Death Certificate - Nolcox, Rodney_12/4/2020 •
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, INDIANA STATE DEPARTMENT OF HEALTH
*,,,:i "CERTIFICATE,OF DEATH -- . .
1.4 Local No:000223 EDR.No :00001 1 024372- ' ' - State No 2020-068138
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1.Decedent's Legal Name(Fist,Middle,last) • - - , , , le:'Maiden Neino(1t female)'. - -.2.Gender. 3.lime Of Death r '4. Dire Of Death(Month/Day/Year)
,RODNEY TYREE NOLCOX - Male• .09:15 AM - 11/30/2020 '
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I @ 5. Sethi Security Number 6a.Age-Yr 6b.Under 1 Year 6c. Under 1 Month 6d.Urder.l Day Se. Under.)Harr
Princeton,Indiana
t"`� � Months , Days Hot±is - . ,nrrirxrlos -
5 9. Ever er U.S.Armed Forces? 10.11 Death Occurred In A Hospital . 1Oa. If Death Occured Somewhere Other Than A Hospital
• - - - El Hospice FscrIty' `❑Decedents Horror ®Nosing liana+)-orrQ-tmm'Caro Fealty
,cz,\ ❑Yes ®No ❑Unknown ❑Inpatient'❑Emergency Deparlmeil OQilpatierit•❑Doad on Arrival 0 Other(spec f) ',1 . ' ' ' I
t - 11, Faciify Name(if Not Institution,Give Street and Number) F " •
- . TRANSCENDENT HEALTHCARE OF OWENSVILLE,,LLC- - - '
t:% 12. City Of Town,slate,And Zip Code - - ' 13.County Of Death'-. . '14,Marital Status Al Trine OI Death .
M, Owensville,Indiana,47665 Gibson ❑Married 0 Married BatSe
parated El Divorced
I 0 Unknown
15. Sun dng Spouses Name 15a.Last Name Before First Marriage 16.Decedents Usual Occupation Widowed 17.Kind Ot Businessllrriustry -
4`' PRODUCTION MANUFACTURING
1"=/( .
18. Residence-Stale tea County ,, , 16b. City Or Town
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t?'' 'Gibson Princeton _ '
'(,f. _18s. Sheet And Number • - .
• 18d Apt No. 18e.Tip Code 161. Iraide City Units?
k`- 2324 N OLD US HIGHWAY 41 Highway 47670 ['Yes ®tdo
f"/f41 t9.Decedent's Education 20.Decedent Of H'
Origin - - 21.Decedents Hato ,
>kt-1- I I Unknown Not Spanish/Hispanic/LatinoStack or Atrioen American
" _22.Parents Name(Fast.Male.Last) 23.Parente Name(First,Middle,last) 23a.Parente last Name Before First Marriage,
��i JIMMIE DON NOLCOX • - - RITA.JEAN NOLCOX' 'HUGHES
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24.In•formant's Name 24a.Relationship To Decedent ' 24b.'Mailing Address✓(Street And Number,City,State.Zip Code)
Tr ' COREY ALLEN NOLCOX Brother • , ' . •
. 2350 N OLD US HIGHWAY 41 Highway,Princeton,IN,47670
25a.Method Of Disposition 25b.Place Of Disposition(Name,01 Cemetery,Crematory,Other Place)- 25c.Location-City,Town,And State
• ❑Burtnl CCCrematiori 0 Donation❑Entombment - '�'
ElRemoval From State
ID CREMATORY: ' ' _ -. Evansville,IN '
plru oih (specify):et(sly):
26.Was Coroner Contacted? 27.Name And Complete Address Of Funeral Facility,' - _ .,,•• .. . ? a Funeral License Number:
IT ' Doyle Funeral Home 520 S MAIN ST,Princeton,Indiana,-47670 i ' . • FH1040001
. CI Yea RI No'" Q
27b. Signature Of IMitum Funeral Service Licensee: - .. y'
,tBA 4TZ(!OCYYLE - ,. - nm�ar(pf Licensee):F 9500
nrE : Electronically Signed tJ •
i ; - • Cafiee Of Death(Sea Instructions And Ettarrrples)
Appr28,Part I.Enter Tile Chain Of Fventg -Diseases,in�'uries,Or Complications-Thal Directly Caused The Death.'Do Not Enter Terming vents 1 Interval:Onset
Such As Cardac Arrest,Respiratory Arrest,Or Ventricular 1-,"lprillation without Showing The,Etiology.Do Not Abbreviate.Enter Only a e Cause On �+ To Death
a , ' A Line.Add Additional Lines If Necessary. _ .
• '' METASTATIC BLADDER,CANCER- ,
Immediate Cause(Final Disease Or Condition Resulting In Death) , A. ! BLANK
-.`t . - SEPSIS WITH ACUTE RENAL' AIL RE AND SEPTIC SH if Any,Leading To The Cause listed On - B•. ' - \\ 1
Line A.:Enter The U Cause DlseaseOrin 4urotaw.w.. al
Underlying ( jury That initiated !', , , .
The Events Resulting In Death)Last C• ,
F 'm f6 how pq;
;,f Pert II.Enter Other Significant ConditionsCoMrtputir,o to Death But Not Resulting In The Underlying Cause Given In Pat I 29.Was AnAutopsy Performed? ❑Yes ®No ,
mg Complete The Cause Of Death?r�, , NONE - �i - 30.WereAtrbpayFird' Available 0 Yes 0� '
t, 31.Did Tobacco Use Contribute To Death? 32.It Female: - - r �' . ma
, ; 33. Ma Of Death: • . . .
�.L ❑MaPt.purtWeii Put Yrt ❑Pr'arantAtTa..d0..7i ❑NatPmpunLBrP.a, rhsrweztbrsdo..a. Natural❑Homicide
❑Yes ❑Probably❑No ®UNvtam ® ❑Accident ❑Periling hRest'pairon
❑Mat►r.vtat.eat Pr•tnwh or,•.To,rim Ufa*own. , ❑bawd.:,,I nagruniwrn.,Th.hat Y.r ❑Suicide❑Could Not Be Determined
34.Dais Of Injury(Month/Day/Year) 35.Time Of Injury ' 36:Place Of Injury(E.G.' Decedents Horne,Construction
e,Ctruction Site;Restaurant,Wooded Area) 37.In)u'ry At Work? •
' _ I :i - ❑Yes El No
`\ 38.Location Of Injury=State 38a.City Or Town ', • I .38b.Street a Number • - 38u Apt.No. . 38d.Zip Cods - •
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�i� - 39.Describe How Irjwy Occurred . '• -- 40.-If Transportation injury.Specify: . ,
] -ti
- .. , - ❑WwaVpr.ax ❑ ❑RI°tlM'r'j] ..! Un o (6P'
41.SignaMe,Of Person Certifying Cause O1 Death: '' '''," 42-Certaier Check�. .t ,f ( ONy One
=' 1� L'E�rfxon r1) I EtecEronjcally Signed Certifying k don )❑Coroner ❑Health Officer-
L . 43.Name,Address And Zip Code Ol Person Certifying Cause Of Deaths, - 44.License Nurttoer 45.Date Certirwrd '
BRUCEiCarlton BRINK JR 410 NORTH MAIN STREET,Princeton,IN 47670 " ' , - 02000610A, 12/03/2020 , - "
46.Addilanal Funeral Service Provider: - , • ,47. ',Nuts:,
1 .
48.Signature of Local Health Officer: `- , e9.For Registrar only-Date Filed(MontivBayfYear): •
-'; -ElectronicallySigned 12/04/2020
% • • ,AMENDMENT TO CERTIFICATE OF DEAT H(ENTRY OR ORIGINAL)
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- 'C-'OL1-36--io,o:-o,01."145�--02�- , _ ' .
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State Form 53395, ATTENTION ESTATE The Social Security I i$being requested by this state agency in pons
order to pursue resit tiny. diwrivire ie voluntary and there wilt be no penalty for refusal.
ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL OF.THE STATE OF INDIANA,ON BACK THAT
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WARNING. TURNS'FROM ORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUMENT HAS A HIDDEN VOID ON FRONT THAT APPEARS WHEN PHOTOCOPIED.
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