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Death Certificate - Curtis, Linda_6/15/2020 •,",-vj --_-. - - - -
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INDIANA STATE DEPARTMENT OF HEALTH
.n.11-:'.1 CERTIFICATE PF'DEATH .., .
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Lc:kat NO 000040 EDR No 000000 66851 State No 013534,'...i .
; I.Decedents Legal Name(First,Middle Lest) ' .. . • 1a. Maiden Name (If female), 2,Sex. ' 3. Time Of Death •I .41 Data Of Death(Month/Day/Year)
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LINDA LOU CURTIS . • ....,,,,, ,11
,1,-;. ,,,,•,o SIMS FEMALE 1010 PM • 03/14/2020
5.Social Security Number ea.Age-Yrs fib. Under 1 Year,, e,c. Under 1 Month8d. Under 1 Day Be. Under 1 Hour 7. Date of Birth(Month/Day/Year) 8.Birthplace(City and State or Foreign Country)
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Than A Hospital • , ,.'JII 1
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=I Y-1•Hospice Facility IS1 Decedent's Home 0 Nursing Hcime/Long-tang Clare Facility
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ivi.p Yes ...,Noll,.,,,,,Unknown 0 Inpatient CI Emergency Department Outpatient 0 Dead 9 Arnvaf0; •i 1,,lb!I'!I•
Other(Specify) ,
111 Facility Name(if Not Institefion,Give Street and Number) •• : , . • • ',.',.1;1,:.
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,1619•COTTONWOOD DRIVE .,,,,,i: . . • -,.•I•T:',,''
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12.City Or Town,State,And Zip Code . !". I • 13. County Of Death 1'i i. . 14.Marital Status At Time Of Death
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Y. '11'11.-•'' 0 Married 0 Married,But Separatedi 91.Divorced
PRINCETON IN 47670' IIIIr ''
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• GIBSON ,;C " ril Nitdowed CI Never Married ,,i,..!'UO.nown
15.Surviving,Speuse's Name• •'11'I,Il..1 , . • •• 15a.Lest fame Before First Marriage 1•:,'•••,.r ' ' 18. Decedents Usual Occupation ' ;I,. 17. Kind Of Business/industry
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is.,fesiclence•State ,, ' . -.. . •
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. . 18a. county ., -Il ii."" 18b. City Or Town • OFFICE WORKER ,..,,:.:;II ,...',1. ' UTILITIES
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i INDIANA . . . ,
,,-,-': GIBSON - ' PRINCETON :
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18c.Street And Number 01 °'''''':' 18d.Apt No. 18e.Zip Code ' 18f.Inside'CilytimIts?
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I 1619 COTTONWOOD:DRIVE ' . " ..,,,11,' I:, . ' . . 47670 Yes No
• 19.,Decedent's Education 20. Decedent Of Hispanic Origin •,I .!,. 21. Decedent's Race
HIGI-I SCHOOL GRADUATE OR GED I III 1. ,..;;,,- :".•,;:i
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I j;, COMPLETED • ., NOT HISPANICI'I • White
1 .22.Parent's Name(First Middle,Last)• ' , 23.Parents Name(First Middle,Lest) '1'01,'1!1' 23a.Parents Last Name Before First Marriage
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,LYNDON SIMS : • .. -;,i1.:F,.:, • '" PANSY SIMS :•.,1I,::: Hill,
' HARMON ,,,.!:•111,.
24.Informant's Name - 1 v dr ''' 24a.Relationship To Decedent 24b.Mailing Address(Street And Number,City,State,Zip Code) i
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STEPHEN CURTIS . 0•...T.,' . • ' SON 1908 TAYLOR AVENUE PRINCETON ,IN 47670 -1.;••L!,!
• .11,•;:,Pi '"'" ., 25.Place Of Disposition -' •l 1.I.. '''.'''. .
25a Method Of Disposition 2511 Place Of Disposition (Name1Of,Cemetery,Crematory,Other Place) 25c.Location-City,T ,
kil Burilg Cielbilon 0 Donation 0 Entombment 1, - ,•1!' il,
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0 Rartiovalrom State . •. • '
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.p.,'Othen(Specify): - AUGUSTA CEMETERY . AUG ' A, IN dgI' ,I,
'28.ras Coroner Contacted? 27„. Name And Complete Address Of Funeral Facility •111111!:'" ' 27a. Funeral Home License Number
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0 Yes El No . . •. ,. I):1. •
'COLVIN FUNERAL HOME INC,425 N MAIN ST., PRIi‘id- ON, IN 47670 FH8300567.1
27b.Signature Of Indiana Funeral Service'Ucensee: "-II ';• ' .47. U :,je.. •i Licensee):
MARK.R.WALTER,, BY 4'1
ELECTRONIC SIGNATURE „. ' 1.••."I: F5D01 le•• ' • 1.1,,
• 1.,.,,, . „:-,'1, - . , ..,pai1i#10f Death (See Inshiktions •nd Exam , ,
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;!, I, '.. -1.9 Approximate
The
,. •28.Part I.Enter Chain Of Events -Diseases,Injuries,Or Complications Tilai rDirectly Caused The Death.D•Not Enter Ina ei.-.1 ,Jo
1' , , Interval; Onset
',I.'• Such As Cardiac Arrest;Respiratory Arrest Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbr. late.Enter Only One Cause On "11,,rir '1::I' ' To Death
11 A Line. Add Additional Lines If Necessary. - . o,i •
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Immediate Cause(Final Disease Or Condition,Resulting In,Death)' ; ,A. PNEUMONIA czjilli. 1421020 ' ..
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Sequentially List Conditions, If Any,Leading TO The Cause Listed On B. . ,';'..!l!.r ,. .,
, , .Due to(Or As A Co enc.01): •
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated •
The Events Resulting In Death)List'I',' C.
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Part II Enter OtherSionIficant Conditions Contributing to Death But Not Resulting In The Underlying Cause Given In Pert I 9. Was An Autopsy Performed?:If','1,...,,,• j,
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, • I• . ; ••,,,:I. '.. • Yes 0 No
141Er ASTATIC BREAST CANCER , . Si. Were Autopsy Finding AVailable To C•;plate The Cause Of Death? ,-,
1-1 Yes 0 No
' '31. Did Tobacco Use Contribute To Death?- '1,„ 32. If Female: ,,' 33. Man - • Death:
_ 1',.:I ,:''' 0 Not Prepare Wean Past Year 0 Pregnant M llroo Meath 0 Nal Pregnant But emianiinuun 42 on,.• , . C.' ,atural 0 Homicide 0 Accident 0 Pending lit,ctistiction
0 Yes 0 Probably E31 No u UnkhoiVit•'• • ,-,
LJ Nal Prepare,Put Pregnant 43 Days To 1 year Wars Death, 0 Unknown If pre rant Wean Ils Pad Year 0 Suicide 0 Could Not Be Determined 1 , , •t 1; _
34.Date Of Injury(Month/Day/Year)',' 35.Time Of Injury 38. Place Of lriji.iry(E.G.,Decedent's Home,Construction Site,Restaurant,Wooded Area)' 37.11njury,At Work?
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,•: 111, . ',I;O. i . ,1.1,!'",1. . ...,0 lYes 0 No
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•,,,,:38.-Location Of Injury-State 38a City Or Town ,. . '''' 38b. Street 8,Number „,11; .-•••o'„'' 38c.Apt No. 38d.Zip Code
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39. Describe How Injury Occurred I i . - . •' • $Q.:1 If Transportgtion Injury,4pacIfy: ,._ .
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. , . tt! • . Li Driver/0watt LJ Passenger U Pensaltten U cam(s1.48/ •I•'. ''‘'.:
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' 41.Signature, Of Person Certifying Cause Of Death: • . 42. Certifier(Check Only One)__
ADRIAN LEE CARTER, BYI ELECTRONIC SIGNATURE • . ,-„: I.,' ' ..1.'' PD Certifying Physician U Coroner LI Health'Officer!
43. Name Address And Zlp Code Of Person Certifying Cause Of Death: ';111•1:. ••_.'„ - • 44. Ucense Number 45. Date Certified
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ADRIAN•LEE CARTER , 1808 SHERMAN DR.SUITE 2209',PRINCETON,.IN 47670-1 . ._,. 02002691A ,
•4711*Akas:• ' 03/17/2020
48:Additional Funeral Service Provider ,. ,1: .'•-,- ; - - - . •
'A!' • . . ' . 1! I.,
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48:'Signature of Local Health Officer:• - ••,.•. , • • , • ,, -
49.'For RegIstratOnly1-Date Filed (Month/Day/Year): I.I
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• .: •• ,.BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE , •- . ',,;.i• :I.,' ' • ,.•-7- , MAR 18 2020 i'
• ,r.III.,.'',-JV •, AMENDMENT TO CERTIFICATE 01'DEATI1(ENTRY OR ORIGINAL)
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State Form 53395 ATTENTION ESTATE The Social Security#Is being requested bithis state agency in order to pursue responsibility. Disclosure Is voluntary and there will be no penalty for refusal..i...,
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WARNING: Tu
ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON-BACK THAT.
RNS'FFiOM ORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUMENT'HAS A HIDDEN VOID ON FRONT AT APPEARS WHEN PHOTOCOPIED. • II' ' O'
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