Death Certificate - Mounts, Thomas_1/30/2020 „.---.
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\r d ' ; INDIANA STATE DEPARTMENT OF HEALTH
y " CERTIFICATE OF DEATH
I ATTENTION ESTATE:The Social Security#is being 4,.�, ' ",,,; my requested by this state agency in order to pursue responsibility.'Disclosure is voluntary and there will be no penalty for refusal
1fL�,• Local No 000007 .EDR No 000000756034 state No 003166
�= -1.Decedent's Legal Name(First,Middle,Last) 1a, Malden Name (If female) 2.Sex 3.Time Of Death 4. Date Of Death(MonNlDayNear)
THOMAS RAY MOUNTS -
MALE 10:00 PM . 01/21/2020
p 5. Social Security Number 6a.Age-Yrs 6b. Under 1 Year 6c. Under 1 Month 6d. Under 1 Day ee. Under 1 Hour 7. Date of Birth (MonthrDay/Year) 8.Birthplace(City and State or Foreign Country)
10.If Death Occurred In A Hospital: , 10a. If Death Occurred Somewhere Other Than A Hospital
cs ❑ Hospice Facility ® Decedent's Home ' ❑ Nursing Horne/Long-term Care Facility
et\ Cl. Yes ® No D Unknown ❑ Inpatient❑ Emergency Department Outpatient ❑ Dead on Arrival ❑ Oyler(Specify),
ri-f 11. Facility Name (If Not,Institution,Give Street and Number) ,
�, 5201 BANNERSTONE DRIVE .
lit 12. City Or Town,State,And Zip Code 13. Coun Of Death •
,y ..'7-Q I_ goo_Oo /p_D,22_ ty 14. Marital Status At Time Of Dear
� OW ID Widowed ENSVILLE, IN,47665 0 r 7 ! GIBSON ® married Married,But Separated 0 Divorced
dowed 0 Never Married El Unknown
d'\\r 15.Surviving Spouse's Name 15a. (If Wife)Give Maiden Last Name 16. Decedent's Usual Occupation 17. Kind Of Business/Industry
'~ WADE
1f,. SUSAN GAYLE MOUNTS LABOR
WHIRLPOOL.(l 18. Residence-State 18a. County 18b. City Or Town ,
r INDIANA . GIBSON . OWENSVILLE -
tt,A\, 18e.Street And Number _ 18d.'Apt No. 180. Zip Code 18(. Inside City Limits?
5201 BANNERSTONE DRIVE r ® Yes ❑ No
47665
.4. ,19. Decedent's Education 20. Decedent Of Hispanic Origin 21.Decedent's Race -
i -i HIGH SCHOOL GRADUATE OR GED
P; „ COMPLETED NOT HISPANIC WHITE
I. 22.Father's Name(First,Middle,Last) 23.Mother's Name Middle,Last)(First, 23a.Mother's Maiden Last Name '
P.V. ROBERT ARTHUR MOUNTS AILEEN MOUNTS LAND
a 24.Informant's Name ' 24a.Relationship To Decedent 24b.Mailing Address(Street And Number,City,State,Tip Code)
LLI
Q SUSAN MOUNTS WIFE . 5201 BANNERSTONE DRIVE, OWENSVILLE, IN 47665
CC 25.Place Of Disposition _
11.1 25a.Method Of Disposition 25b.Place Of Disposition (Name Of Cemetery,Crematory,Other Race) 25e.Location-City,Town,And State
® Burial❑ Cremation 0 Donation 0 Entombment
CC 0 Removal From State
O ❑ Other(Specify): ' BENSON CEMETERY OWENSVILLE, IN
0 28.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility ' ' 27a. Funeral Homo License Number.
LLI
cr ® Yes ❑ No
W - HOLDERS FUNERAL HOME,319 SOUTH MAIN STREET, OWENSVILLE, IN 47665 FH11700008
I- 27b. Signature Of Indana Funeral Service Licensee:
J 27c. u�tie Number(Of Ucenseo
Q BRANDI MACER, BY ELECTRONIC SIGNATURE FHZ-1400065
LL . , Cause Of Death (See Instructions And Examples)
28.Part I.Enter The Chain Of Eventg -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Termi Eve Approximate
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without ShowingThe Etiology. Interval: Onset
- ', A Line.'Add Additinal Lines If Necessary, obgy.Do Not Abbreviate.Enter On One C e On L F To Death
0 ' Immediate Cause(Final Disease Or Condition Resulting In Death) A. CARDIAC DYSRHYTHMIA D----.N.N
72 HOURS
• ow `a"'" �,JAN 3 0
B. CORONARYRTERYDISEASE 2U2�
Sequentially List Conditions, If My,Leading To The Cause Listed On to(Or AsA Consequent.oa 3 YEARS
i N Line A. Enter The Underlying Cause(Disease Or Injury That Initiated
ft' The Events Resulting In Death)Last C. CHRONIC KIDNEY DISEASE. 10 YEARS
to(Or „r�rA A.A c,r..rr
y. t • D. HYPERTENSION
GIBSON COUNTY AUDIT 15 YEARS
fy� Part II.Enter Other$ipniffeant Conditions Contributing to Death But Not Resulting In The Underlying Cause Givin In Part I _ 29. Autopsy Performed?
rTYPE 2 DIABETES MELLITUS 30. Were Auto ingAva@ameToCo ❑o The CauseOfDeath? ❑ Yes ❑ No
r! 31. Did Tobacoo Use Contribute To Death? 32. [(Female:
33. Manner Of Death:
0 Not PnRun vew,v.r Year ❑ Pr,' r U Tin.oe owl, 0 Not Pregnant,But Pregame cairn 42 D.y.or o..m ® Natural 0 Homicide ❑ Acciderit 0 Pendin Investigation 10' 0 Yes 0 Probably® No 0 Unknownp
I'e ❑ Not Pregnant But Pregnant 43 Days To 1 year Before Dee+ ❑ Unix",a Pr.gnut wtnn TN Per Year 0 Suiddo❑ Could Not Be Determined
34. Date Of Injury(Month/Day/Year) 35. lime Of Injury 38. Place Of Injury(E.G.,Deceden't Home,Constriction Site,Restaurant,Wooded Area) 37. Injury At Work?
1
i ,P - ❑ Yes ❑ No
pip,. 38. Location Of Injury-State 38a. City Or Town 38b. Street&Number
38c\.pt No. 38d.Tip Code
tip.: 39. Desrnbe How Injury Occurredgq If TranSppr}�pau Injury$peli(y.
p.
41.Signature,Of Person Certifying Cause Of Death _. 42. Certifier(Check Only One)
KRISHNA MURTHY,'EY ELECTRONIC SIGNATURE ® Certifying Physician 0 Coroner 0 Heath Officer
C43. Name,Address And Lp Code Of Person Certifying Cause Of Death: 44. License Number 45. Date Certified
't- KRISHNA MURTHY 685 VAIL STREET, PRINCETON, IN 47670 '
01031888A 01/22/2020
ImCC-l.' 48.Additional Funeral Service Provider: Aker47,' s:
\V 48.Signature of Local Health Officer. , - ' • 49. For Registrar Only -Date Filed (Month/Day/Year):
4 BRUCE BRINK JR,BY ELECTRONIC SIGNATURE JAN 24 2020
,11, ? ', AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
i� -
TState Form 10110 (R64-07) / / tV •
WARNING. TURNS FROM ORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUME T HAS A HIDDEN VO DPON FRONT THAT APPEARS WHEN HOTOCOOPIIEDIANA ON BACK THAT