Death Certificate_Martin -.:_..e;�.,. ...�.... ..ar._.... _-.._-_ .y�,..rr...a.vemrwa o.=�=�Y.�l-=rr!=�a•.1rn�Twre�.l•ri -ram�'✓lrlr
r '' ` !~ INDIANA STATE DEPARTMENT OF HEALTH
>� ( � CERTIFICATE OF DEATH
`� J Local No 000069 EDR No 000000708031 State No 021729
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)
I
T g CHARLES LEROY MARTIN " MALE 03:18 AM 05/02/2019
5. Social Security Number 6a. Age:Yrs 6b. Under 1 Year Sc. 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 Country)
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Hospital
®mrr ❑Hospice Facility ®Decedent's Home ❑Nursing Home/Long-term Care Facility
,0 0,Yes El No ❑Unknown El Inpatient El Emergency Department Outpatient El Dead on Arrival CI Other(Specify)
%� 1, Facility Name'(If Not Institution,Give Street and Number) - - . •, -
425.BLAINE AVENUE
-%6 12. City Or Town,State,And Zip Code 13. County Of Death 14. Marital Status At Time Of Death ' '
®Married❑Married,But Separated ❑Divorced
PRINCETON, IN,47670 GIBSON El Widowed ElNever Married 0 Unknown
`?=;P 15. Surviving Spouse's Name 15a.Last Name Before First Marriage 16. Decedents Usual Occupation 17. Kind Of Business/Industry
MARY LOU MARTIN . WALKER LABORER • GOVERNMENT 18. Residence-State . • 18a. County ' 18b.,City Or Town .
INDI
� ANA . GIBSON PRINCETON -
18c. Street And Number 18d.Apt No. 18e.Zip Code 18f. Inside City Limits?
1425
BLAINE'AVENUE 47670• 0 Yes 0 No
•
19. Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedents Race
. 9TH-12TH GRADE; NO DIPLOMA NOT HISPANIC ' White .. - ,
9. 22.Parents Name(First,Middle,Last) 23.Parents Name(First,Middle,Last) 23a.Parent's Last Name Before First Marriage
RALPH MARTIN VIVIAN MARTIN • ONKST
24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address (Street And Number,City,State,Zip Code)
W MARY MARTIN WIFE 425 BLAINE AVENUE, 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
LLI ®Burial ❑Cremation ❑Donation❑Entombment ' .
•
CC . 0 Removal From State •
O ❑other.(Specify): ' - . COLUMBIA WHITE CHURCH CEMETERY PRINCETON, IN '
0 • 26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility 27a Funeral Home License Number.
LLI . .
CC 0 Yes ®No i COLVIN-FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 ' . - FH83005671
ILI
_ 27b. Signature Of Indana Funeral Service Licensee: - 27c.License Number(Of Licensee):
JAYANNA.WEAVER, BY ELECTRONIC SIGNATURE . FD21800025 '
Cause Of Death (See Inson n Exam Approximate
V- 28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The a h. N Ent r nal Interval: Onset
' Such As Cardiac Arrest;Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Ab i .e On i To Death
0 A Line. Add Additional Lines If Necessary. a .
Immediate Cause(Final Disease Or Condition Resulting In Death) A. RESPIRATORY FAILURE MAY 2i00 20 '° DAYS
l q„ence oq:
Sequentially List Conditions, If Any;Leading To The Cause Listed On B. CHRONIC OBSTRUCTIVE PULMONARY DISEASE YEARS
i.r..-' Line A. Enter The Underlying Cause(Disease Or Injury That Initiated Dve m(a A.A wn.errven,e oq
siV The Events Resulting In Death)Last
C. wren.�.
��f •
D. GIBSON-COUNTY AUDITOR '
l Part II.Enter OtherSionificant Conditions Contributino to Death But Not Resulting In The Underlying Cause Given In Part I 29. Was An Autopsy Perforrned? El Yes
®No
30. Were Autopsy Finding Available To Complete The Cause Of Death?
•er CARDIOMYOPATHY,HYPERTENSION,CHRONIC KIDNEY DISEASE CI Yes ID No.
/� 31. Did Tobacco Use Contribute To Death? 32. If Female: 33. Manner Of Death:
4e ❑Not Prepare Vase Pact Yea, ElPregnant At Tone Of Nell, ❑Not Pregnant.BN Pregnant when 42 Days Of Deem ®Natural 0 Homicide ❑Accident ❑Pending Investigation
❑Yes ®Probably 0 No 0 Unknown•
i,� .I El Not Pregnant.But Pregnant 43 Days To 1 year Before Death ❑unknown If Pregnant weer The Par Year 0 Suicide❑Could Not Be Determined
; 34. Date Of Injury(Month/Day/Year)'' 35. Time Of Injury 38. Place Of Injury(E.G.,Decedent's Home,Construction Site,Restaurant,Wooded Area) 37. Injury At Work?
El El
38. Location Of Injury-State '38a. City Or Town 38b. Street 8 Number 38c.Apt.No. 38d. Zip Code
{- 39. Describe How Injury Occurred 40. If Transportation Injury,S ecify.
9��: ❑DRnrroparam m r ❑Pe .npar Paaarrmn❑Om p.�er(sryl
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41. Signature, Of Person Certifying Cause Of Death: 42. Certifier(Check Only One) -
RAMESHBHAI P PATEL; BY ELECTRONIC SIGNATURE ®Certifying Physician 0 Coroner ❑Health Officer
tr i 43. Name,Address And Zip Code Of Person Certifying Cause Of Death:
•
�'' 44. License Number 45. Date Certified
RAMESHBHAI P PATEL' ,685 VAIL ST., PRINCETON, IN 47670 01040266A 05/03/2019
46. Additional Funeral Service Provider. I 47. 'Akas:
17-" .
48. Signature of Local Health Officer. . 49. For Registrar Only-Date Filed(Month/Day/Year):
4 BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE MAY 06 2019 .
;-I.
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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IState 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.
fff���▪��� ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND OND SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT
11VARNINGa_ . TURNS FROM ORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUMENT HAS A HIDDEN VOID ON FRONT THAT APPEARS WHEN PHOTOCOPIED.