Death Certificate - Tice, Tommy_9/16/2020 j ;Ayr:., INDIANA STATE DEPARTMENT OF HEALTH 6 3 4 3 4 9
k' CERTIFICATE OF DEATH
refs
041810
\���`'` Local No 000172 EDR No 000000220686 State No
1.Decedent's Legal Name(First,Middle,Last) la.Maiden Name(If female) 2.Sex 3. lime Of Death 4. Dale Of Death(Month/Day/Year)
TOMMY GLENN TICE MALE 06:00 AM
. 5. Social.Security Number 6a.Age-Yrs 6b. Under 1 Year 6c. Under 1 Month 6d. Under 1 Day Be. Under 1 Hour 7.-Date of Birth (Month/Day/Year) 8.Birthplace(City and State or Foreign Country)
52 Months Days Hours Minutes
Hospital
❑Hospice Facility S Decedent's Home ❑Nursing Home/Long-term Care Facility
®Yes ❑No 0 Unknown ❑Inpatient ❑Emergency Department Outpatient ❑Dead on Arrival
❑Other(Specify)
11. Facility Name(If Not Institution,Give Street and Number)
5766 WEST 550 SOUTH
12.City Or Town,State,And Zip Code 13.County Of Death 14. Marital Status At lime Of Death
OWENSVILLE, IN,47665 0 Married Married,But Separated El Divorced
GIBSON ❑Widowed ❑Never Married ❑Unknown
15. Surviving Spouse's Name 15a. (If Wife)Give Maiden Last Name 16. Decedents Usual Occupation 17.Kind Of Business/industry
SUPERVISOR MANUFACTURING
18. Residence-State 18a. County 18b. City Or Town
INDIANA GIBSON OWENSVILLE
18c. Street And Number 18d.Apt No. 18e. Zp Code 18f.Inside City Limits?
5766 WEST 550 SOUTH 47665 ❑Yes S No
19. Decedents Education 20. Decedent Of Hispanic Origin 21. Decedent's Race
HIGH SCHOOL GRADUATE OR GED
COMPLETED NOT HISPANIC White
22.Father's Name(First,Middle,Last) 23.Mother's Name(First,Middle,Last) 23a.Mother's Maiden Last Name
DOYLE LEE TICE MARTHA P SCOTT PHELPS
24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address(Street And Number,City,State,Zp Code)
TAMMY WILLIAMS SISTER 5766 WEST 550 SOUTH,OWENSVILLE, IN 47665
25.Place Of Disposition
25a.Method Of Disposition 25b.Place Of Disposition (Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State
S Burial ❑Cremation ❑Donation❑Entombment
❑Removal From State
❑Other(Specify): COLUMBIA WHITE CHURCH CEMETERY PRINCETON, IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility 27a. Funeral Home License Number:-
El Yes ❑No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671
27b. Signature Of Indiana Funeral Service Licensee: 27c. License Number(Of Licensee):
MARK R.WALTER, BY ELECTRONIC SIGNATURE FD01013010
Cause Of Death (See Instructions And Examples) Approximate
28.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line.Add Additinal Lines If Necessary.
Immediate Cause(Final Disease Or Condition Resulting In Death) A. RESPIRATORY FAILURE 30 MIN
Duo to(Or Ae A Gansewanoe 0*
Sequentially List Conditions, If Any,Leading To The Cause Listed On B. COPD 10 YRS
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated °"o to(OrA.A Consequence CH):
The Events Resulting In Death)Last C. CIGARETTE SMOKING 45 YRS
Due to(Or As A Consequence 0*
D.
Part II.Enter Other Significant Conditions Contributing to Death But Not Resulting In The Underlying Cause Glvin In Part I 29.Was An Autopsy Performed? ❑Yes S No -
30.Were•••• y Finding Available To Complete The Cause Of Death? ❑
ALCOHOL ABUSE Yes ❑No
31.Did Tobacoo Use Contribute To Death? 32. If Female: 33. Manner Of Death:
❑Not Pregnant Wiuvn Past Yeor ❑Pregnant oOrDeath ❑Not Prevent But Pregnant WNvn42 Dew OfDeeth a Natural 0 Homicide ❑Accident ❑Pending Investigation
S Yes ❑Probably 0 No ❑Unknown
❑Not Pregnant.But Prevent 43 Drys To 1 Before Death ❑Unknown If Pregnant WMm The Pest Year ❑ .ulcide❑Could Not Be Determined
34. Date Of Injury(Month/Day/Year) 35.Time Of Injury 36. Place Of Injury(E.G.,Decedent's Home,Construction Site,-estaurant,Wooded Area) 37. Injury At Work?
i I:.. _. ED
oyes El No
38. Location O(Injury-State 38a. City Or Town 38 Seat Nu.bar 38c.Apt No. 38d.Zip Code
39. Describe How Injury Occurred SEP
.� 2020 C, 40. If Tr. sportation Injury,S ecify:
Jts nr... for ❑Paaserga Eisse. Crian❑OErer(SpacRy)
41.Signature,Of Person Certifying Cause Of Death: 42.Ce 'er( eck Only One)
ROBERT D.BOND, BY ELECTRONIC SIGNATURE / S •rtifyi : thyslcian 0 Coroner ID Heath Officer_ __
43. Name,Address And Zip Code Of Person Certifying Cause Of Death: _ n��1 44. License Number 45. Date Certified
ROBERT D.BOND ,685 VAIL STREET, PRINCETON, N 47670GIBSON COUNTY ' -i •R 01030202A 09/23/2011
46.Additional Funeral Service Provider. 47.•Akas:
48.Signature of Local Health Officer. 49. For Registrar Only -Date Filed(Month/Day/Year):
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE SEP 26 2011
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
(6 , 1r) y--- 100 - col - 9-4 1- --GA
Slate.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.
' IVRA-20
(7/05) : :`f't,