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/' �"'\ INDIANA STATE DEPARTMENT OF HEALTH
G `
% i CERTIFICATE OF DEATH •
1 sShc f 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.
1% Local No 0001 80 EDR No 000000745414 state No 058972
1.Decedent's Legal Name (First,Middle,Last) la. Maiden Name (II female) 2.Sex 3. Time Of Death 4. Date Of Death(Month/Day/Year)
{r EARL WILLIAM GREEN . - MALE 15:42 .
141,4 5. Social Secunty Number 6a. Age-Yrs 6b. Under 1 Year 8c. Under 1 Month 6d. Under 1 Day 6e Under 1 Hour 7. Date of Birth (Month/Day/Year) 8.Birthplace (City and State or Foreign Country)
7.6 88 Months Days Hours Minutes 11/07/1931 CHICAGO, IL
. 9. Ever in U.S. p Armed Forces? 10.If Death Cr.r irr,;d In A Hosital:
L 10a. If Death Occurred Somewhere Other Than A Hospital
❑ Hospice Facility ® Decedent's Home 0 Nursing Home/Long-tens Care Facility
'1P ❑,Yes ® No 0 Unknown 0 Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival ❑ offer(Specify)
6J�,�f 11. Facility Name(If Not Institution,Give Street and Number)
.Kit 205 EAST OLIVE DRIVE `
171 j 12 City Or Town,State,And Tip Code - 13. County Of Death 14. Marital Status At Time Of Death
EE&_t'' ® Married 0 Married,But Separated 0 Divorced
......4.
� PRINCETON, IN,47670 GIBSON 0 Wldorwed 0 Never Marred 0 Unknown
yyl,,� 15. Surviving Spouse's Name 15a. (If W fe Give Maiden Last Name 16. Decedent's Usual kr. n9 po ) Occupation 17. Kind Of Business/Industry
ki TELECOMMUNICATION
MARY ROSINA GREEN ROBESON LINEMAN S
la 18. Residence-State 18a. County - 18b. City Or Torn ,
INDIANA GIBSON PRINCETON
11 18c.Street And Number 18d. Apt.No. 18e. Zip Code 18f. Inside City Limits?
r�
r.,//r
205 EAST OLIVE DRIVE 47670 ® Yes ❑ No
((mil 19. Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedents Race
p ; SOME COLLEGE CREDIT, BUT NOT A
fDEGREE NOT HISPANIC WHITE
i
c22.Father's Name(First,Middle,Last) • 23.Mothers Name(First,Middle,Last) 23a.Mother's Maiden Last Name
-
'7d EARL GREEN DOLIMAH GREEN DIXON _ _
CI24.Informant's Name 24a.Relationship To Decedent 24b Mailing Address(Street And Number,City,State,Zip Code)
W 0.) MARY ROSINA GREEN . WIFE 205 EAST OLIVE DRIVE, 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
0 Burial® Cremation 0 Donation 0 Entombment
CC 0 Removal From State
O 0 Other(Specify). EVANSVILLE CREMATORY EVANSVILLE, IN
0 26.Was Coroner Contacted? 27, Name And Complete Address Of Funeral Facility '27a. Funeral Home License Number.-
'" ® Yes 0 No ' DOYLE FUNERAL HOME, 520 S MAIN ST,-PRINCETON, IN 47670 FH10400010
F 27b. Signature Of Indana Funeral Service Licensee: 27c. License Number(Of Licensee):
BARRETT W. DOYLE, BY ELECTRONIC SIGNATURE FD29500009
Cause Of Death (See Instructions And Examples)
LL 28.Part I.Enter The Chain Of Event @ -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Approximate
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On Interval: Onset
• A Line. Add Additinal Lines If Necessary. To Death
O Immediate Cause(Final Disease Or Condition Resulting In Death) A. CARDIAC ARREST MINUTES
`> Do*to for As A coro.wmw do _
r Sequentialty List Conditions, If Any;Leading To The Cause Listed On B. CARDIAC ARRHYTHMIA MINUTES
Line Ae Enter The Underlying Cause(Disease Or Injury Thal Initialed mI A' quell*o
���(- The Events Resulting In Death)Last C
i.. D. I
rtf, Part II.Enter Other Significant Conditions Contributing to Death But Not Resulting In The Underlying Cause Ginn In Part I s onmed?
llu � ❑ Yes ® No
CDIABETES MELLITUS, HYPERLIPIDEMIA, OLD AGE ere ps Available ToC•mpleteTheCauseOfDeath? ❑ yes ❑ No
31. Did Tobacoo Use Contribute To Deat? 32. If Female: 33. Manner O Death:
" ❑ Not Pregn.n wan P.a v..r ❑ Pr.p,W At Tm.mo.05 ❑ Na Pregnant eel Pr.�i a7 Day.or ee Natural P Homicide ❑ Accident ❑ Pending Investigation
❑ Yes ❑ Probably® No ❑,Unknown ❑ Nat Pr.ve.rc eN Pmnara a Days To l y..,eta.Dears ❑ u.av n IfPnanun ^Said•:❑ Could Not Be Determined
34. Date Of Injury(Month/Day/Year) 35.Time Of Injury 36. Place Of Injurydib,� n' �D Site : etaurant,Wooded Area) 37. Injury At Work?
' 111IIIVVVVVV U Ll lJ ft ❑ Yes ❑ No
II-, 38. Location Of Injury-State 38a. City Or Town 38b. Street 8 Number 38c.Apt No. 38d.Zip Code
r,k, ; .
39. Describe How Injury Occurred If Trayssp�lyon Injury,gpecify:
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41. Signature.Of Person Certifying Cause Of Death: 42. Certifier(Check Only One)
RAMESHBHAI P PATEL, BY ELECTRONIC SIGNATURE ® Certifying Physician 0 Coroner 0 Heath Officer
`t 43. Name,Address And Zip Code Of Person Certifying Cause Of Death. 44. License Number 45.Date Certified
pP,
' RAMESHBHAI P PATEL ,685 VAIL ST., PRINCETON, IN 47670 01040266A 12/02/2019
46.Additional Funeral Service Provider 47. 'Akas:
l 49. For Registrar Only -Date Filed (Month/Day/Year):
r X. 48. Signature of Local Health Officer.
BRUCE BRINK JR,BY ELECTRONIC SIGNATURE • . DEC 04 2019
,/• AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
2 I L{ 0 3 OOP O C .Oc9N i
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�l State Form 10110 (R6/3-07)
� = WARNING. TTURNIS FROMCORANGE TO ELLOW WHE
N RDUBBED.ORIG NALL DOCUMENT HATS A HIDDE VO DPON FRONT THAT APPEARS.WH NE HOTOCOPIED AN ON BACK THAT ,