Death Certificate - Barrett, Jerry_11/7/2019 It?' ` ^ • INDIANA STATE DEP; RTMENT-OF HEALTH 'r'(r/>(rq (''f.a71
0ERTIFICATEOFDiATH ��
°, :.e '' Local No 000222 EDR No.00000067-1409 , State No 051534 - ��
Lp,4 1.Decedent's Legal Name(First,Middle-Last) - 1e. Maiden Nartle�•(If female); , • 2.Sex " 3. Time Of Death--+ '4- Date Of Death(Month/Day/Year)r •
;TERRY LEE BARRETT . MALE . 06.57 AM 10/19/2018 . _
W5. Social Security Number 6a.Age-Yrs 6b. Under 1 Year Sc. 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)
* 76 Months Days Hours Minutes
Hospital - -
❑(Hospice Facility 'El Decedent's Home El Nursing Home/Long-term Care Facility.
r,.. El Yes ® Unknown No ❑ 0 Inpatient❑Emergency Department Outpatient ❑Dead on Arrival ❑Other,(Speci fy)
11',--'' ' 11. Facility Name(If Not Institution,Give Street and Number) -
;� ' i,
t�k _3344 WEST MARY ROBERTS-DRIVE . - - - ,I
1!°, 12. City Or Town,State,And Zip Code - 13. County'Of Death ' - 14. Marital Status At Time Of Death -
!i •
®Married 0 Married,But Separated ❑Divorced
PRINCETON, IN,47670 . • GIBSON , ❑Widowed ❑Never Married ❑Unknown
liri=ti 15. Surviving Spouse's Name 15a.Last Name Before First Marriage 16. Decedent's Usual Occupation 17. Kind Of Business/industry
)fn�
PHYLLIS BARRETT MORRIS . PRESS OPERATOR MANUFACTURING
qW 18.'Residence-State 18a. County .
18b. City Or Town
- - i ,
•
INDIANA GIBSON - PRINCETON
In
18c.Street And Number
_ • '18d. Apt No, 18e. Zip Code - 18f.Inside City Limits?
otpc,e`L pp 3344 WEST MARY ROBERTS DRIVE 47670 - ❑Yes ®No_
I' 19. Decedent's Education 20. Decedent Of Hispanic Origin 21.Decedent's Race -
IV HIGH SCHOOL GRADUATE OR GED " .
•
COMPLETED NOT HISPANIC , - White '
[,i •, 22.Parent's Name(First,Middle,Last) •• - 23.Parent's Name(First,Middle,Last) 23a.Parent's Last Name Before First Marriage
ps; , EARNEST BARRETT - GRACE BARRETT SAULOMON .
CI24.Informant's Name 24a.Relationship To Decedent 24b;Mailing Address(Street And Number,City,State,Zip Code) - '
IL PHYLLIS BARRETT . WIFE 3344 WEST MARY ROBERTS-DRIVE, PRINCETON, IN 47670
Q 25.Place Of Dispoglon-.' -
Cc 25a.Method Of Disposition 256.Place Of Disposition(Name Of Cemetery;Crematory,other,Place) 25c.Location-City,Town,And State , •
W 0 Burial ®Cremation ❑Donation 0 Entombment
•
IC 0 Removal From State + - . • - ,
0 ❑Other(Specify): • -• EVANSVILLE CREMATORY- • .. . , -,EVANSVILLE, IN `.
Q 26.Was Coroner Contacted? . 27. Name And Complete Address Of Funeral Facility -. I, . .. 27a. Funeral Home License Number. •
W ,
CC ®Yes 0 No DOYLE FUNERAL HOME, 520 S MAIN ST, PRINCETON,IN 47670 FH10400010
I- 27b. Signature Of Indiana Funeral Service Licensee[ - - - ,''" 27c. License Number(Of Licensee):. _
BARRETT W. DOYLE, BY ELECTRONIC SIGNATURE • FD29500009
. ,Cause Of Death (See Instructions And Examples) - Approximate .
28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-Thai Directly"Caused The Death:Do'Not Enter Terminal Events Interval: Onset
t
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.,Do Not Abbreviate.Enter Only One Cause On I • . • To Death •
• - A Line. Add Additional Lines If Necessary.
•
• ' Immediate Cause(Final Disease Or Condition Resulting In Death) A. CONGESTIVE HEART FAILURE 3 YEARS
j uye NrxODto r once o
Ir�,, Sequentially List Conditions, If My,Leading To The Cause Listed On B. ISCHEMIC CARGO YOPATHY 3 YEARS',
fp • Line A. Enter The Underlying Cause(Disease Or Injury That Initiated - - !I Do.'.,..(or
A.
eon1egUen�of),
j, ' The Events Resulting In Death)Last _
tr D. . i .
for ra:oq:
Part II.Enter Other Significant Conditions Contributing to Death But Not Resulting In'Di nderlying Cause GiveTln Part I ' 7 29.Was An Autopsy Performed? t .. • '
Yes El No
ifr• TOBACCO ABUSE,CHF,ISCHEMIC CARDIOMYOPATHY `' .a�07 �utopsy Finding Available To Complet The Cause Of Death? ❑Yes 0 No
1�F` 31. Did Tobacco Use Contribute To Death? 32. If Female: •• ' O Y- "'a 33. Manner Of Death:
V ❑ • ❑Not Pregnant Milts Peet Yea ❑Pregnant At Tee Of D.agl 0 NotPmpua,Hot Prignanl wgtln l2 o.ys Or Deeth El Natural 0 Homi e'r❑Accident ❑Pending Investigation
❑Yes ®Probably❑No Unknown - _
It - ❑Not Pregnant But Pregnant 4,Days Totyear ea0.xe Death ❑U '„'If�Pngnartl vwntrTM P. e. 0 Suicide❑Coul�ot Be Determined '
34. Date Of Injury(Month/Day/Year) 35. Time Of Injury 36,Place Of Inju ' :G.,D e,Construction Site,Restaurant, ooded Area) 37. Injury At Work? •
11,1
. !^��ppcc((����11•((``p�ITY AUDITOR ' ❑Yes p No
i 38. Location Of Injury-State 38a. City Or Town 38b.�StrVEt-8`f411rithe'f - 38c.Apt No. 38d,Zip Code
L.
k6 39. Describe How Injury Occurred 1 - 1 - '' 40, If Transportation Injury,S ecify.
155 . ❑DMeNOpeuW ❑Peeeergcr�Petl.YNn❑ONer lSpctYj
r41. Signature,Of Person Certifying Cause Of Death: - - -. 42. Certifier'(Check Only One) '' - `
' RICHARD MICHAEL CLARK, BY ELECTRONIC SIGNATURE • - \;,I - El Ceaifying Physician i;, ` El Coroner ❑Health Officer
43. Name,Address And Zip Code Of Person Certifying Cause Of Death: ' 44. License Number 45. Date Certified '
r; RICHARD MICHAEL CLARK , 510 N. MAIN ST., PRINCETON, IN 47670 - • 02004079A ' 10/22/2018
k' 46. Additional Funeral Service Provider, . . 47.'Akas: ••
•
,r
k' 48. Signature of Local Health Officer. 43'For Registrar Only -Date Filed(Month/Day/Year):
DI
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE . ' i - . •OCT 23 2018
i AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
E (;) "-- 11 l S..."1-- no- - co- 4 -. 09 1 ;.---:° Ok• 4---- . ..-- '
'.'Y4 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. ,
Ii: WARNING. TURNS FROM ORANGE TO YELLOW WHEN RUBBED.GORIGINAL DOCUM N NAS ASHIDDE VO DPON FRONT T AT APPEARS WHEN PHOTOCOP ED.�A ON BACK THAT