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I" ; INDIANA STATE DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
'` s"'' Local No 000198 EDR No 000000662832 State No 043936 2
1.Decedents Legal:Name(Fast,Middle,Last)' • la Maiden Name(lffemale) 2.Sex 3.Time Of Death : 4.:DateDf Death(Month/Day/Year) •
EARL E SINK ,.•
• MALE 08:17 AM 08/30/2018
5.Social Security Number 6a.Age-Yrs eb.Under 1 Year. Sc. Under 1 Months 8d. Under 1 Day Be. Under 1 Hour 7. Date ofl3irth (Mordt/Day/Year) 8.&dhplace(City and State or Foreign Country)
Hospital
0 Yes 'No f:.'❑Unknown 0 Inpatient❑Emergency nerd Outpatient ❑Dead on Arrival' 7-.-1-
,..... otheHospice Faulty ®Decedents Home ❑Nursing Harwll.ong-farm Care Facilely ;
❑Other( Y) ,
11. Fealty Name(If Not Insihtfion,Give Street and Number)
564 WEST WARNOCK STREET :,;b. _. •
12.City Or Tenn,State,And Zrrp Code • 13.Car tyOf Death 14.Marital Status At Time Of Death '
Dfrorced
PRINCETON,IN,47670 GIBSON El Mar Manes But Separated
0
Widoowedwed ❑Never Married 0 Unknown
15.Suaviving,Spouse's Name 15a.Last Name Before Fast Marriage m 16.Decedents Usual O .9ation 17.Kind Of Business/Industry .
BARBARASINK PHELPS' MOTOR REPAIR ELECTRIC MOTORS •
18..Residence-State 18a Countytil ` l•'•:'i'• •18b. City Or Town -
INDIANA GIBSON l PRINCETON•
18a Street And Number .. • 18d.Apt.No. 18e.Zip Code 18f.Inside City Limits?
561 WEST WARNOCK STREET 47670 Ef
Yes 0 No
.19:-Decedents Education 20.DecederttOf FI'spatucOricyn - 21.Decedent's Race - •
SOME COLLEGE CREDIT,BUT NOT A ;:..; .
DEGREE NOT HISPANIC'`' Wtulte •
22.Parent's Name(Fast,Middle,Last) !"•• 23.Parents Name(Fist Middle,Last) .. - 23a Parents Last Name Before Frst Marriage
ROY SINK • FLORENCE SINK- • HUFFSTALLER
24.Informants Name � - 24a ReLarout.lirp To Decedent 24b:.MadrrgAddre s(SbeetAnd Number Cary,State,rip Code) •
BARBARA SINK t-�:.'°i WIFE 561 WEST WARNOCK STREET,PRINCETON, IN 47670
. 25.Pace OfDfsaositron .. . -
25a Method Of Disposition ::: 25b.Place Of Dimon(NameCcS,erru tery.Crematory,Other Place) 25c.Location-City,Town,And Stare
®Burial 0::(*Mallon 0 Donafion-❑Entombment iv:c{`, • .
❑,Remove]From State !jr `z;"'% •
0 Other(Spectty): COLUMBIAiVVEIFTE CHURCH CEMETERY PRINCETON,IN `.
26:Was Coroner Contacted? 27;NameAnd ComplelrAddress.Otiitrieral:Faciity: - _ 27a Funeral Home License Number .
❑Yes El No �.'!7 y '
•
.a':.'COLN/IN FUNERAL HOME INC,425:N MAIN ST.,PRINCETON,IN 47670 FH83005671 ..-.
27h. Signature Of Indiana Funrrai.Setyice"ticensee- 27c.License Number(Of Licensee): •
MARK R.INALTER:: BY'.ELECTRONIC.SIGNATURE FD01013010 -
+? u6;1:.. :,Caius OFDeath (See Insinictions And Examples) •''•r: is Approximate
28.Pelt L Enter The Chain Of Events-Diseases,Injuries,Or Cornpfmati9pfhattlirectlyCaused The Death_Do:N tEn er•Termatal Events •,,":-':, Interval- Onset
Such As Cardiac Arrest,Respiratory Ai rest,Or Ven alcular Florfita5o.n .14fithiitrtShowargTfteEtiology_Do Not Abbreviate.Enter Only One Cause On, „`_::.,_" To Death
A Lute. Add AdditionalLines ff.Necessary. i .-11;- -
.1V,' _ill'' 00.,.,1:
Immediate Cause(Final Disease Or Condition,Resutting In Death)" A. STAGE4 COLON CANCER WITH METASTASES TO THE LIVER;' :, 6 YEARS •
ran i(orAsA Coreararm Dv. '-
Sequentially List Conditions, If Any;Leading To The Cause Listed On B- ':
Line A. Enter The Underlying Carte. itpaseOrInjiryTttat Ind aa+aLorA.n ref •
The Events Resulting In Death);Last '..-. C. ,. .
1rz' .'rrj:. . -Met(Or As Aca�qur,se a): -u.�,-, ,
Jib... . :I?
Path EnteiOther:m,•ad Gi Conditions C to Death Sot NotResrd�tg,taTpe'UfidertymgCarsaGNank tI nPa :-ArnAuktpsy• .total?.::!i424:r.::' El Yes 21 No •
G'! I / 30.Were A„••• Finding Mailable To Complete The Cause Of Death? El
Yes 0 No
31. Did Tobacco Use Contribute To Death? 32.If Female: t • 33.Manner Of Death:
❑t p,,t�-epatT. , El Arr..�oro®m r r w r rt v+��o.rpetoem ®Natural 0 Homicide ❑Accident ❑PetdngIrtvestigatioh
0 Yes El Pnabably®No ❑Urtkrtrntrtr ❑NMP,M..1.ertpre�IIa3oareTEt /aebreiDaZa ❑ ....•.WICit'mesPactYear ❑Suicide El Could Not BeDetrmuned .. .
34.Date Of Injury(MonthlDayffear) 5 35.Tune Of Injury Place !..7:.:(E.G.,Decedents Home, ••. •,• Site,Restaurant,Wooded Area) • 37 t Work?Injury At
'` , �� it ❑'Yes ❑No
38.Location Oflrrjuey_State... 39a City Or Town - S�."Street&Nr O� 38a Apt_No. 38d.LpCode •
�O
39. Describe Has Injury Occurred 40 If Transportation Injury.Specify:
�'� • ' ❑DevactOpanra ❑ ❑r 'n❑a>ar(�=M)
•
41.Signature,Of Pc ottCuatGyrtg Ciaise OFDea8t 1 -` e''• •. Certifier(Check Only One) '
THOMAS.MICHAEL WAITS:„BY ELECTRONIC SIG 'TURE.- C1 ..r F CedTying Physician ❑Coroner ❑Heabh order
43.Name,Ad'ass And Zip Code Of person Certifying.Cause Of Deatic ,: � Q�tyl,, 44.LrcensaNianber 45.'Data Certified
THOMrAS:MICHAEL WAITS ,.3699 EPWORTH ROAD; EWBURGH,11a1630 0105fTA-2A 09/07/2018
48:;AtlaEawl Funeral Service Provider: -'J .._....:._.:..: - ,.;
Local Officer: ,•.._
48.'Sigrtature of Health Offi ' . 7- - 149. For Rer.strarOatly'`-Date Fled(Month!Day•fYear): „
BRIE BRINK JR,VIA ELECTRONIC u rNATUR_ 2 `' fl ___ SEP 07 2018
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