;1.Oeca,T stegat Namt(prs\Mame Las9 Hr��,'��!� ' TY, :NIK;/I It j-I A,'ali{ta ITIVecoleDil rc-- it; '.••I 2:•httt�p��'' 7 Tmea •h r .r. d pa:Of Dea9;(NpnJJDay/Yearl� n,`rlE%,CW,�:v''wr.�y �. �!i,• '0,.,...b : .4 / rid, I s?' / : c.;< !({Yf€Ir;a• 1 r ll ' :✓ r .;��/ ▪ �\AI." 't„r c`\• .race ) � .tL� ',a C'02/i /2 c:: VIRGINIA MtWHITE` rti. ''r HOLLANDi•rt. .� r �?FEMALE 05:51 AM 7t� 02/12I20 6 r� 5-S�oci`al5tosuyttnber,.6a Age Yrs 6b Undert Year• '6c. Underl T,Ea:Under'Day 6e'Under1 Ha! inDamofbioni(ModdJDa}leat)„ a:0BvamrpIlac (Cly and StateorFo(egn Country)/;(,j L.�C: \\ "w V �Z`k... a-,1,�-.� 'Ix�. .. J', �j�:i��v ❑Rospce Fapm\.D Dece•'mr'ss Home ❑Nc a tionaon9 term G_re Faa3ly �" / Ill 1 ❑i ,%31,, 4❑'I9uro"ill ,1:271ii t .i te:aiy✓eoavinr alPa eat. ❑PeaadnlAmmal 'OOdeit(S"peoN) t/ol(1 Y" fl,, nil ,y !i i-�'! i`Yifnl - mf, ',1 11[Fs Name;(4 Net in" .Cie Street and Nunber)' \� < \tC ,\may\\a, Y+ - \�J4� a 'tt\ ,` b\ter. $' ' ? DEACONESS GATEWAY � / l� \ 14 /T\i, fr ,I t. Y i.i" �: \ %. - . .: '. 112'Ctry Of i State,And lip Cote t ,i ,13 CountyOt Death.," I s a Marital Status At Time OID Death ,A F , ':r \ \cYda`.o Iia ,�:' �.. 1. ®r b,ied❑r.UMed But 5rara:M ❑owwrsp; NEWBURGH IN:47630 . : WARRICK'' -.. ❑l'e°e"<o'�❑^ee'Nameb%'O Unknown iI 1 '15 sun'mng Spwses Nane` .5a.(If V.:e)Gfue r tapers Last Nate 16!Decedents USUS OcwWt '1T. 14dcfbuseassfndusuy ' .▪ JACK WHITE s < , COURTESY CLERK ., GROCERY:RETAIL t B. Residence sate' ISa;County . 'lSb ClryW Town - '.\ T,., 1 INDIANA is a :d GIBSON C�4t,, z.::-C,'J P,RINCETON s.t•4 : .+Sri: Sri : 'aCti`+'E-s`:; Y: tit 1l'L' `l `It i ,1&C SueeAdNu ce t �j^ l 1 Y/' t 't1Bd Ap:NO 1Be 2ipCooG >- Iaf..made Cty}Lrvb?- I F' Jr; IR.�• •• . t FY-- • .L I' - r Ir . ' �'• , '11 Fe- 5( 4097;WEST-SPLIT RAIL LANE t, $••% `: [ ,. . = 1 \ '7`I ❑Yes ®No . 1 . v. \,fir", \ b47670 `\ - sN( t9 DecedensEoua.ion - " .i 120 Decedent Oflbspanic Odgln 1 21 Decedent's Pax 1 i1 -I" to IIj �U°1l \ r h \ :.'KJ/ .44 r ���c\:®1 \1`.L ` .7' `.',i I ' .s' I1/ / • 'w e 9TH.7 112TH GRADE NO DIPLOMA NOT HISPANIC .,._✓t White > T r' n ▪ / .:-.- :-AA 22"F`refs Name(First.fiddle Last) 1 .'/ / I 2] MOtefs Na a(First'rlddle Last) .: 23a Momels Mader last Name ix, it EMERY::HOLLAND . . ' ':I, .It,.._- -.1oJ [Oa HOLiLANDlIrIT��tlI(Gk}li�/..,I . itd C NTWELL _ , I' 2a-bfomats Na a-• " - 2da'Rlaeons'up To Decedents -245Maang Address•(Sweet Ma Nutter.City;Sax Zp Code) 1 Fc .,.• N i �i,1-.1,v 4 t\a i'.•t :iir /'dii,.��%i�?, rs ^ 1'�\�ic. =! N. , • , JACK WHITE ' > HUSBAND .._, I �: 4097cWESTSSPLIT.RAIL-L:ANE,'PRINCETON;IIN'47670 ,. . . ,- a M ,F' `s+ 4'C _ efV25 Plac osaon'ac ii 25C\• `Ott Tow`\v State'el\\\:t\\ _ 25a ,, Olperrrrspoe.ion / i 25b. ce Qspoupon(.a e, Cemetery Crematory.O.n Place)r1''25c Location-Gry,i„..T And State 1 ri•/' ©Bmal ❑Cre `son ❑Do a,on❑E .4fnrrmt t C . G ❑Removal FrpTEtate .. l- J- 'J. `.;�i ,r>t..:_ \'YJrr: ,/j r., /( �F•R \ i I❑Diner(sl erey !s: COLUMBIA WHITE CHURCH CEMETERY! / PRINCETON.'IN r tt 2I t i .4 • 26.Was Coroner Contaeed't 21 Na And Complete Address Ot Fv oral Fad ry. •'c\\�t^ -.A"^t\\ fly '` .`E. S /a Home Lcanse Numbr • RI n: '\ {:• / nra+; l Tr\ r .t f ,,.• -Sir,.: - , ,, �. tem.. + ❑Yes ®No ' 1 / . 5 SM ST t IN / t �I / 1 s 2 r 1 re . •: i., DOYLEIFUNERAL HOME 520 S MAIN ST PRINCETON-IIN'_47670 �J L ' . 10400010� ▪ r' 2/p Signawre Of bdiana Funeral Service L'rensee t.:ST: R`\.ih,U: r / ✓ . ,, 2/c L,�,,ee��l u n e BARRETT W DOYLE BYlELECTRONIC SIGNATURE G I 1 , . /tt.:✓i I}/ _It:ri FD29 0 ' r1II` ▪ / _ \ cni vd Th o.. er yk.Events �O\� - rih2proumate..,'' �$uPartIEnterThe flanCof F :.stories tncaler ibOr Camas Withon T}atng The Caused The Not AoreNbtE nt&Old One eats pall (' - , x Te Death A drdlacAai RespiratoryIfcini. "O V4 ":..a Fbnllatian Wtno3i Showing Th`E" ''''Do AObre'"<t Erna ONy One Causa On' N��. . : :Td DeaN. '•-Alice A d Add.inal lees 4 Necevary - \LIT s 1 \ 4 - Y• • S , • , 1 lmmed ate Cause(Final Disease Or Condition Resulsog In Cam) A ..SEPTIC SHOCK 1 IIIfG '. c -cc0 r . : .T .G c y d-.Id. n.....r`.Pn • Utr. (NON-' \.- . 1 q Sequenoaly Ust Cand lions, If Any,'Lead ng To The Cause Lrsted On B ACUTE CHOLECYSTITIS " -f. m o s ': %} •O\\�1� '' . •].' ' v Line EnerT}leUnde".pngCause(Diseasa Or Injury That Initiated '�" \ , II�`ti ,, ,-rt:- `(_(�i e ' . C y 'NTne Events Resulting In Dean)Last '�\ / C. - " ?•.,�...' • ..J.i, .t<5 ,850\` wetb og .0 _ 0Part II:E ter Obe Sgnsca t Condtions Conmbotno to Dealt B Not Resulting In Tne Underlying Cause Givin InPan l I '29-Was An Autopsy Performed? s,'y •. - S •..1 r, rAu, ,..i 'r ❑Yes S®No i 1 t1.rl CONGESTWE HEART.FAILURE - 9 30,Were Autopsy Finding Avatabx To Complex The Cause O'Dea'i \`i. _ mow- �+ .,�.w.,:�<. - \\z"-,:w-n ..i❑Ves.❑No... 3t-Da Tobawo Use Cdnmbu,e To Dealt? 32.-Y Fenale - . / - ✓ '✓ / 33 Manner Of Dea't r ' kit ❑ .A .., ❑ i Oro.. 1—tt.'w,w..sew ,r-ewe rot..ao... ®Natural:❑No.udce`❑Amdmt *❑Pendigltes.gasat - a ❑Yes ❑P obady,O;No ❑U known "21 \ t !l' '\ w �w'f 1�y�< r t. �` a - , . , _ ❑^rune ,.+a. .en / a .o. i ,r❑w.ury w.,-, .r. ❑&ode 0 Could Not Be Damned i . . t 34 date Of injury(I.bndVDayrYear), ]... Tine Oflryury 36 Play Orlyury(E.G.:Deadens Name Conso, n$x Reswram.Wooded Area); 37 I.Atry at Work ❑Yes` ❑No ?hi 3&;Locaton Of Injury State. -\ i 38a=City Or Tom,' - 38h Seet&Number • I 38c AptNo._ 38d.Zm Code; • 4. 39:9escnbe HowInjury _P -, s F \ + d0 Imo/-T'O.sDa�bNry L.1° (^y'^ ❑a�.lso.vrl i t.:Aug Cause Of Deatn: 4C BASSAM_YOUSEEvB ELECTRONIC'SIGNATURE ... t -` . :_':4".`--• a®CervfytngPnysrd�o�Oc'berm_. -❑HeaeiCroce�- ' I 43 Name Address And Ito Code or Person Cert]yug Cause Of Death." 44.License Number a&.Date Centel BASSAM•YOUSEF., 600MARY.STREET,.EVANSVILLE IN:47747. .. . >. :>' 01042166A l - 02/15/2016.. .. 55,Asddp nalF neal Service e Provider `v I 1 � O Aas. . r� ( ` `itit—C'-i\'V �\. )4:: \ \. S :,IS nti _. 0 kC\W.. AVc �:L,S:14 \` .Z- 1{I \41e .-Mkt r' 4' �\ ; a9 9aWreor-ora-. ---"acI s�-•'lei r~i ,t- 1• ,1 i a . -- r�ir aeonRs91'fit - -7.ed}lrn _Yea' I ' I 3 l' ( RICKY&MEAGERVIAELECTRONIC'SIGNATUREu,i IEitkl tec' .E_ 1 L .__ I r:.". /. i :FEB-16:2016.. ,csuu z4 IGa ;- '% ;4�•�,��T' n- y::L.� i l\ .,\stir?. iAMENDMENTTO CERTIFICATE O F.DEATH(ENTRYOR ORIGINAL):\ 7SF„7' ,l!',-45.-,>:6- 2F.-\ -7,7-C fir i' T¢t D 1 / fI I i I .V I III'vltl / 1:14 I / IIr ,::tli•'al Yi II r L iG IF/ ▪l v I �lilt 1��/el� �`tii ,,. ! 'ill ) .�V' -' ; / E,/r I, ' ,c ilv.h ti ti r -. L EC41r L,�'1`•EY. `•li .dc'�`+ II �j4'wr I �i 1: �1 1.�: / '�.R1�� �C� �II-jVO '"'GC� I,/ I,! "� "i"I ,„ „ta' . •'If -emu CL J-�'t D'--.f▪lJL,t.•C `L ✓�1jV ..., �+t�, ,c y�• s - `i r- Rr-.•^ i /, Wit,;:.• rr\ �tt Rt•r .rtr ----,-; .n�itii?i f .'e�i'".J'.iR�.irr i:r /.I,: .ln�;'"...nab' n>,'� . rp.,.:: Slate Foie 533951'y3TTENTION ESTA E:The Sooal Secants a Is beug'requeated by tyls�siate agancyfi bider td p•asueiiesporal rd:Ksduiure s vdw}ery and thole alit bi no pena$y fw feF isal/f'f LI ' " ORIGINAL DOCUM EAR: AS A'MULTCOLORED BACKGROUND'ON SPEQAL WHITE SECURITY AND- E GREAT SEAL OF AIE STA OEINDIANA ON BACK THAT r� WARNING▪ TURNSFRM/ORANGE TOYELLOWWHENRUB0ED,;Ofi1GINAl tflMENT$1ASWDDENVDIOONFF1NTThAT - $WHEN PHOTO"COPIEA>'�r• .111 : 'L�'� 1a'- "r "' `''.^ `�`,t.r � +k STATE OF INDIANA !- } .`�,�•. S-C I.`t-kl.. -rq �c -, -—ll• y , ,•�s hates,.....- �.!i `�if.� �`�i.-� \ i/.