Death Certificate - Market, James_4/25/2022 . . - ------- -- -- -- -- --- ------- ----- -- -----.
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INDIANA STATE DEPARTMENT OF HEALTH /
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CERTIFICATE OF DEATH (
;ter" Local No 000135 EDR No 000000647690 State No 027869 - -
1.Decederm.Legal Name(First.Middle,Last) le.Malden Name(:f female) 2.Sox 3.Tore OI Death
PRINCETON, IN
9. Ever In U.S.Armed Farces? 10.If Death Occurred In A Hospital: 10a. If Death Occurred Somewhere Otter Than A Hospital
0 Hospice Falsity ®decedents Home 0 Nusing Horne/tong-ram Cam Facility
0 Yes El No 0 Unknown 0 Irpeterd 0 Emergency Departmerl Outpatient 0 Dead on Arrival ❑Other(specify)
11. Facility Narne(If Not Ins_yrion.Give Street and Number)
1910 BOULEVARD PLACE
12.City Or Town,State,And Zip Code 13.County Of Death 14. Marital Status At Time Of Death
®Married 0 MarriedBut Separated 0 DivorcedPRINCETON,IN,47670 GIBSON ❑Widowed 0 Never Married 0 Unknown
15.Surviving Spouse's Name 15a.Last Name Before Fist MaMage 18. Decedents Usual Occupation 17.Kind Of Business/Industry
AUTOMOTIVE BODY
TERESA MARKET MOUNTS AUTO BODY REPAIRMAN REPAIR
18.Residence-State 16a. County 18b. City Or Town
INDIANA GIBSON PRINCETON
lad.Apt.No. 1Be. Zp Code lit. Inside City LHrtts?
tact Street And Number
❑Yes 0 No
1910 BOULEVARD PLACE 47670
19.Decedents Educaton 20.Decedent Of Hisparc Origin 21. Decedents Rice
9TH-12TH GRADE; NO DIPLOMA NOT HISPANIC White 23aPamrfatastNaraeameFvsta(emcee
22.Pas (Find Parents Name(F Middle.Lest) 23.Parents Name(Fast Middle,Last)
FRANK J MARKET SUE ANN MARKET BEASLEY FINE
24.Informants Name 24e.Relaforardp To Decadent 24b.Mailhtg Address(street And Number.City.State.Zip Code)
TERESA MARKET WIFE 1910 BOULEVARD PLACE,PRINCETON, IN 47670
25.Place Of Dlspas:ttan
25a.Method Of Olspos born 25b.Place 01 Disposition(Name Of Cemetery.Crematory,Other Place) 25c.Loci5on-City.Town.And State
®Buriat 0 Cremation ❑Donation 0 Fnmmbment
❑Removal Front State
❑Other(Spedfy): COLUMBIA WHITE CHURCH CEMETERY PRINCETON, IN �f rs FueelHamaliosrtw
28-Was Coroner Contacted? 27. v er m
e And Complete Address Of Funeral Facilty
❑Yes El No ICOLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671
27b.Sgmati.e Of IndianaSe Licensee: 27c UM.. �+t.
(Of Ntrriber Licensee):
MARK R.WALTER, al BY ELECTRONIC SIGNATURE FDO/ 013 T L
Cause Of Death (See InatrucNons And Estamplea)
28.Part I.Enter The Chain Of F Vents -Diseases.[Nunes.Or Complications-That Directly Caused The Death.Do Not Enter Tern:nal Events To
Such As Cardiac Arrest,Respiratory Arrest,Or Veruriou'ar Flbd:tatlon Mittho01 Showing The Etiology.Do Not Abbreviate.Enter Ony One On
A Late. Add Additional Lutes If Necessary. [ 2�2�
Immediate Cause(Final Disease Or Condition Resitting In Death) A METASTATIC ADENOCARCINOMA OF P.OSSTATEECommena
APR �7
Sequentially List Conditions, If Any,Loading To The Cause Listed On B. a�mror... d a� Q�
Line A. Enter The Underlying Cause(Dsease Or tripay That Initiated c ())l1T O R
The Events Resitting to Death)Last C. o*.ter,r-C ra-o-e«t\ GIBSON V NT Y P
o.
Par IL Enter Other l212 to Dealt Bid Not Resitang to The Undanytrtg Cauca Given In Part 1 29. Was An Autopsy ❑Yea
30.Were Autopsy Finding Available ate Of De'dh? ❑Yes 0 No
31. Did Tobacco Use Contribute To Death? 32. If Female: 33.Manner Of Death:
0 Ma n.vd. ....P.rvwPm..❑P ..Au Mr ao..n 0 I..hn.et.o.e.n.e....e...2 ism area NISI aomi 0 Homicide 0 Accident ❑ not Peng tnvesbgation
CI Yes 0 Probably 0 Na ®UnkrttsMn
0 w.w.a...so P..e.w o sm to t,..•eeer.o.m, ❑u+.o.,a roma..Noma.PH Mar ❑Suicide Could Not Be Determrted
34.Date Of Injury(Month/Day/Year) 35.Time Of Irt)uy 38. Pace Of Injhay(EG.,DecaderOs Home,CenstruWon Site,Restaurant.Wooded Area) 37. Wliy At Work?
0 Yes 0 No
38a.Clay Or Toast 38b. Strgt 1 Number 3Bc Apt.No. 3Bd.Zip Code
3B.Location Of Irtlury-Suter ..
39.Describe How Injury Dcaured 4d. If Transporttlon trtury.feria ❑am..neo.It
. ❑da.trca.d.r ❑Pn lnco O
41.Sigra-u re.Of Person Cat 50ng Cause Of Deatit 42.Certifier(Chad.Only One) Health Officer
STEED JACKSON ,BY ELECTRONIC SIGNATURE_ - - ®Certifying ❑Coroner El
_ 44. License•Nttrtber 45. Data Certified
43.Name.AQCress And Zip Code Of Person Cartllylmg Deem:Cauca Of Dea -
ERIC STEED JACKSON , 1033 MT. PLEASANT RD.,EVANSVILLE, IN 47725 01047256A 06/04/2018
47.'Alum
48.AdBrt.oel Funeral Service Provider
49. For Registrar Only-Da Filed(Matt/Oay/Yeer):
48.Signatureof Local Heath OfficerDabsJ U N 05 2018
AMENDMENT BRINK JR,VIA ELECTRONIC SIGNATURMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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Stete Form 53395 ATTENTION ESTATE:The Social Sorority A Is being requested by this stale agency in order to pursue responsibility. Disclosure Is voluntary and there will be no penalty for refusal.
WARNING: OTURNSRIGINAL FROM DOCUMENTORANGE TO HAS A MULTICOLOREDVELLOW RUBBED.BACKGORIGINAROUND L ON SPECIAL WHITE SECVRDDEN VOIDT PAPER AND
FRONT THE GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT
WHEN DOCUMENT HAS A HI ON THAT APPEARS WHEN HOTOCOPIED.d ti
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