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� :. "�� CERTIFICATE OF DEATH 5ij.1 J' "' 4
\`;r r':/l Local No 000127 EDR No Oye.0 erl!,1 .`?; b:1,, State No 031773
1.Decedent's Legal Name(First.Middle,Last) 1a. :Ida... (I = - 2.Sex 3.Time Of Death 4.Date Of Death (Month/Day/Year)
LESLIE EUGENE TINSLEY _ MALE 05:30 AM 07/03/2013 _
C.Social Security Number ha. Age-Yrs 813. Under 1 Year 6c. Under'I Month 60. Under 1 Day 6e.Under 1 Hour 7. Date of Birth(Month/Day/Year) 8.Birthplace(City and State Or Foreign Country)
82 Months Days Hours Minutes CAVE-IN-ROCK, IL
9.Ever In U.S.Armed Forces? 10.If Death Occurred In A Hospital: 10a. If Death Occurred Somewhere Other Than A Hospital
❑Hospice Facility ®Decedent's Home ❑Nursing Home/Long-term Care Facility
RI Yes 0 No.0 Unknown 0 Inpatient 0 Emergency Department Outpatient 0 Dead on Arrival ❑Other(Specify)
11. Facility Name(If Not Institution,Give Street and Number)
7747 SR 64 EAST
12.City Or Town,State,And Lp Code 13. County Of Death 14. Marital Status At Time Of Death
®Married 0 Married,But Separated U Divorced
FRANCISCO, IN, 47649 GIBSON 0 Widowed 0 Never Married 0 Unknown
15.Surviving Spouse's Name 15a.(If Wife)Give Maiden Last Name 16. Decedent's Usual Occupation 17.Kind Of Business/Industry
FRANCES M TINSLEY PAGE OPERATOR BOATING
18. Residence-State 18a. County 18b. City Or Town
INDIANA GIBSON FRANCISCO
18c.Street And Number 18d. Apt.No. 18e.Lp Code 18f. Inside City Limits?
7747 SR 64 EAST 47649 0 Yes ®No
19. Decedent's Education 20. Decedent Of Hispanic Origin 21.Decedent's Race
8TH GRADE OR LESS NOT HISPANIC White
22.Father's Name(First,Middle,Last) ' 23.Mother's Name(First,Middle,Last) 23a.Mother's Maiden Last Name
GEORGE RUSSELL TINSLEY • 'MAHALEY TINSLEY WILEY
24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address (Street And Number,City,State,Zip Code) .
FRANCES M TINSLEY WIFE . 7747 SR 64 EAST, FRANCISCO, IN 47649
25.Place Of Disposition
25a.Method Of Disposition 25b.Place Of Disposition(Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State
❑Burial ®Cremation ❑Donation 0 Entombment
❑Removal From State
❑Other(Specify): EVANSVILLE CREMATORY EVANSVILLE,IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility 27a. Funeral Home Ucense Number.
❑Yes ®ND CORN-COLVIN FUNERAL HOME, INC.,323 N.MAIN ST. PO BOX 278,OAKLAND CITY, IN
47660-0278 FH19400002
27b.Signature Of Indiana Funeral Service Licensee: 27c.License Number(Of Licensee):
JOHN W WELLS ,BY ELECTRONIC SIGNATURE FD01009940 .
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. CHRONIC OBSTRUCTIVE PULMONARY DISEASE 5 YEARS
Duo to(Dr MA Consequence Orr.'
Sequentially List Conditions, If Any,Leading To The Cause Listed On B. DEME 2 YEARS
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated Omo(O A.Afcnaquenaoj .
The Events Resulting In Death)last C.
. .411(10001. Due to for Aa A Consequence 0t' _
D. _
Part II.Enter OtherSignifcant Conditions Contributing to Death But Not ul'g I e'•nderiyiin st.J Mn In Part I ;, 29.Was An Autopsy Performed? 0 Yes ®No
•Co 30.Were Autopsy Finding Available To Complete The Cause Of Death? ❑Yes ❑No
31. Did Tobacoo Use Contribute To Death? 32. If Female: ��`�, 33. Manner Of Death:
❑Not Regnant Wi
gan 0 r a rAu di t But Ptooneni Min 42Bays Death ®Natural 0 Homicide 0 Accident 0 Pending Investigation
0 Yes 0 Probably❑No ®Unknown ❑Not Pregnant But Pregnant 43 Days To1 agar Bolero De .41 u uPraon..t%%Mt, v El Suicide 0 Could Not Be Determined
34. Date Of injury(Month/Day/Year) 35.Time Of Injury r!. ce Of I ry(E.G.,Deced s ne Co iruction Site,Restaurant,Wooded Area) 37. Injury At Work?
Owl I ❑Yes ❑No
38. Location Of Injury-State 38a. City Or Town ose4 38b.Stree &Number_ grill/"P.- 38c.Apt.No. 38d. Lp Code
39. Describe How Injury Occurred ,J 8.,:,If Transportatlon Injury,S ecify:
rhotiop otor ❑P.mrger j�Padesefen❑OthertSpeiayi
41.Signature;Of Person Certifying Cause Of Death:, 42.Certifier(Check Only One)
JON M HALL, BY ELECTRONIC SIGNATURE ®Certifying Physician ❑Coroner ❑Heath Officer
43. Name/Admess And Lp Code Of Person Certifying Causg Of Death: 44.License Number 45. Date Certified
JON M HALL ,4015 GATEWAY BLVD=-STE.3000, NEWBURGH, IN 47630 01050887A 07/10/2013
46.Additional F'Steral Service Provider. ; 47.•Akas:
48. Signature ofLtcalHer alth.Of8cer.. 49. For Registrar Only-Date Flied(Month/DayNear):
BRUCE BRINK JR,VIA ELECTh ONIC SIGNATURE JUL 11 2013
-.:,, AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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' ' ( - S _ 2 I...,300- 00 0 ( 6 b 8 -0 C 4..f.
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.=^ItateFerm 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.
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