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t1®°r`'' / Jnq INDIANA STATE DEPARTMENT,OF.HEALTH �^ _ ` /�
( ,Ij CERTIFICATE OF DEATH
1.DecedenYsLegalNLOoal N o00ame (First,Middle, t00.40 EDR No OOOOO) la. Maiden Name f07e66851 2 Sex• State N o Time f013534 Death 4. ateofDealh(Month/Day/Year)
P. LINDA LOU CURTIS _ ' • SIMS FEMALE 10!10 PM 03/14/2020
r, t
or5. 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/Day/Year) 8.Birthplace(City and State Foreign Country)
%
Hospital
- 0 Hospice Facility IE Decedent's Home 0 Nursing Home/Long-term Care Facility
l El Yes 21 No 0 Unknown ❑ Inpatient❑ Emergency Department Outpatient 0 Dead on Arrival ❑ Other(Specify)
!�\9 -
(' 11.Facility Name(If Not Institution,Give Street and Number)
1619 COTTONWOOD DRIVE - ' V
)4% 12.City Or Town,State,And Zip Code . , 13. County Of Death 14. Marital Status At lime Of Death
C�+- 0 Married 0 Married,But Separated 0 Divorced
6� PRINCETON, IN,47670 GIBSON ® Widowed 0 Never Manied 0 Unknown
/,1,y 15.Surviving Spouse's Name 15a.Last Name Before First Marriage 18. Decedent's Usual Occupation 17. Kind Of Business/Industry
f0.
eSri
OFFICE WORKER UTILITIES
�l, 18. Residence-State 18a. County 18b. City Or Town.
INDIANA GIBSON PRINCETON
A c 18c.Street And Number - 18d.Apt No. 18e:Zip Code 18t. Inside City Limits?
it 1619 COTTONWOOD DRIVE 47670 ❑ Yes 0 No
V19, Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedent's Race
k HIGH SCHOOL GRADUATE OR GED
t. COMPLETED NOT HISPANIC White
�c 22.Parent's Name(First,Middle,Last) 23.Parent's Name(First,Middle,Last) 23a.Parent's Last Name Before First Marriage
4, LYNDON SIMS PANSY SIMS HARMON
24.Informant's Name 24a Relationship To Decedent 24b.Mailing Address(Street And Number,City,State,Zip Code)
w STEPHEN CURTIS . SON 1908 TAYLOR AVENUE, PRINCETON, IN 47670
Q V 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
W ® Burial ❑ Cremation ❑ Donation 0 Entombment
CC 0 Removal From State
O 0 Other(Specify): AUGUSTA CEMETERY AUGUSTA, IN
O 26.Was Coroner Contacted? . 27. Name And Complete Address Of Funeral Facility 27a. Funeral Home License Number.
CC0 Yes ® No
W COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671
27b. Signature Of Indiana Funeral Service Licensee:. 27c. License Number(Of Licensee):
J MARK R.WALTER, BY ELECTRONIC SIGNATURE FD01013010
Q Cause Of Death (See Instructions And Examples) Approximate
LL 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
CI A Line. Add Additional Lines If Necessary. Pii-
O Immediate Cause(Final Disease Or Condition Resulting In Death) A. PNEUMONIA
Due m(oraaAcomeaenoe Of). '4%,/
,41:
� Sequentially List Conditions, If Any,Leading To The Cause Listed On aova to to as A Consequence09: ��`/O
C Line A. Enter The Underlying Cause(Disease Or Injury That Initiated 2
0.• The Events Resulting In Death)Last '
I\( C.
OoeIn(Or AsACmoequence0Q.G/
eS
4-e D. .
Part II.Enter Other Sicnificant Conditions Contributino to Death But Not Resulting In The Underlying Cause Given In Part I 29. Was An Autopsy Performed? CO
0
30.Were Autopsy Finding Available To Completi§yT Death?-
r METASTATIC BREAST CANCER ❑ Yes ❑ No
i0 1 31. Did Tobacco Use Contribute To Death? 32. If Female: 33. Manner Of Death: '9(o
0 Not Pregnant w.eNn Past Veer ❑ Pregnant At Tone 01Death 0 Not PregnaN,But Pregnant Min 42 Days OfDeath ® Natural 0 Homicide 0 Acdden{ �endingInvestigation
0 Yes 0 Probably® No 0 Unknown
4y0 Nol Pregnant.But Pregnant 43 Days To 1 year Berme Death 0 Unknown if Pregnant Mtn The Pest Year 0 Suicide 0 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,Restaurant,Wooded Area) 37. Injury At Work?
X. •
V ❑ Yes ❑ No
OM. 38. Location Of Injury-Stale 38a. City Or Town 38b. Street 8 Number 38c.Apt.Na. 38d.Zip Code
/
k 39. Describe How Injury Occurred 40. If Transportgtion Injury,Specify
❑rnn.rcow am ❑❑P.range ❑p.ae�an 0
ou er(sw.,r)
`P`. 41. Signature, Of Person Certifying Cause Of Death: 42.Certifier(Check Only One)
+�C ADRIAN LEE CARTER BY ELECTRONIC SIGNATURE I ' El Certifying Physician ❑ Coroner 0 Health Officer
t 43. Name,Address And Zip Code Of Person Certifying Cause Of Death: 44. License Number 45. Date Certified
•
ADRIAN LEE CARTER , 1808 SHERMAN DR.SUITE 2209, PRINCETON, IN 47670 02002691A 03/17/2020
,./' 46.Additional Funeral Service Provider. 47. 'Akas:
f� ( 48. Signature of Local Health Officer. 49. For Registrar Only-Date Filed (Month/Day/Year):
ro BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE MAR 18 2020
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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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.
WARNING: TURNIski
FROMCO ANGE TO YELLOW WHEON RUBBED.ORIG NI
ALL DOCUMENT HAS A HIDDEN VO DPON FRONT THATEAPPE RS WH NE HOTOCOO;
EDIANA ON BACK THAT