Death Certificate - Wills, Phillip_7/14/2020 (a�7f.� v-� :n " ' t " ' tr .,,,, CERTIFICATE OF DEATH �:a" r 4f , r,�A", (.,.. o,..r,�� ��1
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✓ ' ��'""'4 INDIANA STATE DEPARTMENT OF HEALTH
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'1 CERTIFICATE OF'DEATH ,
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Local No 000117 EDR No 0000007"90061 State No 036279
,• 1.Decedent's Legal Name (First,Middle,Last) la. Maiden Nagle(If female) , 2.Sex 3. Time Of Death - 4. Date Of Death (Month/Day/Year)
r PHILLIP DOUGLAS WILLS .
;,;fi MALE 03:00 PM 07/03/2020
5. Social Security Number 6a.Age-Yrs 6b. Under 1 Year 6c. Under 1 Month 6d. Under 1 Day 6e. Under.1 Hour 7. Date of Birth (Month/
Nursing Home/Long-term Care Facility
(irkM Yes 0 No 0 Unknown 0 Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival 0 Other(Specify)
12',. 11.Facility Name(If Not Institution,Give Street and Number) . -
'CE 1002 SOUTH RACE STREET .
!;'/t 12. City Or Town,State,And Zip Code 13. County Of Death 14.Marital Status At Time Of Death
,i ® Married❑ Married,But Separated ❑ Divorced
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PRINCETON, IN,47670 GIBSON ❑ Wdowed 0 Never Married ❑'Unknown
y t 15. Surviving •
Spguse's Name 15a.Last Nagle Before First Marriage 16. Decedents Usual Occupation 17. Kind Of Business/Industry
' . GAYLE WILLS POPE ' TRUCK DRIVER TRANSPORTATION
t,• 18.E Residence-State 18a. County 18b. City Or Town� INDIANA GIBSON PRINCETON -
lr�( 18c. Street And Number 18d. Apt.No. • 18e.Zip Code 181. Inside.City Limits?
(� 1002 SOUTH RACE STREET - 47670 0 Yes 0 No
Li?' 19. Decedents Education 20. Decedent Of Hispanic Origin 21. Decedent's Race
4 HIGH SCHOOL GRADUATE OR GED
k COMPLETED NOT HISPANIC ' . , White-
fir 22.Parents Name(First,Middle,Last) 23:Parents Name(First,Middle,Last) 23a.Parent's Last Name Before First Marriage
NORVAL WILLS QUANITA WILLS ELLIOTT
0 24.Informants Name 24a.Relationship To Decedent 24b.Mailing Address(Street And Number,City,State,Zip Code)
N' GAYLE WILLS WIFE 1002 SOUTH RACE STREET, 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 ra Burial 0 Cremation 0 Donation 0 Entombment
CC 0 Reriovei From State •
O 0 Other(Specify): WHITE RIVER CHAPEL CEMETERY - BOWMAN, IN
O 26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility 27a. Funeral Home License Number.
CC0 Yes El No
W COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671
27b. Signature Of Indiana Funeral Service Licensee: 27c. License N mber Of Licensee);
J JAYANNA WEAVER, BY ELECTRONIC SIGNATURE ! ;80025 '
Q Cause Of Death (See Instructions And Examples) Approximate
U. 28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter :rminal Events Interval:•.Onset
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate. er Only 0 To Death '
0 A Line. Add Additional Lines If Necessary. ,
Immediate Cause(Final Disease Or Condition Resulting In Death) , ' A. MALIGNANT NEOPLASM OF U '•-Y r • ER a MONTHS
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1 ,."'"!.. Sequentially List Conditions, If Any,Leading To The Cause Listed On B. •I : IOO
(Disease Or Injury That Initiated }�The Events Resulting In Death)Last e�oe:
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kJ(j D. ll /
�¢4 Part II.Enter Other significant Conditions Contributing to Death But Not Resulting.ln The Underlying Cause Given In Pa I 29 s :--•�r. ��orned?
r�. 1���'7r7�11 0 Yes ® No
�j'<' yy�@ Kpmri Complete The Cause Of Death?
W( MALIGNANT NEOPLASM OF URINARY BLADDER I R SO •1.V• g T, H ❑ Yes 0 No
I'��r 31. Did Tobacco Use Contribute To Death? 32. If Female: 3. Manner Of Death:
;`E0 Not Pregnant WrNn Put Year 0 PnpnanlAlT eo1Death 0 Not Pregnant,: -grunt w1Nn42Drys ® Natural 0 Homicide 0 Accident 0 Pending Investigation
0 Yes 0 Probably El No 0 Unknown
I , 0 Not Pregnant,But Pregnant 43 Dap To I year Before Death' , ❑ Unknown II Pre pant YAM,TM 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?
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fYY-' - ❑ Yes ❑ No
) � 38.Location Of Injury-State 38a. City Or Town - • 38b. Street 8 Number 38c.ApL No. 38d. Zip Code
°• q9 If Trans oration In u g
39. Describe How Injury Occurred �' ❑bm.r+oP.rs.r ❑Paseenp.Y.❑Peanrian 0 aner lsp.5r l
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0 41.Signature, Of Person Certifying Cause Of Death: 42. Certifier(Check Only One)
t' BRUCE CARLTON BRINK JR, BY ELECTRONIC SIGNATURE - , ElCertifying Physician 0 Coroner 0 Health officer
C • 43. Name,Address And Zip Code Of Person Certifying Cause Of Death: 44. License Number 45. Date Certified
BRUCE'CARLTON BRINK JR ,410 NORTH MAIN STREET, PRINCETON, IN 47670 02000610A 07/06/2020
't'ci•-- 46.Additional Funeral Service Provider. 47.'Akas:
,^�,f 48.Signature of Local Health Officer. 49. For Registrar Only -Date Filed (Month/Day/Year):
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE . „ JUL 06 2020
bry AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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j State 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.
ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON'BACK THAT
ti WARNING: TURNS FROM ORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUMENT•HAS A HIDDEN VOID ON FRONT THAT APPEARS WHEN PHOTOCOPIED
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