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Death Certificate_Alldredge Ii i,---iniis'..✓,T�yrd.:-%' rl “ rslt J: (v ,IND vi -r; f 1 1 /0 r t') t/r t—it, jT�.,r" r (, ...,". r ' i r r- ' ,r am y ,<I :I �:�1 it uND,AN jSTA E Dk ,�,iTt T`,, c r te ,, I fl-f: , ' - 1•w '�' f(! ,fix G ,1'�t,I'iti,€ f ,r Ir' -' I`i I C` .. ' u✓ ,xr,.' ..�a L i .. .,3 ./-i ,''' .4?.:, � ;. . �< ,�ERTI ICAT O ��EATH< .. t .- -, � ;,,, ;. t tryr-� i i'� •y. e t•" T. - i ;i,�%;•::,� �^.1`• �•�. % �. i- , tit f f�"` `\'%i jli,`:: ,•r+`_1'.^ j �; 'tIjill( IEt';:.tR{� r'l:;c i ( f,• rIT v d / i '�: s,,.:e�}} s : 1;• */�i I I,r' 1 r i / s r it s l Y • : !, .r816-'a L0C,a1 No ,U.Q0 8 : ♦'�.,EDR_g �:OQll:0.0443= '07 Z: ` r' State N,o�( �,$.4$ . fl , •. .. ^.drpecedent•siegalNaine;(Frst 91M16, 85t)i< \ ja Maiden Name(If•femafe);; z�y r 2 Sex -3 Time Of'DeSt.a. ;'4ffD,ate'.9.1,RM h(Mott'\ r tick' PA^•.¢r i))y`'.t C ;Silt ,' ' .i ij�,• �:r ) i Z ' i7' ('f.I 11 1tl �''^, ni°i'rdit- `V" j�,I.• U.C:ittbRERG s}, -� ._� _`. ` 'MALE. `:��O7'F7_AM 4/a 3/20155 :;;., < ,,, '5 :Social.Security NciniW t6u Age•=Yrs 6b Under 1 Year. Sc Under 1 Month';8d Under 1 Day 6e:`'Under l hoer 7 Dete of Birth(MoniktfOe:sear). 8 8'irthpl4ce.(City.andState or i;nrergn pountry)'1 I I:'�% 'w y ter' ryr - t. tr q %a*i (r` n ( ,x 1 ✓ •- , 64•) Months Days Hours Minutes PRINCBTON'IN Y . › . t` 9:i Ever m U S.Armed Forces? 10 If Death Occurred In AHospital 48a If Death OccurredSomtwhere Other ThanA Hospital . 1. -_ r - - ; • ❑'hospiceFacility ®,Decedent's;Nome 0cNur ing•Nos'ree/Long-t rrnCareFaoli ,4,,, ❑;Yes ®'NQ ❑•Unknown ❑,(npatrent 13 Emergency Department Outpatient ❑Dead on Amval l❑Other(Specify) ♦ "i"v; k11 'Faci9ry Name;Of Net:inetitetleni Give Street_and Number) • t 919 SOUTH MAIN STREET , 12.s City Or Town State,And Zietede?, - 13 County Of Deatfi -14,Mantel Status At Time.Of Death.: \ ®Manned❑MAmed B.it 5 ted ❑Divorced- ,• " -a I Widowed` ❑NeyerMa , D Unknown ?> PRINCETON IN 47670 -, - z, . GIBBON .:' . : ..• .,, 15=Sir iving'SPousesName 15a.(If Wife)Give,Maiden Last Name 16 Decedents Usual Occupation i7r E0ndOf Businessnndustry;. ;l f 'CAROLYN As. LLDREDGE S. . < SISK SHIPPING•AN• D RECE IVING. MANUFACTURING f :18=,Residence:'State= •18a. County - -" 118ti 'CityOrTown 4s ,_• INDIANA.:` . . . ;.:-.',;•::.GIBSON •' PRINCETON ' r ii 18c. Street And!Number -,: , -'> ` .. . " - .., a • • :. ��-�� `;. t ;� � Apt No 18e Zip�Code 18f-lnside`CdyLmits? 1sd 4 919 SOUTH MAIN STREET _ . - 47670-.._- ®Yes D No 19. Decedent's,Ed ucabon '20..Decedent Of Hispanic origin,:- ''215 Decedent's Race" „, 1> SOME COLLEGE`CREDIT;BUT NOTA^. DEGREE>;. NOT.HISPANIC . White :22.'Fettier'sName'(First;'.Middle Last);r ' • `' - ' me(First,Middle,Last)- 'M 23a. others Maiden East.Name" , 23.-Mothefs Na ;HERBERT EUGENEALLDREDGE s .s;- • MARY:ALICE ALLDREDGE ' MONTGOMERY `24:Informant's'Nainee ;"•24a.Relationship So:Decedent •. 24b:MeilingAddress(Street And Number City,.State Zip'Code) • „ + CAROLYN ALLDREDGE`,;'"• WIFE ;919 SOUTH MAIN':STREE'T, PRINCETON IN 47.670 '' 25'.Place.Of.Disposition. ' - • ''N 25a Mettiod:OfDisposition,'; :; '- '25b:Place Of Disposition:(Name Of Cemetery,Cremeto y Other Place) 25e:Location-City Town,'And State ®; 0 Bunal Cremation 1]Donation❑;Entombment' ' . ' ❑Removal From State_ ` ' - r ' • ❑Other;(Specify),..., - , ,, _: CHUR CHiCEMETERY PRINCETONi IN.,, , : - : '28E Was:Coroner Contacted? '-'\• ; '27:`Name And Complete Address:Of uneral•Facility , • ' 27a Funeral Home Lrcense Number LI Yes ®'No •COLVIN FUNERAL HOME INC;425 N MAIN ST PRINCETON IN,47670 ., 4H83005671 r. !27b Signature...Of ridana.Funeral Service L^eosee - v - •27c License Number(Of Licensee)-. MARK R¢'WALTER, BY.=ELECTRONIC`SIGNATURE ?'FDO101301:0:.' . .,.� r , Cause Of peath (See'I nstructlonsAnd Examples) Approximate ,, .28.Part IiEQter The:Chain Of Events Diseases Injuries,Or Complications ,That DlrectlyCaused The Death Do;Not EnlerTerminel Events Interval Onset Such As Cardiac Arrest„Respiratory Arrest.Or Ventncular Flbnllation Without Showing The'Etiology.Do Not Abbreviate Enter One Cause On, To'Death • A Line Add'Addttinal Lines If Necessary. - , : Imnmediate'Cause.(Final Disease Or:Condition Resulting-In::Death) ' A. CANCER OF THE ESOPHAGUS WITH LIVER METASTASIS. 3 YEARS ' Du 1,(m Aa ACo qua of . \\ Sequentiall List Conditions if An Leadin To The Cause Listed Or . \ Y Y 9 6 o �o to aAcormque o Line A Enter The Underlying Cause(Disease.Dr injury That Initiated 9 • i r The Events Resulting In'Death)Last ' C, Duo to(Or As A coneawuence Oe:` " `'Part1I Enter OtherSienificantConditions Contnbutlne to Death;But Not'Resulting In'The Underlying Cause Givin In,Parti- 29,:.Was An Autopsy Performed?• : ij.Yes, ..®;No. f-- 'CHRONICOBSTRUCTIVE PULMONARY DISEASE'GASTROSTOMYTUBE.PAST INCARCERATED INGUINAL' 30,.Were Autopsy,Fnding Available To Complete The'Cause Of Death? t " 'HERNIA .. . ,,, • • ,. -,-� ... . ,, ia_Yes ❑,.No , x 31::iDid Tobacoo.Use Contribute To peach? ' 3,2 if Female: ' ' ;• : ' i '' ,- -33'Manner Of Death.- - 0 N_IPreyn nt!MINnPagv.., ❑PnpneniAiTimaDroe N ❑N iPr o ot.eatPreyn mwemna2D aloe;or ®Natural❑Homicide ❑Accident .❑Pendinglnvestigetton ®,Yes ❑Probably.[]No_❑Unknown - - - - - . c r ;.- - ❑Nrr?r.egnantBui Pregnant 43 Days re1/a Barorepyt ❑u ww,muDn:goa two i,rmn k: •❑'Suicide❑:CouldNotBeDetermined 34. DateOf Injury'(MonthiDay/Year) ; 35,Time Of Injury', : 36 Place Of Injury(ES.,D H• e C. struction Site;"Restaurant;Wooded Area) 3,7„t=Injury At Work?- - ❑Yes ❑No 38. Location Of Injury State 38a. City Or Town 39b Street + 38c Apt:No %38d zip Code • 39:Descnba�How InjuryOccu-ced 40 :Iortation Injury fy. r w\ Qr ohIm� iD� qP � ❑o�rlaPe�nj '41:Signature;;,Of INM5nicettifytifig,,geitSOfMatti: - • - • ♦ �� elk- eck Only:One) : WILLIAM',R.WELLS BY,ELECTRONIC•SIGNATURE '... .'„ llt3«t ❑Corder . .p H eatttofficer ng Physician "43:Name'Address And Zip Code:Of Person Certifying Cause Of Death: - • .::44 License Number"`' ">:45 Date•Certfied ♦ INILLIAM R WELLS 510 NORTH MAIN'STREET PRINCE►ON IN 47670 GO r 0101779bA 04/1'4/201.5 46 tAddibonal:FuneralService Provider' - ;, .. a ;�S '47�Alms' .` - 11 .48.SignatureofLocaDhealthOfficer,.' ,'r ed(Mo th/Day'ear)_r • /▪ .ri •', - - �: 49 ForRegTs'traTOnty DateFdt ..� n nr BRUCE BRINK JR VIA ELECTRONIC SIGNATURE ,APR,15i2015 Y `; AMENDMENT TO C ER71FICATEOFDEATH.,(ENTRYOR ORIGINAL) • .F ^i•51��V :I 1/© i %' tt\r�rl D r i�:. r r S 3'' Gr-1 Q�r `4�,�` E 3 Y/.I;1.•fl i %!.I..ur�i cirs �:x t ,.r, :,,, :e i.. C itF r^ (,ea <.:r- .. sr.r �ti t;s, �I R ,.r. /f.`, itJ, j %State:Fo(mp331.5 igrENT ES;TATE'�TheSsfcla Security#Ts b*rigire uestedb,thisistaleagery fi o to-E.VI a As.RIe sib ttygtt!isclosur;e.t 1 u .•arid therety:7-M„n „F "'19,velusa7i } f+. •M,�)1. ti r4 Y r/.�t t;.ri.siC�b.r jMi I!//,Lid�l,�•f{)S.i` vl..:�t�j 4:✓%�V}j`�/•�.�jS�•r'y l�,..`•,J'� ti r. :,<0, Glf�(At DOCUMEfA.V.-1AS(�MUCQCOIAREp ,KGA(�UfJD'O)7,S�EC17 WHIT SECUR �PAFEl3,440 T*GAtEK A4kip ' 41Z fIINDIARA'ONBAGIfT �� .11`yA/A'R N`i .,. . T.tdRNS FROMIORANGENOAtE'L''LOMWHEN,RUBBED..ORIGINALtidCUMENT,NAS,HIDDENA1010:ON�ONT%THAT;ARPE7IRS_WkI P.IKOTO•CORltb li` itr