Death Certificate - Adcock, Gilbert Ray_10/24/2019 m_______________.........,.,... ...., ..„.,„ „,.......,,rto„ • • , ":2,4"!:ftio- _.......__.......... ill
'iiiii!!Iiii,,' INDIANA STATE DEPARTMENT OF-FitiNgtH ,.1
.-",;,,tr•-•=•.%s%A , CERTIFICATIOFIIIDEATH l',dill i!ril!!10,
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Local No 000644 EDR No 000
10 ' 32133 State No iii!!.1-111,(1,,d1
046044,1',.„,!!,t, '
1.Decedent's Legaglati (First,Middle,Last) la. MaidehiNehe Ilf female) 2.Sex 3.Time Of Death I I 4.1,Date Of Death(Month/DayNear)
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GILBERT RAY ADCOCK 0:101,,,,'11' ',11;MA.L,E 05:02 AM 09/15/2019 q
5.Social Security Number 6a.Age-Yrs 6b. Under,I,Year!!,'6.c. Under 1 Month 6d. Under 1 Day Be. Under 1 Hour 7. Date oil giqhMohthfDayA'ear) 8.Birthplace (City and State or Foreign Country) 111
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i,,,•!!. Hospice Facility 0 Decedent's Home El Nursing Home/L on gr te irn Care Facility
121 Yes DIIVOIXtUnknown ra Inpatient El Emergency Department( Outpatient 0 Dead OOMPH, 0 Other(Specify) . .1•I-;1,:','
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11. FaCitityllifaina'(If Not Institution,Give Street and Number) III.111 .'Ill''
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DEAC 0 NESS GATEWAY 1,ii1i!II!ii1ii!
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12.City Or Town,State,And Zip Code !,•.,1,II:" 13. County Of,Tli;4111"11IIIIII' 14. Marital Status At Time Of Death .•.I1(1/•IIII1111 111
1411 6.1400
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111,lilliIIIIII LSI Married 0 Married,But SeparatectIllit191,10,PIT:ect
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NEWBURGH,IN,47630 • ., 'ktJI
WARR•.'1,,,...1 Ei Vticlowed 0 Never ManiediIII,09 lyknown
15.Surviving gpouse's Name . 15a.Last Name Before First MarriagrifiIIIIIIIIIP' 16. Decedent's Usual Occupation i, . 17. IGnd Of Busineaigndusby
40 II IIIIII,p., '1 411
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,4!11IIIIIIIii. 11,'''I. 4,1111,1 .I..! I I.' • ...
MARt HAljEAN ADCOCK 'MR ON FACTORY WORKER!' ,. ' MANUFACTURING
18a. Countyliliii 1,
igu,R§pletiE•e"-State11111111:"IIIIIIII"In''' 18b. City Or Town
.
MIPI,1111,0'11:.' di!!''•!111111,,III.11' .
ri/Q1b1ANA . GIBSON iiiiii;111111,:'
- PATOKA 1;11111111h.. I.18c.Street And Number ' . 1111111 i..11;!'IIIIII" 18d. Ap4.No. lee. Zip Code 18(1111InSide Ortnimits?
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• , - 111b III il r 11:larlyes 0 No ,••
207 EAST CROSS STREET.' .01011111111111.4 47666 .,1:1'.1MAih.'
,ii IlieRcedent's Education ,. 20. Decedent Of Hispahiqprigin
., 'Ilq 411 111$1!: lllr 21. Decedent's Race
l 1 . . .
.,
i GM SCHOOL GRADUATE OR GED .11104, .,
'111.111111 '
. •111,111l1 , 'MPLETED '-NOT HISpme , White . !,'llil.,•.,.,,i,
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22.Parent's Name(First Middle,Last) 23.Parent's Name(First Middle,Last) Ill: tl,I ' 23a.Parent's Last Name Before First Marriage
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TAYLOR ADCOCK , . , ROSE ADCOORmIllii ...),,ligiiiiiIIIII,
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24.Informant's Name . ---' 24ari.IIIIIRed'll:laill'tillitiip To Decedent ' 24b.Mailing Addr6??I'tepne And Number,Ci S te, ip de) E. '"IIIIIIIIIIIIIIII!!!I
• 4IIIIIIIII8 I
MARTHA JEAN 1!Iiiil.,14 liIII
-ADCOCK WIFE 207 EF\Still110 . SS STREET, PATOKA, IN 47666
11111 ll'111111''
ph, 25.Place Of DigAIIIICri III IIIIIIIIIIIii,,
25a.Method Ofil9iposition ' 25b.Place Of Disposition (Wain§Of119emetery,Crematory,Otheir Place) 25c.Location-City,Town,ArEIG
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0 BuriALI0idiremation 13 Donation El Entombment A111111111 II' 11 ..
Ejliapagrom State .1 1r,',,,,,,I I • I. ,
ALII11IIILL,,ILI" I,,",...,111,;I:11114 • '..,c.!
lje-FIPPer(5FocIfY): EVANSVILL4k,pKt MATORY EVANSVILLE, INV' • Jh
-2.1gWas Coroner Contacted? 27. Name And Complete Addresa Clf IFEheral Facility ' ,.; 27a. Funeral Home L.Mwe Number.
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,1111111!1I1111„I GIBSON COUNTY AL'DITOR LII111iih,
0 Yes ta No
..: ,. COLVIN FUNERAL HOME INC,425 N MAIN ST.,,IiitRIINCETON, IN 47670 • FH8300567.11.1llili"
27b.Signature Of Indiana Funeral Service Licensee:
' IIII IIIIIIIIIii: 27e. License Number(Of Licensee): :11!!'IIII II::11111;II;1".:
• MARK R.WALTER''',1:'BY ELECTRONIC SIGNATURE ..am rii.. . I 1,,, ,li„' FD01013010.• •. 1:::;,....:11.1111,1
Jill Iiik,1111 1,"'.: O00 Of Death (See Instiqd ions And Examples)
Approximate
iqiii,1!Ilii2ts.Part I Enter The Chain Of Events -Diseases Injuries Or Complicals4H, a4 Directly Caused The Death.Do Not Enter Terminal Events : ,;:,!..•,.. k Interval: Onset
''III j",•Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillaticillth,IA'S owing The Etiology.Do Not Abbreviate.Enter Only One Cause 00,Irr:!1,••,',. • 'To Death
111,1 i
,1'_A Line. Add Additional Lines if Necessary. 6'1111'1111 111111101'
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Immediate Cause(Final Disease Or ConditioniResulting In Death)11•11,I il A ACUTE ON CHRONIC RESPIRATORY FAILURE DAYS ,,1.IIIIIih,
.1113xleldtOr As A Consequence 01):
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. . 01,.11111,11liF ."r'r"''' 1111;1'.
Sequentiallyl , i. list Conditions, If Any,.Leading:To The Cause Listed On B. COPD jiii;III114,1111Hiji, yFjoilIIII!p'•'
- Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
411"I.VIIIIii c'"w ce'mAc'''' '''''''''00: .11:1'illili'i;'11111'
The Events Resulting In Death)'Last " ,,IIIIIHritiorlfrpis
C. HEART FAILURE WITH P. FivtD EJECTION FRACTION'IWIIII'THI'l.: 1;C:'HISTORY OF CAD
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..1141'"'Illi • .,„ lilliil!ill:;.. .,„,,, Due to(Or As A Consequence 01):
calpiPh•Hi '
Death?!1,111kNigti#Other Significant Conditions Contributing to Death But Not Resultiogl rilithe'illiiierlying Cause Given In Part I 29.Was An Autopsy Perforrd?'-,.' '
0 Yes 18I No
III 'lli:,0- y:1pin To Complete The CauSe Of
ellt E ON CHRONIC RESPIRATORY FAILURE 1.111111'' !Ilk I!,30.Were Aufspsy Finding AEl Vtight=1 No
31. Did Tobacco Use Contribute To Death? .,'I. 32. If Female: . ,,iliii 111111',"1111, 33. Manner Of Death: ,.,1IILII!,I!,,..1111I'IiIIIII.
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0 Net Postulant Irlithin Past Year Ei Pregnant At Time Of Death Ei non,,,00.6r#004./mwthin-,2 Dap Or Death 1,81 Natural 0 Homicide 0 Accident 0 IiriiglIriAtigation
0 Yes to Probably 0 No 0,Unknown
0 tel Preinant But Pregnant 43 Days To I yea,Be=Death El Ustot 4 6AitAhlthln The Past Year 0 Suicide 0 Could Not Be Determined .!:::II,.1•1111111,11,•111,111100
NIFate' Of
Injury(Month!D aylY ea!) ' 35.lime Of Injury ,'I'lliIIIIIII1 36. Place OfilrirjiNi(ElIG.,Decedent s Home,Construction Site,Restaurant Wooded Area) 37,'.111,0At Work?
111 1911IIIIIIIII 14 1111111 Iliiiii 111111, .11111 'IIIIIIIIII W',
. „ . 'Il'IIIP Yes 0 No
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Mil • 11,i3lIk Location Of Injury-State 38a. City Or Town ill l'I'l I,,,I111:i, : 38b. Street 8.Number I!IIII''i!', ' 38c.Apt.No. 38d. Zip Code
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39. Describe How Injury Occurred .,.1,.i,,. 11. 40:"11 Transportation Injury,3pecify:
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,1111111FIIIIIi'l:'111111 01-.0..00pera. Op......3.,0 Pedestrian Oahe'(BROW .100,110 1 Itil
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.el Illillgi:4 fl.',g'''' , 0.1!!ille;t111,11 hl"
41.Signature,Of Person Certifying CauseOf Death:
,1111h111111
II-.,"I.. 42. Certifier(Check Only One) 1111,
_ 1111,1%„al,
MICHAEL,ALLEN MURILLO:18Y ELECTRONIC SIGNATURE ••,11R1,,.!II. I 'ill , Certifying Physician .0 Coroner U Ilealti)O del'
43. Name,Address And Zip Code Of Person Certifying Cause Of Death: '"4:11111 44. License Number 45. Dattpertified
11q•II.' 0.'111111 IIIIIIIII,
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MICIOAEL ALLEN MURILLO ,600 MARY STREET,IrirlIALICLNII11011!VILLE, IN 47747 020.Q54b2A 09/20/2019
Alplqrnal Funeral Service Provider '111'"" . .,III47,1.*AIcas:
.1111' , ,Ic 1..
III.,Ili,,IIIIIII,I;I:' 'II, ill
; 4.e"Signature of Local Health Officer .. , Ij1,1 111110 11111., 49. For Registrar only -Date Filed(Month/Day/Year):
.. .. 111,
i RICKY B YEAGER,VIA ELECTRONIC SIGNATURE 41111'111111,;,:1,111[,' SEP 23 2019
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•,j::••.; '' AMENDMENT TO CERTIFICATE 04;Fh(ElyITRY OR ORIGINAL) „ZIII,%11111ii
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State Form 53395 ATTENTION ESTATE:The Social Security#is 6640 requested by this state agency in order to pd .M eliesponsibility. Disclostie*volunta and there will be no penalty for rek IVO
WARNING. ORIGINAL eobumeNT HAS A MULTICOLORED BACKGROUND ON SPECIAL INHIT1 'OWAITY PAPER AND THE GREAT S OF THE STATE OF INDIANA OgISAC,01141A
. TURNS FROM ORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUMENTIAS i''VI InbEN VOID ON FRONT THAT APP S WHEN PHOTOCOPIED. .0:011 ''°'.
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