Death Certificate - Owens, James_9/24/2019 E .'' ' .rw i.. - r/i..aira''-'.-r _ _ _ _ - \' r1T..'.f "Ynrr ell...1\. -rys•.�\e ,lf...l•
_ INDIANA-STATE DEPARTMENT OF HEALTHr CERTIFICATE OF DEATH4(17
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°� = Local No EDR No: 042705 \ 2
�.hr 000138 000000728753 state No , - .
r`, 1.Decedent's Legal Name(First,Middle,Last) " • 1a. Maiden Name (If female) 2.Sex 3.Time Of Death 4.Date Of Death(Month/Day/Year)
•
JAMES ANTHONY OWENS -.MALE .-03:00 AM 08/26/2019
,4,-. 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
Hospital
❑Hospice Facility ®Decedent's Home ❑Nursing Home/Long-term Care'Facility
, ( . ®Yes ❑No ❑Unknown ❑Inpatient❑Emergency Department Outpatient ❑Dead on Arrival El Other(Specify)
•
11..Facility Name(If Not Institution,Give Street and Number) • . . , '
' 419 SOUTH HART:STREET '
I.,y 12.City Or Town,State,And Zip Code 13. County Of Death 14. Marital Status At Time Of Death
a
®Married 0 Married,But Separated ❑Divorced
'if PRINCETON,IN,47670 GIBSON 0 Widowed ❑Never Married ❑Unknown
1T 15. Surviving Spouse's Name 15a.Last Name Before First Marriage 16. Decedent's Usual Occupation 17. Kind Of Business/Industry
LUMBER
CLAIR JUENELL OWENS WILLIAMS WOODWORKER CONSTRUCTION
l 18. Residence-State. 18a. County 18b. City Or Tov_n _ - -
b j' '
INDIANA - - GIBSON .. PRINCETON
iyi 18c.Street And Number 18d.Apt.No. 18e. Zip Code 18f. Inside City Limits?
419 SOUTH HART STREET 47670 El Yes ❑No
t 19. Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedent's Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC ' White
\r 22.Parent's Name(First,Middle,Last) . 23.Parent's Name(First,Middle,Last) 23a:Parent's Last Name Before First Marriage
LAWRENCE C.OWENS BETTY JOYCE OWENS GRAY
24.Informant's Name 24a.Relationship To Decedent ' 24b.Mailing Address (Street And Number,City,State,Zip Code)
W
CO CLAIR JUENELL OWENS WIFE 419 SOUTH HART STREET, PRINCETON, IN 47670
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
Ill ❑Burial.®Cremation ❑Donation❑Entombment
(Y ❑Removal From State '
O 0 Other(Specify): MONTGOMERTY CEMETERY OAKLAND CITY, IN
in 26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility 7a. Funeral Home License Number.'
LLI
CC ®Yes ❑No • COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 H83005671
1.J.) 27b. Signature Of Indiana Funeral Service Licensee: 27 I se mber( ' nsee):
J RICHARD DEAN HICKROD , BY ELECTRONIC SIGNATURE 10 1
Q 1 ' . I Cause Of Death (See Instructions And Examples) .311,-' �� Approximate
LI- 28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Event- (... Interval: Onset
Q ' Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On �� �j To Death
_ A Line. Add Additional Lines If Necessary. S Q
`O Immediate Cause(Final Disease Or Condition Resulting In Death) A. ACUTE MYOCARDIAL INFARCTION (�IY7INUTES
/ Duo to(Or As A Consequence 00' -
2"'�• Sequentially List Conditions, If Any,Leading To The Cause Listed On B. J ,�� P
Due to(Or As A Consequence On. Q
VW Line A. Enter The Underlying Cause(Disease Or Injury That Initiated GO
',NN The Events Resulting In Death)Last C nSGN
•
($$ Due to(Or Ae A cor.equena Of). r\�
L V
yJ D.
Part It.Enter Other Significant Conditions Contributing to Death But Not Resulting In The Underlying Cause Given In Part I 29. Was An Autopsy Performed? ❑Yes ®No
Ire30; Were Autopsy Finding Avalable To Complete The Cause Of Death?
a , HYPERTENSION,PROBABLE UNTREATED OBSTRUCTIVE SLEEP APNEA 0 Yes ❑No
'�.y�
/t.' . 31. Did Tobacco Use Contribute To Death? 32. If Female: 33. Manner Of Death:
El Not Pnprunt Wakn Past Year El Pregnant At TLne Of Death 0 Not Pregnant.Bart Precinct wow 42 Oyu of ow El ❑Homicide 0 Accident ❑Pending Investigation
�` ❑ ❑ ❑ ®Yes Probably No Unknown ❑Not Pregnant.But Pregnant 43 Days To I year Bebre Death ❑Unknown If Pregnant Min The Pad Year ❑Suicide❑Could Not Be Determined
34. Date Of Injury(Month/Day/Year) 35.lime Of Injury 36. Place Of Injury'(E.G.,Decedent's Home,Construction Site,Restaurant,Wooded Area) 37. Injury At Work?
{.a� - ID Yes El No
\�( 38. Location Of Injury-State 38a. City Or Town 38b. Street 8 Number 38c.Apt.No. 38d. Zip Code
•y ..
I`'� 39.Describe How Injury Occurred 40. If Transportation Injury,S ecifyr.
tiT�. - ❑DMeriOPerator ❑Parenger DPeeaerran❑ott.r(sWdp')
p41.Signature, Of Person Certifying Cause Of Death: - 42. Certifier(Check Only One)
,; MISTY G.-HOKE BY ELECTRONIC SIGNATURE 0 Certifying Physician ®Coroner El Health Officer
43. Name,Address And Zip Code Of Person Certifying Cause Of Death: 44. License Number 45. Date Certified
MISTY-9: HOKE i 203 S. PRINCE ST., PRINCETON, IN 47670 09/03/2019
46.Additional Funeri Service Provider. I 47. 'Akas.'
`� 48.Signature of Local Health Officer. . 49. For Registrar Only -Date Filed (Month/Day/Year):
t. BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE SEP 04 2019
,..:16 AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) ,
: 1 aU ''' _ e rr- Kok- COa . 00r7 -. 0as-.
( State Form 53395 ATTENTION ESTATE:The Social Security#is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary and there will be no penalty for refusal. '
WARNA' ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT
YYI ��IY I IY� TURNS FROM ORANGE TO YELLOW WHEN-RUBBED.ORIGINAL DOCUMENT HAS A HIDDEN VOID ON FRONT THAT APPEARS WHEN PHOTOCOPIED. v