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o f INDIANA STATE DEPARTMENT OF HEALTH 1
t ;= CERTIFICATE OF DEATH
Local No 000063 EDR No 000011099450 S No 2021-023770
i \ 1.Demds.e Legal Ne,a.(Fbd.SOdee.L. Ia.lrsld.n Name Br 1 m.. 2.aaaer 3.Tree 01 Own
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JERKY LIVERMORE \�f
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•� ®Yea 17 No ❑Lmbw.n p b ❑Ealepeery Deportment OuVamaK 0 Dee4pp Abbr. 0 ome(e>s7sah) 04
`4 11.Fairy teem(o Nat lmaamaa.Gee Suva and Huber)525 MEADOWLARK Drive ,J
12(1y Or Toa.Shaw.And Dp Coda 13.Oatody 01 Mo. 14.Matt.$gin AS T,s OI Death k„1
t�` Princeton.Indiana 47670 Gibson ®Ymfedp Stied.BA Runes
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L\ 15.8-1.ta9 l;poaaFs Name 1����._� Ha d
ms Before Find Matrboe 10_Daeede Umbel Oaatpebn 17.Kind*BadMma hraby
f ESTHER LIVERMORE BFib LINEMAN PUBLIC UTILITY
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P IN Gibson Princeton ). I
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►/(, 525 MEADOWLARK Drive 47670 Ores NO 1
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m 19.Dedente Education 20. Decode.01 1 21.D.odelte Rem '1
High School graduate or GED completed Na Whitercl )?(
22 Pere.:Nam e(Rea.Mtge.Last) 23.Parents Name(First 1811..Late 23a Patent.Lest Norm Before Find Neale. O,
,1� THOMAS LIVERMORE JANIE LIVERMORE YOUNG 0
CI 24.tdorrtaode Kano 24e.ReIstionship To Dimedenl 24b.Ma a. Address(Som.AM Name.010,Sob.Zip Code) C
W ESTHER LIVERMORE Wife 525 MEADOWLARK Drive.Princeton.(N.47670 Q
a ll 25.War.01
CC 25a Healed Or DbpmQlon ?spar Place a a Dhporekn(Name dL.lree ry.�a�ry°1 l.f R..) ..Lmdm-City.Torn.And Stab T•
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CC 0 Flea..From Mane COLUMBIA WHITE CHURCH CEMETERY Princeton.IN r-I
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W 33 Wes
Doyle Funeral Home 520 S Main St,Princeton.Indiana.47670 v,
CC p Yoe ❑No F1110400010
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LL 25.Pant L Enter Tile -Otseawa.Wiles,Or Complications-That Direc2y Caused The Death Do Nal Etter Teamed Events interval Onset 3:1I
Such As Callao Artee, Or Ve tsksdar F2.r aSaa Wttnui Shoefue The Etiology.De Not Abbrestate.Este Only One Cause On To Death �.
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Q bsaate Cause(Fine'Disease a Coe16tlo1I Ra 9 In death)II i_ A. ;.)e « la 3 years rn,
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In Pan I�/ t y'r> „ An Autopsy Performed? plies MI No el
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9a7a67acpb rpcfar EectrOtlice[ty S(gnbd�oil aR)r � Comae aHornOgmr ;'S 43.Harm.Address And Z4 Cod.01 Person Certifying Cause 01 Doha% _ - - ISDee 0 Nm,e SA.Dab CeQO.d
f/y Jared Jacob Kocher 802 E Oak Street.Ft.Branch,Indiana 47648 _ _ 071228A 04/29/2021 2,4
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y••Dos Frw(31.10. SVal.ar1: 05/03/2021
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7 A@NFTO CERTIFICATE OF DaATr1(ENTRY OR OR1O(NAL)
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r( State Form 53303 ATTENr10N ESTATE:The Social Security•l�l0'lr+""-'by old.stab It9e5Ey m Order to pursue nadp�ty.Oladoaao b Yol antaryilld tare a0D be no penalty tot reused- '�d
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WARNING- ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA ON BACK THAT
TURNS FROM ORANGE TO YELLOW WHEN- BBED.ORIGINAL.e M a HAS A HIDDEN VOID ON FRONT THAT APPEARS WHEN PHOTOCOPIED. �'s^
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