Death Certificate - Curtis, Linda_6/15/2020 •,",-vj --_-. - - - -
-1i,•?-7,V1
INDIANA STATE DEPARTMENT OF HEALTH
.n.11-:'.1 CERTIFICATE PF'DEATH .., .
17-,'
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)
r '1 I 11 I' ,•1;11„ 11,
, • ,.
.1 1
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)
c ••,,H 1,•J
Than A Hospital • , ,.'JII 1
t •,I;1_4;'.,' - 1 1,...,.
=I Y-1•Hospice Facility IS1 Decedent's Home 0 Nursing Hcime/Long-tang Clare Facility
t
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,:.
{
,1619•COTTONWOOD DRIVE .,,,,,i: . . • -,.•I•T:',,''
, 1
12.City Or Town,State,And Zip Code . !". I • 13. County Of Death 1'i i. . 14.Marital Status At Time Of Death
l't ,'• ,.;''';;','•,,;',.I" . • '':••• II kir'
Y. '11'11.-•'' 0 Married 0 Married,But Separatedi 91.Divorced
PRINCETON IN 47670' IIIIr ''
, , ' .:1.,, :.;;, . .
• 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
"•11,-
. .
i 1 'or,
is.,fesiclence•State ,, ' . -.. . •
. -
' . ,. ,
,;i•••'1111: .' ;
. . 18a. county ., -Il ii."" 18b. City Or Town • OFFICE WORKER ,..,,:.:;II ,...',1. ' UTILITIES
. ,.:• 11",
, 'I,',.' . •
•,.. f', '11;II. ' ,.1;,... .. .
.111 ,,,,,,III
. • .
i INDIANA . . . ,
,,-,-': GIBSON - ' PRINCETON :
.
18c.Street And Number 01 °'''''':' 18d.Apt No. 18e.Zip Code ' 18f.Inside'CilytimIts?
' -1•I•:!1,I. ' . . ' • ,.-,-' ,,'
. .
1-.
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
, , I'.. . II
.. . ..
1-1,11,•:'
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
I • • i• ' ';I:4:W...l•I''
11
,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
•,,
21'1 1-i ','•:hi.'
''''111''' '' ... i•i•,Ir•'1,', ,
'.',. i , . _ . , ..:1., !,;[,,•,!1
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,
' ,11'01' ,
• I'
0 Rartiovalrom State . •. • '
..• '....'-v, I'-.."1''.;:lr' , , •
.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
'0•I'• ' .';1' ,
'
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 , ,
,
;!, 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 •
, 11'...,. . . , . .,...1'1,111,1',I''''h
,
Immediate Cause(Final Disease Or Condition,Resulting In,Death)' ; ,A. PNEUMONIA czjilli. 1421020 ' ..
'..•Id:, ....10{0s MA 0. .
• :id:, P., . III
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.
. , 11.1.1i ''. A
I •
. ,•:,„
ttrEmarTtbri,IN:ii,T,11yil1,Ai.i:Dit,OR I
, . j;,1::•
.
:1 .
D:,' ;11 II
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,
, .
, • 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?
- : ..;•
,•: 111, . ',I;O. i . ,1.1,!'",1. . ...,0 lYes 0 No
"r' ,..„1 ';'.1 ,-;•
•,,,,:38.-Location Of Injury-State 38a City Or Town ,. . '''' 38b. Street 8,Number „,11; .-•••o'„'' 38c.Apt No. 38d.Zip Code
t .
, • •-,.._..
It. , - •
' '
' , ,.
••
't
39. Describe How Injury Occurred I i . - . •' • $Q.:1 If Transportgtion Injury,4pacIfy: ,._ .
, • -,'' i•''.I,I,'" ,.
. , . tt! • . Li Driver/0watt LJ Passenger U Pensaltten U cam(s1.48/ •I•'. ''‘'.:
. l'!.!.••,....'I,''
' 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
- ..,,•
,..,I'',,' - . - ' ' ,.1.:"'11•;
," ,.. . •
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.,
.
48:'Signature of Local Health Officer:• - ••,.•. , • • , • ,, -
49.'For RegIstratOnly1-Date Filed (Month/Day/Year): I.I
,
• .: •• ,.BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE , •- . ',,;.i• :I.,' ' • ,.•-7- , MAR 18 2020 i'
• ,r.III.,.'',-JV •, AMENDMENT TO CERTIFICATE 01'DEATI1(ENTRY OR ORIGINAL)
i.,...::. ,i• -'1'
III, 'I , - CD
''I--;',••I , ...........n..1-3; ''
•
II I.',I-11';•''' . ' •11 I'' ., .
•!'l 14.1'll-'-'' • . •
.1,1 il•• • '
' • ,
• . .
i ' • • ;,• I 1'
.1, 1111 •
,. ..
. . .
1:''' ` .
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...,
, .
.,. ., .,, '•
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'
tfilge-S‘.2. .2.1' 111irdi."--....".0.,......b'-,.-.1.6fenfb,...-,r,:ide.,,..-_-.1./5lind t._...-44..,...Utlt,i1A1.3 aluz.i.7-_,:i5t.1tiz - - . . -Allar.fitata•Vass",...-illaeont 3.-...J.noil ..-•allaisatil-Z-^...ssat.,..--'.13..tatfit
