Death Certificate - Simmons, Lunolia_1/25/2021 -� xa III I. M,. �s�. N N70,11:,,I.!,111'..'1.11:1"1,711.,1',1:111-' ...(Th*:.:461-'",;
¢ 1 m 4 ! 1 _ r� i?�+;�11 R:e. Gt' rt���1pit �; \�l Ih 111 lu '' CERTIFICATE OF:DEATH
P�,,; i� 111j111..11p1 . - 1,�:.i I,pll , Ir°° Lacall• I�o''001'17...�` 1.Decedent's Legal Na a Fus Middle,Last EDR NO 000011037278, ` p�;fi, a t ) la. Maiden Name(If female) 12.Gender State Ne2020-0760 l' 1l 11,'
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till i IIII I!ilir 3.Time Of Death II d?a(ai01 Death,(Monlh/�eyLYearj
r: LUNOLIA AUGUSTA SIMMONS. IIIIh11'„,, YOUNG ;,1. Female 04:50 PM yl {21/2020 •
t - 5. Social Security Number 6a:Age-Yrs. 6b. Under-1 Year: 6c',iUnder 1 Month 6d. Under 1 Da 6e. Under 1 Hour 7. Date of Birth Iu„ ';
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l a'illl 1t Y (�lonth/DayNear) 8.Birthplace (City and State or Foreign Country)•,.
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• 9.Ever in U.S.Armed,fiwces? .10.If Death Oct:up`ed.')n A'Hospital: , 10a. If Death Occurrd Somewhere Other Than A Hospital ' s•-
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'6reJ ❑Yes I&1 N 1 (iknown Inpatient. ;❑Hospice Facility ❑'Decedent's Home 0 Nursing Home/Long•term Cared :0.1y ,,
I q. A ® P ❑Emergency Department Outpatient 0 Dead on Atnvaf _ alter/
`P 11. Facll' ' I (III ', 0 Other(Specify) il'1 I�'11 ,�y� i
Mert{e (Ii Not Institutiory,.Give Street�andNumber) �� ;_ y
f IIIII.I,, 1 DEACONESS GATEWAY IIII ll1 f Zas
12. City.+Dt i dwp,State,And ZipCode Al 'I!,:..,I' 1
IIII lilt I,rll I iI! 13. County Of Death I 14, Mahtal Slalus At Time Of DeatTf 0?,e it
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&: Newburgh, Indiana,'47630
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y ;. - ' 'r ll'llll',10,,,lirill Warrick 'i ®Widowded❑0-Married,NevertMarri Married ❑'grip ri
15. Su vivingSpouse's Name I I I I,i II 15a. • Name Before First Marriage 16. Decedent's Usual Occupation yp - IJ1 IIIII II I,I g II P 17,'Kind Of Bus(rtes�l•�rM§�
1��, 111111,1 I,' HOMEMAKER I„'" ,,, DOMESTIC Ill�,gi 1
`0-- 18 a fbe ce Lslate , II III' li'l
fin Ili'lird 11h II' .. ,,I - 18a, Coun 18b, City Or Town II II I 1
s IN 'IIII,' I Gib �I IIIIIII IIIiIiI
'L.II,'i,,, Princeton il, il„
P 'MCP-Street And Number I,., �
)�\ : 608 N GIBSON'Street - oil!,u1pr,Ulj'I'161', � • 18d. Apt No 10e. Zip Code 1ef. InsldeCrl Llmils?
l' 'Ii�I' II' 1 11 I ,,, +lilil6 I'1p11 l III ., -` iI 47670 Ye Ild No,- _ !
,Yt 19 Decedent s'Education ''�;1�i,I ll�ll; -- - - 20. Deced Hispanic Or nyoYI'DA%
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• 21. Decedent's Race !S
,I19tK=12th grade,No Dipl6ma r' ,tt�`` II'. — l I
g Not Spanlsh/Hlspan),' S( Black or African American> I'll ^, ,\
IjIII iIQ2lParents Name(First,Middle,Last) ',I,!!:.'` Y� j'I I;;Iipll
E I ', �� 23,Parent's Name(First,Middle,Last) '1 23a,Parent's Last Name Before First Marriage '
6r'� plil!' WILLIAM EARL YOUNG I �0 16 MAGNOLIA AUGUSTA YOUNG III
��,, ,', �, ARMSTRONG
Fy jr. 24.Informant's Name • ',I!Illii IIU
24a.Rialathaihip To Decedent 24b.Mailing Address,(Street And Number,City,State,Zip Code)
i ALFREDA HARRISON 11j 011111'1111;1'1o' •.: Daughter 507 GARDEN GRACE Drive,Indianapolis,IN,46239 1j''l l I I I�'I'p 'h'll 11 ill) "'`. ,x IIIII yl!! ('•' . 25.Place Of DIsposltionl ' 1 I1 . (
25a Method Of Disposition t',,,; I' 25b,Place Of Disposition (Name 0)Cemetery,Crematory Other Place) 25c,Location-City,Town,And State I•ilia IIIII'ill', i
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,ma I�Buriallll'l (tr atlon {Ili 1 ii �„ ,
gfn, 0 DonaOo ❑Entgmbment
❑ReroovaLrrbm State, - I I Ilil Ill r!I 11i'
0. I I�'I
i I',i SAND HILL CEMETERY Princeton,IN lip IIIII Ill'''
❑Other(Sbeclry); i ;1I II -'
• Ii26ijWa$Coroner Contacted? 27 Name And Complete Address Of Funeral Facility • ,
Cowin Funeral Home Inc N MAIN ST.,Princeton,Indiana 47670 ! 27a..Funeral Home Ucense Number, ''i
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❑Yes r. No 'i'I',1110 !I FH83005671. �IiiIII l r 1
27b. Signature Of Indiana Funeral S.II1llpolltc@nsee:
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( � ,/f,¢[� ''I' 27c. License Number(Of Licensee): i
ar
,,!-1 Electronically Signed I FD01012 �{,
_i ,r IIIII', 1.III,, Cause,Of Death (See instructions And Examples) '
i28'part I.Enter The Chain Of events -Diseases,Inures,Or Com Ilcatlo s 1' I'4 I u1 Approximate 555555 j P e 'ghat Directly Caused The Death.Do Not Enter Terminal Events 11 ll�,,III! ' ' Interval: Onset
11 f 1., (fc'h As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Shbwin The Etiology,
IA 1 :; A'Line. Add Additional Lines If Necessary. g Do Not Abbreviate.Enter Only One Cause On To Death,. ,Ip,
• I :' Immediate Cause(Final Disease Or Condition Resulting In Death);,'ill" A, CARDIAC ARREST •, ,;
-4 ,1r.1•ll,III.. II Doug(Or As A Consequence On I I,
4 y j 111I ��II!' B ATRIAL FIBRILLATION •I I ; I Ill n,.
Se uentiall List Conditions, It Any,Learl4 i ,?te Cause Listed On I ,
D Line A, Enter The Underlying Causg(glsi'as Or Injury That Initiated •
Ouem(aASACoce.quonceOq: glllli l p
rt The Events Resulting In Death)LLst;i111 'I'Ii,'I' o
ih 1 II '' C. ijl, 1
e • 1 p I II I'I I,I IIII •I Due to(Or As A Densegoww
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I III Oh, IIII,110,
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Part II EiliOtherSignificant Conditions Contributing to Death But Not Resulting In•The Underlying Cause Given In Part I
29. Was An Autopsy Pedonned7 +il I•i l ,_ l i
1 1 •6,:i ❑Yes . -®NO• r A :.1
I;lS ) RE PULMONARY HYPERTENSION 1'I II IIIII II 30 Were Autopsy Finding Avallagil i lTo•Complete The Cause Of Death?crt '3,'(;yi�Dld Tobacco Use Contribute Td Death?I111i I 32. If Female:-- I, 1,IIll1! • --. - - - - - l ❑Yes.❑No
I,1!1'II ❑Not['reliant wakn Post Year P1 33. Milliner Of,Dealh:- ;'
0 Yes 0 Probably 0 No ®Ur1k,:i,'Illll,I� ❑, regnanlAtTan°O1 Death 0 Not P egnan B.iPleananl' hin 42 Days Of Death ®Natural 0 Homicide 0 Accident ❑Pending l(Z3etigatlon
IIII !, ❑NaiPmgnm,ElulPr.yznI43DayaToIyearBelloDeah ❑UninoxgP';. ' ItWahin The PastYear ❑Suicide❑..CoukallotBeDetermind Il1ILI 11•I'
4A 34, Date Of Injury(Month/DaylYea I)1 1;'I ii I•'' 35,Time Of Injury • . 36,Place Of In)ury(E.G.','Decedent's Home,Construction Site,Restaurant,Wooded Area) 37.:In I'
F' II I I11, „ -
I till I'i!I,�IIIIiII it g AYWork7
1, lip' Il.1i'11,j es 0 No _
I 38-Location Of Injury,State • - .38a. City Or Town 38b. Street 8 Number
\ 11�'111 !i;!., 38c.Apt.No. 38d. Zip Code
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IIL1 39. Describe How - .:" ,,'�''i''', '
r Injury Occurred I iI Ili�:II ,
11I1II III I I
40 II:Transportation Injury,Specify:
- IIIII i''11, ❑041' nOvenror ❑Passena.r❑P.aearnen❑omen lsa.rayt I'IIII II i1q .
•
^'1 41,Signature,Of Person Certifying Caugl lC.ls_Ili 1,tl{'il" I P p r
It Ail I j!I„1!II' ;I 42. Certifier(Check Only One) III I IliiileI I, r :a
Electronically SI ned r.t sera physician f
43. Name,Address And Zip Code,19 RO'IdhHCertit in Cause Of Death: Y g certifying Y 0Coroner ❑Health Otllger•,,,
44. License N rnber 45. De)..GeHlricid
AVIgR i'RRi;600 MARY STREET,Evansville,IN 47747 II1`'I• iilrii I,,,
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` 010748231Ai1!iil'' 12/30l2020' 46 pld)iyt prtiailruneial Service Provider: III- - ,LI
1,II'Ilh.l! 11 • 4711 AkaS; 1
48 ISj9nature of Local Health Officer: 1I,,I' 1 49. For'ReglstraYlOply•A,Date Filed-(Month/Cay/Year):
•
lVdCYB t'EAGER - Electronically. S ned I 12/31/202Q 1
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Illli III III AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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p1„State Form 53395 1.j •
ATTENTION ESTATE The Social Security#is being requested by this state agency In order to pursue responsibility. Disclosure lsvoWntary and there will be no penalty tot refusal.'- " `I
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