Death Certificate - Ziller, Edward_9/20/2019 ,~ """°�> ��INDIANA STATE DEPARTMENT OF HEALTHIITC Otn4\
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CERTIFICATE OF DEATH
4'':. ="'' Local No EDR No t .,. 000071 000000709'096 State No .022754
1.Decedent's Legal Name(Post,Middle,Last) la._Maiden Name (If female) - - 2.Sex "3.Time Of Death = 4. Date Of Death (Morrth/DaylYear)
rf EDWARD ALEC ZILLER _ MALE 05:10 PM • 05/07/2019
h 5. Social Security Number 6a.Age-Yrs '6b. Under 1 Year 6c. Under 1 Month 6d. Under 1 Day Be. Under 1 Hour 7. Date of Birth (Month/Day/Year) 8.Birthplace (City and State or Foreign Country)
a
f%"' 72 Months
tDays Hours Minutes
Hospital
•
.0 Hospice Facility ❑Decedent's Home ®Nursing Home/Long-tens Care Facility
I 0 Yes ®No ❑Unknown ❑Inpatient ❑Emergency Department Outpatient 0 Dead on Arrival :0 Other(Specify) _it,;\c . ... . , "
11. Facility Name(If Not Institution,Give Street and Number)
C GIBSON GENERAL•HOSPITAL-SNF , '
12. City Or Town,State;And Zip Code
15a.Last Name Before First 13. County Of Death 14. Marital Status At Time Of Death
L
0 Married El Married,But Separated ET Divorced
,[/tom, PRINCETON, IN,47670 GIBSON
16. Decedents 0 Wdowed ❑Never Married 0 Unknown
Y j 15. Surviving Spouse's Name
Po Marriage t's Usual Occupation 17. Kind Of Business/Industry
/ TEACHER EDUCATION
18. Residence-State 18a. County 18b. City Or Town
INDIANA GIBSON � . ' PRINCETON
!�,I 18c. Street And Number '18d. Apt.No. I 18e..Zip Code 18f. Inside City Limits?
204 3RD AVENUE 47670 0 Yes 0 No
19. Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedent's Race
� MASTER'S DEGREE(MA,MS, MENG,
• MED,MSW, MBA) NOT HISPANIC White
1 22.Parent's Name(First,Middle,Last) 23.Parent's Name(First,Middle,Last) 23a.Parent's Last Name Before First Marriage
44
Yr
SILVIO ZILLER PAULINE ZILLER GRIVETTI
24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address (Street And Number,City,State,Zip Code)
0
W CARRA MEUTH •DAUGHTER 1322 PHILLIPS ROAD, BOONVILLE, IN 47601
N
Q 25.Place Of Disposition
CC 25a.Method Of Disposition 25b.Place Of Disposition (Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State
W ®Burial 0 Cremation 0 Donation❑Entombment ,
CC ❑Removal From State
O 0 Other(Specify): ST JOSEPH CATHOLIC CEMETERY• PRINCETON, IN •
26,... .Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility 27a. Funeral Home License Number.
W .
cc ❑Yes ®No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671
W 27b. Signature Of Indiana Funeral Service Licensee: 27c. Lice br(Of Licensee):
JAYANNA WEAVER, BY ELECTRONIC SIGNATURE FD21
Q Cause Of Death (See Instructions And Examples) Approximate
U. 28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On 1440) To Death
0 A Line. Add Additional Lines If Necessary. (�
0 Immediate Cause(Final Disease Or Condition Resulting In Death) A. RENAL CARCIMONA METASTATIC TO BONE SL MONTHS
Duo to(Or As A ConsequenceOence Ofb 0
•
P.") Sequentially List Conditions, If Any,Leading To The Cause Listed On
0B. DIABETES �0� YEARS
0Line A. Enter The Underlying Cause(Disease Or Injury That Initiated Due t°(° �A e.n'
The Events Resulting In Death)Last C. METABOLIC ENCEPHALOPATHY SQ MONTHS
(■� Due to(Or AsAwr.ewenoe . 0,.
t i D. HYPERTENSION 'V h,. YEARS
AL6
Part II.Enter Other Significant Conditions Contributing to Death But Not Resulting In The Undedying Cause Given In Part I 29. Was An Autopsy Performed? 1 '� A®No
1r 30.Were Autopsy Finding Available To Complete Thagse Of Death?
f RENAL CARCIMONA TO BONE ❑Yes El No
� 31. Did Tobacco Use Contribute To Death? 32. If Female: 33. Manner Of Death:
I* El Not Pregnant N9lin Past Year El Pregnant At Tine Of Death 0 Not Preprurt But Pregnant Ntlkn 42 Days OTC/oath ®Natural ID Homicide El Accident ❑Pending Investigation
�• ❑Yes 0 Probably El No ❑ Unknown
t((t((l���
0 Not Pregnant,But Pregnant a DaysTo I year Before DWI Ell UnknownII Pregnant Nahm The Peat Year El Suicide El Could Not Be Determined
((l 34. Date Of Injury(Month/Day/Year) 35. Time Of Injury 38. Place Of Injury(E.G..Decedent's Home,Construction Site,Restaurant.Wooded Area) 37. Injury At Work?
❑Yes ❑No
38. Location Of Injury-State 38a. City Or Town 38b. Street 8 Number 38c.Apt No. 38d. Zip Code
?If 39. Describe How Injury Occurred 40. If Transportation Injury,S ecify:
1 t ❑omuroprev. ❑'. .riper DPemrrmn❑om.rtsp.:4)
��f** 41.Signature, Of Person Certifying Cause Of Death: 42. Certifier(Check Only One)
BRUCE CARLTON BRINK JR BY ELECTRONIC SIGNATURE ®Certifying Physician 0 Coroner ❑Health Officer
111 . 43. Name,Address And Zip Code Of Person Certifying Cause Of Death: 44. License Number 45. Date Certified
16 1r BRUCE CARLTON BRINK JR ,410 NORTH MAIN STREET, PRINCETON, IN 47670 02000610A 05/10/2019
� 46.Additional Funeral Service Provider:- 47.'Akas:
)*, 48. SI„ature of Local Health Officer: 49, For Registrar Only-Date Filed (Month/Day/Year):
IIJ t BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE MAY 10 2019
qTz� AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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aLQ - II - Ia - \ Guk - Dom ,--7. El - OaE- .
oState Form 53395 ATTENTION ESTATE:The Social Security#is beingrequested bythis state agency in order to pursue responsibility. Disclosure Is voluntary and there will be no penalty for refusal.
1 L WARNING: TOUR
RNISN FROM O ANG TOS ELLOW WHEON RUBBED.ORIG NALODO UMEN HI A ASHIDDE VO DPON FRONT T AT A PEARS W NE HOTOCOPIEDIANA ON BACK THAT
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