Death Certificate - Mason, Edward_6/15/2020 ,[ Ihi`wNu1111;1111n ■ 11rif1+,I1v :
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�y M TATE:The Social Security#is berin requested bythis state'a en lgf7 ' rtb11pursue responsibility.•Disclosure is voluntary and there will be no ' llllll I(f 1refusal
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I,4I10,4 19H0 000034 EDR No OQII , ' 1' 65937, state No.0125' ;,'lludll,lb"' f •
1.Decedent's Legal 1 1i 1,1;(First,Middle,lasst) 1I1 ! la. Maiden f 1, ,,(If female) .2.�•III 3.Time Of Death ` I If pate ate Of Death(Monfh/D /Y
011111,III1 , 11i111,,,II
EDWARD KENT MASON III111V;!IIIIIIII' " e• . - 05:00 PM.'-'. 03/10/2020
cl; 5.Social Security Number 6a.Age-Yrs 6b. Unc rl I 11.116c. Under 1 Month 6d. Under 1 Day Sc. Under 1 Hour 7.-Date f I I bnt/DayNear)_ 8.Birthplace(City and State or Foreign Country)
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""1 11 II'';;III pIII���4I I IIII 1 b Hospice Facility a Decedent's Home_ 0 Nursing Home/Long •l ,101 ality •
0 Yes ,ill, 1 " unknown 0 Inpatient❑'Emergency Department Outpatient 0 Dead1lop,.1111 ❑ Other(Specify) IIIIU 11111e •
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11.Faci(, I 'a„ilia(If Not Institution,Give Street and Number) '111111111''111 I11111111011!'
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317 N TH.EMBREE.STREET ,,l��; •„�,Vm11�
12.City Or Town,State,And Zip Code. II,•!q,l piv,11111;5-' 13.County D fiii 1I¢Il' 14.Marital Status At Time Of Death II,�I4'li,IlIl
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1111 I° • • ® Married❑ MA. .°°,But Separatepliia BrOked
" PRINCET N,IN,47670 ul!"' ❑ 1Mdowed MA.
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I 15.Surnvtn9'S .je's•Name 1'IIIIIIIi 15a. (If Wlf!I Ie•Maiden Last Name •.1!(II) 16. Decedents Usual Occupation •.1111II I1111i 17.K Ind Of Busi' ,Ildustry
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I' IIIIIb'l11 a • BRIDGE BUILDING ,�,,'Lli119$
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8 MAINTENANCE 'IIIJII'1�II, IIUIIiii RAILROADII(6I sld nee-State - 18a.County ,,Ii11•i111111111, 'i11 18b.City Or Town .11IIIII�jI111!I�'"II.11 _
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• - 18c.Street And Number iv.11 II III - IIIII,I' ! 18d.Apt.No. • 18e.Zip Code 18fllh R' Fiji Limits?
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r DG eritsEducation ''UiliillUl"' - 20:Decedent Of �1 n m III 21. Decedents Race 1 ""III 11
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t b i ul1 • ,,, 1 i Il l IICI1 11,P 23a.Mother's Maiden Last Name
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r r= ELVIS ARTHUR MASON a,l1l'!1111 I„IIII' ' Ilil,
II _ • DORISDORIS•LUQf a ,I'mASON RODGERS 111J1 I�U1),,1�II
24.informants Name Ipl;l IIIII ;III"' 24a.Relationship To Decedent : ) 24b.Mailing,IAdgl s • t And Number;City,State,Zip Code) 1I111111011i.
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' 1111111 1111116IIIII illI11, IIII i i .II!llll,d '
11111i I'l'''1'11l" WIFE 317 OV1fTiIIIEMBREE STREET, PRINCETION„IN 47670 Ip,1II! lIIIIIIIIiIIIu'
CHERYL A�MASON .niil,,„,ll 1,lllub•• .. , I1111 .,'hill'
1 • 11liiilll1111Uu. 111 IV'' i'I'„I�lllln h,. 25.Place Of Dts• �h'� • '4l ilia., ,
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25a.M 'dj l Plabosition - 25b.Place Of Disposition J, f cemetery,Crematory.Other Place) 25c.Location-Ci j,,Town,And 'III 1 I 1' •`'
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I . ❑ 1 11 11 I"Cremation❑ Donation 0 Entombment 1111111h;1iPu L 1' 11111111,,,1111j 111
III °'" 111111111u1i11111!lu��
�, ,�111fr 1�,'ial From State I,111111111 III o
II®;ier(Specify): EVANSVILII (,R MATORY . EVANSVILLE,IN IIII;11II1Ul•' '
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26:Was Coroner,Confacted7 yp1111 1 _ .era]Home U Number.
,IUIIII!iIIpII I"I'eAndCampleteAddress uneral Facility . 1111111111.1111." I1I1,111. I.
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❑ Yes ® No II111111I bLVIN FUNERAL HOME INC,425 N MAIN ST a, , I``JJ1I�119u11lII11I11 II'
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27b,,,,Signature Of Indiana Fig0_' iee Licensee:.. - - • .hill'III 11!Iii 27•. cense Number(Of Licensee):. '111 111,11111111p
10#1, 4NNA WEAVER!iI ELECTRONIC SIGNATURE III'IIII;l111,IJ Iq iII!Li1ii 1 Ill" . • '.•21:80002 IIII. I Jill i
IIIII 1j Iu - a1'II Of Death(See Instructions And Examples d11'I' •
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1•y II'u1„11�8.Partl.Enter The Chain OFEvents -Diseases,Injuries,Or Compli W�� 1 at Directly Caused TheDeath.Do Not Enter Terrtii =1 ,�n ,Ih,",. �
a IIII Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillati i� Showing The Etiology.Do Not Abbreviate.Enter OM One c :Le I I IIII, nt, Onset
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Immediate Cause(Final Disease Or Condit Ilulting In Death) A PANGRFJITIC ADENCARCINOMA lh,
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IIII 91III B. PANCREATICASCITES IIIII 1�1'., JUN° �, , � 1Iu.
• Linea Enteueptially r�The Under! n st Conditions, ti ° m J seOrr�In eCaThat Inilisttiated r'1'�IIIIIIIIII Rue mp AsA Consequence oh: I' I�Ililllllll
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/ The Event 1 ulting In Deatfl IIIIIIIIII
C. CIIl1IpNIC PAIN DUE TO NE SM I I
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°!IIiIIII IIIIII'Illlii!III i 11E1?Iii11y ,iABEfES MELLITUS 1 1 ,1 I Y ALI 0 YEARS •
I IIj!'fpter OtherSignificant Conditions Contributing to Death But Not Res II}j(1 )7il'1 p,'Underlying Cause Givin In Part I; 129.Was•n Aufao ill lib ❑ ': ® No
c i�I REATIC ADENCARCIMI( �IIA IIIII111,111 111I1 30.We A .psy Ending A 1fid To Corn.-e eCause Of Death? ❑ I.
y. pl,1�1 „. 111C)11i Ir 1�0Elli,IP No
iiA 31.Did Tobacco Use Contribute To Y,'1 i1 32. If Female: - IIII"I1111,i1111"II 33.Manner r.�Death: • llllll;II', III"11D'
4' 'Ili! IIII IIII. '., l IIIII
Ili 1IIIIIu , 0 riolP egnam Past ❑ PosaaelAer or Deem ❑ Nor "P vnuan •
dz Days orDeam re]0.Homicide ❑•Aecident ❑ ell V'liv.I stigation
V ❑ Yes ❑ Probably RI Ne,L��I1�II I'i, - • r. 'I` II�IIIIIIIIII' ;Ir0'
milll,II,,11111,, ❑ notrreeoaat;BAOre�amrowysTo1yearBeforeDeath 0 c01 ' 1s�IwramThpra�iYear ❑ Suicide❑ C.ouldNotBeDetemuned,1111ll Alp,
c' III Of Injury(MonitllDe j�y 6•' 35.Time-Of Injury '111 III, 36. Place Oil Ir M'I'(E.G.,Decedent Home,Construction Site,Resta N,/ooded Area): �"�I1 pli'A.t Work?
1:,i1 111 rlliju 1 ' ,iglu,I,i I11. ��u 11` III '�I Yes ❑ No
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1.I''3g.Location Of Injury-State • ' ^_.38a.City Or Town) 1 I I�111,ml•,.••.. 38b. Street&Number • •
• ,,.1 I 1 111�A1I" 38c.Apt No. 38d.Zip Code "
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L , IIIIU I j' 40. If Transportation Injury,.a�+k,r,ecify: 'IIIIIIII "r';
39.Describe How Injury Occurred_ ,UIII,..1101111t.1,,q IIIII "!1u IIiIIII 111' i ❑.Drwerrolrelot r O Parse,,ger lJ Ped.u,ao❑omer ts'°4'). •'!III' 11111111 IIII .
ry .I.11111„'II,II', 1I111 n1i��III„HI!,I IIII' i "U111l11i'd11'''I dl
.c 41.Signature,Of Person Certifying �,,l th IIIII 42. Certifier(Check Only One) I IIIIIIII 1•„"'
M 1'''I i 1"' ` 1,'111I,!IIIIIIIIIIII ®'Certifying Physician ❑ Coroner • ❑ k)� I14�-vlt r'� .
BRUCE RLTON BRI' ,BY ELECTRONIC SIGNAT E !IIIIIIIIp 111E ,
' 43 N dt $.And Zip Code Of brson Certifying Cause Of Death. - 1 ,IIII }'"!IIIn 44. U e1(' tier - 45.Dathlernfied
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a i1! I CARLTONt BRINK JR• ,'410 NORTH MAIN,! I II , PRINCETON, IN.47670 Ii, P 11110A . 03/12/2020
•'•i I It 0tIonal Funeral Service Provider. • II' III f 111! - .i I.4/1111,l*-s
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p 48.Signature of l ocalHeaRh Officer. III ,I Iy11IIQl In •, • 1 11 II111111111011. 49. For Registrar Only-Date Fled(Month/Day/Year): II ,1!"111111i111111' .
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BRUCE-BRINK JR,BY FAE a ON• IC SIGNATURE -/. II111 I1IIiII11i11r MAR 12 2020 • IO11;1'i hi11'QII
)• U!41i 111"!III hill' - AMENDMENT' TO CERTIFlCATE OF 11(E�1TRY OR ORIGINAL .,Piii111,11I1111I1
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( State Form10110 (R6/3-07) OR ouMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL W Q1Y 4A4i1�a'
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W�RNIwe/� NNCpWIaISY PAPER AND.THE GREAT SEAL OF,THE STATE OF INDIANA 1'II I' !WHAT
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