Death Certificate - Akers, Thomas_11/14/2022 a+•^"- INDIANA STATE DEP RTMENT OF HEALTH a
CERTIFICATE OF DEATH f
..17/ 0 I
Load No 000026 EDR No 000011063025 State No 2021-012349 i
1.Decedent's Legal Name(First MitldM,test) Ia.Maiden Name CM female) 2.Gender 3.Time Of Deirdre
Thomas Arnold Akers
Chicago.Illinois i
9. Ever in U.S.Armed Forces? 10.It Death Occurred In A Hospital 10e_ a Death Occurred Somewhere Other Than A Hospital
❑tioepiee Facility ®Decedent's Home ❑Nursing Hon+eAmPterm Care Fadity
El yes ❑No El unknown 0 inpatient 0 Emergency Department Oupaaene ❑Dead en Arrival ❑other(Specify) !
11_Facility Name(ifNot ice erre•Give Street d Hoods 327 E Oak Street l
12.City Cr Town.Stab,And Zip Code 13.County Of Death 14.Menet Statue At Time Of Deft
Princeton,Indiana,47670 Gibson ®p Married❑Menred,But Separated❑❑Divorceded
Widowed ❑Never Married LMmown
15.Surviving Spouse's Name 15a.Last Name Before Fist Marriage 16. Decedent's Usual Occupation 17.Wrd oteuswwwwsirstry i
Airline Cargo Agent Transportation !
te.rleaidence-State laa.County 18b.City Or Town
_ i
IN Gibson Princeton '.
tad:. sere.,And Number
18d.Apt.No. lee.Zip Code 181. Inside City Links? j
47670 RI Yea 0 No
327 E Oak Street
f
19-Decedent's Education 20.Decedent Of Hispanic Origin 2i.Decedent's Race
8th grade or less Not SpanlahlHlspaniclLalino White
22.Parent's Name(Fist.Middle.last) 23.Parent's Nome(Fist,Middle,Last) 23a.Parents Last Name Before Fill Marriage
Andrew Akers Dorothy Akers Wales
24.Informants Name 24a.Relationship To Decedent _ 24b.Marling Address(Street And nkunber,City,State,Zip Code)
Donna McIntosh Daughter 327 E Oak Street,Princeton,IN,47670
25.Piece Of Disposition
25a.Method Of Disposition 25b.Place Of Disposition(Name 01 Cemetery.Crematory,Other Place) 25c.Location-City,Town,And State
tilt Burial El Cremation ❑Donation❑Entombment
0 Removal From state Oak Grove Cemetery Poseyville.IN
❑ at' e :
26.Wes Coroner ? 27.Name And Complete Address Of Funeral Facility 27a Funeral Home License Number
WCOntacbd
Colvin Funeral Home Inc 425 N Main St..Princeton.Indiana,47670 FH83005671
❑Yea 13No
27b. Signature Of Indiana Funeral Service Licensee: 27c. "'srse Number(Ot Ueensee):FD21800025
layanna Electronically Signed
Cause Of Death(See Instructions And Examples) Approximate
28,Pan I.Enter The eilCk�Fvdmts -Diseases, Or Comp�ations-That Directly Caused The Death.Do Not Enter Tenurial Events Interval:Onset
Such As Cardiac Arrest,Respiratory Arrest,Or V Faniahon Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. AddAdditional Lines It Necessary, Milagnant Neoplasm of prostate 6 month
immediate Cause(Final Disease Or Condition Resulting n Death) A. a,.n to,44ACom.e,.s or
LineEnter LnderlyngNCause(Disease Or Injury That Initiated
Any.Leading To The Cause Listed On B oweia.w.waw.a++.on
The Events Remitting In Death)Last C. ov.alaud A.wca.w,w...cry
D.
Part II.Enter Other SioriScare Conditions Cortribusno to Death But Not Resulting In The Underlying Cause Given In Part I 29.Was An Autopsy Performed? ❑Yes ®No
90.Were Autopsy Finding Avattable To Complete The Cause Of Death? ❑Yes ❑No
xt Mannar Of Death:
N Si.Did
Tobacco Use Contribute To Dean? • an..a ores ❑a.t...w•�annrew........owe. ®Mensal❑Homicide ❑...deft El Pending Investigation
wew.r•rrwe, ❑Pm"...
❑Yes ❑Probably®NO ❑/UnkaN,
� .wi..rr.aWRgv..n4i o.rs r.+yr wr.o.rn Elr�...,wr,a.,.e.^twe..T..r'nr.tnth ❑Suicide❑Could Not Be DebrnWsd
34.Data Of injury(MondVDay 35_Trnne d in ury 96.Place Of!Nifty(E.G..Decedent's Home,Construction Site.Restaurant.Wooded Area) 37.tale's Al Work?
11 14 .11
O ❑Yes ❑
38.Location Of Merry-Stab O``
City Orl-Town 38b. Street a Number 38c.Apt.No. 38d.Zip Code
V ,� 40.8 Transportation hen'.Specific
34)-Describe Hoe Injury Occurred /)N'S'`' iwoo e One i_Onewee ... ..❑oe..teo..an
al. of Pe son CertifyingCertifyingo ON G 42 Certifier( om.ya
U Electronically Signed Certtiyirogra Phtnaan )❑
xi ❑Health Officer
�j' ` Case Deem: .4.License Number 45.Cate ConnectCedae
43.Name,Address And zp Code«wag a
Michael J Allen 3801 Bellmeade Avenue 200A,Evansville,IN 47714 01048785A 03/05/2021
47.'Alec:
M.Adebane Funeral Service Provider
49. For Registrar Only -Date Filed(MonevDa inter): 03l08/2021
leer a of Local Health OtSoer: Electronically Signed
'Bruce�rvt ryr AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR oa1O4HAy
to 1..Q - ‘a- O-t- ,,3::). t-- 0 oc) . gal-- 0 e?' .
State Form 53395 ATTENTION ESTATE:The Social Security a Is being requested by this state agency in order to pursue responsibility. Ohdosure is voluntary and there wit be no penalty for refusal.
WARNING: TTURNI tl S FROM ORANG TO YELLOW WHEON RUBBED.ORIGINALL DOCUME T HAIS A H DDE VOID ON FRONT THARTEAP EARS WHEN HOTOCOPIED ANA ON BACK THAT