Death Certificate - Clark, Donald_11/14/2019 .e' vc..., r rras- nn.\I,--.7, ' ;W...'SV ISM' Wt..'w - mate--.,v/
tI j �'""`� • INDIANA STATE DEPARTMENT OF HEALTH •' ',, /* , CERTIFICATE�OF'DEATH .
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� ` ,.o denrs Legal Name
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N 0001 5J8 • EDR No 000000737860 2:�x s>�3e N 050990 Date OfDeath (Monlh/DaylYear)
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ih DONALD C CLARK1a. Maiden.Name (If fernale) MALE 05:30 PM 10/17/2019 •
5. Social Security Number 6a.Age-Yrs 6b. Under 1 Year 6c. Under 1 Month 6d. Under 1 Day 6e. Under 1 Hour 7. Date of Birth.(Month/Day/Year) 8.Birthplace(City and State or Foreign Gauntly)
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• 0 Hospice Facility EllDecedent's Home 0 Nursing Home/Long-term Care Facility
CI Yes ® No CIUnknown CI Inpatient 0,Emergency Department Outpatient 0 Dead on Arrival ❑ Other(Specify)
l - 11. Facility Name(If Not Institution,Give Street and Number) - -
k.Q 1334 SOUTH OLD STATE ROAD 65,ROAD
gA�l� 12. City Or Town,State,And Zip Code• 13.County.Ot Death 14. Marital Status At Time Of Death
(�-t ElManied❑ Married,But Separated 0 Divorced
�f,: PRINCETON, IN,47670 - . GIBSON ElWdowed 0 Never Married 0 Unknown
'IN15. Surviving Spouse's Name 15a.Last Name Before First Manage ` 16. Decedent's Usual Occupation 17. 'Grid Of BusinessAndustry
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lo,k1 BEVERLY CLARK WILKERSON MANAGER PETROLEUM
!/t l• 18..Residence-State "18a. County 18b. City Or Town
11M.:• . INDIANA GIBSON PRINCETON -
(\F - 18c. Street And Number - , 18d.Apt No, 18e. Zip Code 18f. Inside City Limits?
1334 SOUTH OLD STATE ROAD 65 ROAD 47670 ❑ Yes 0 No
`. 19. Decedent's Education(420. Decedent Of Hispanic Origin 21. Decedent's Race - -
.: - HIGH SCHOOL GRADUATE OR GED
('
'. • COMPLETED NOT HISPANIC ' White '
'. 22.Parent's Name(Frst,'Middle,Last) 23.Parent's Name(First,Middle,Last) . 23a.Parent's Last Name Before First Marriage
,, WILLIAM ARTHUR CLARK MARY CLARK , . WALLACE
0 24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address (Street And Number,City,State,Zip Code) '
•
W BEVERLY CLARK WIFE 1334,SOUTH OLD STATE ROAD 65 ROAD,PRINCETON, IN 47670
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
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LLI 0 Burial': Cremation 0 Donation❑ Entombment
0 Removal From State - -
O 0 Other(Specify): CLARK CEMETERY OWENSVILLE, IN . .
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility - - ,I , 27a. Funeral Home License Number.
cc , ❑ Yes ® No '
W •COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671 .
Q27b. Signature Of Indiana Funeral Service Licensee: 27c. License Number(Of Licensee):
MARK R.WALTER, BY ELECTRONIC SIGNATURE I FD01013010'
Cause Of Death (See Instructions And Examples) Approximate
V- 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 To Death
CI ' A Line. Add Additional Lines If Necessary.
O Immediate Cause(Final Disease Or Condition Resulting In Death) A. CORONARY ARTERY DISEASE i, 4HOURS
Due to(«As A Consequence oq. .
/� Sequentially List Conditions, If Any,Leading To The Cause Listed On B. Due to(Or As ca�.w en A 05'
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
')\ The Events Resulting In Death)Last C
Due to(«MA Consequence Op:
t
D.
Part II;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
MYOCARDIAL INFARCTION 30.Were Autopsy F nding Available To Complete The Cause OI Death? ❑ Yes ❑ No
31. Did Tobacco Use Contribute To Death? 32. If Female: 33. Manner Of Death:
❑ Not Pregnant w9in Pest Year 0 Pregnant At rm.Of heath 0 Not P,.gner&But Prernenr Men ao Days of Death El Natural 0 Homicide 0 Accident 0 Pending Investigation
N. ❑ Yes 0 Probably 0 No 0 Unknown
yd> N❑ Not Pr.gn. .But Prevent 43 Pre ntDays Tot year Bator*o..n, Cl (Planer II Pregnantwe,i, PeatNotDetermined
r P. Year ' t 0 Suicide 0 Could Be ,
q(L- 34. Date Of Injury(MonthlDay/Year) • 35.Time Of Injury 36. Place Of Injury(E.G.,Decedent's Home,Construction Site,Restaurant Wooded Area) 37.Injury At Work?
gyp,, : - ❑ Yes ❑-No
I�( 38. Location Of Injury=State 38a. City Or Town 38b. Street S Number 38c.Apt.No. 38d.Zip Code
`` 39. Describe How Injury Occurred of If Transpo�bon Injury,gpecify:
❑Dn erroP.rem ❑P....yn❑P.6a mn 0 owr(sparyl
t41.Signature, Of Person Certifying Cause Of Death: 42. Certifier(Check Only One) '
LARRY WILLIAM LUTZ,:BY ELECTRONIC SIGNATURE I 1 ` IN Certifying Physician 0 Coroner 0 Health Officer
[(, 43. Name,Address And Zip Code Of Person Certifying Cause Of Death: 44. License Number 45. Date Certified
- LARRY WILLIAM LUTZ , 802 E. OAK ST., FORT BRANCH,IN 47648 - ' 01027538A ' 10/21/2019
•ate, 4 46.Additional Funeral Service Provider. '47.'Akas:
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ti 48.Signature of Local Health Officer, t 49. For Registrar Only-Date Filed (Month/Day/Year): .
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE OCT 21 2019
�� 'AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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State Form 533g5 ATTENTION ESTATE:The Social Security#is being requested by this state agency in order to pursue responsibility. Disclosure is voluntary and them will be no penalty for refusal.
ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT
,�; WARNING. TURNS FROM ORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUMENT HAS A HIDDEN VOID ON FRONT THAT APPEARS WHEN PHOTOCOPIED.