Death Certificate - Sillery, Trevaun_1/24/2023 tkLr �F4t ��cr�r- e• rsar -ar - tir.,r -Sr -- ,r.w -71' ---------- -- ----- -----M1- _ ..... ._.,. --7-_-__.----_-_._
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a INDIANA STATE DEPA TMENT OF HEALTH
a CERTIFICATE OF DEATH
te Local No 000153 EDR No 000000590372 state No 037446
. C ,
>�e 2.Sex 3.Time Of Death
SecurityTREVAUN LEE SILLERY
WABASH, IN
t0a. If Death Occurred Somewhere Other Than A Hospital
9. Ever in U.S.Armed Forces? 10.If Death Occurred In A Hospital: ❑Hospice Facility ®Decedent's Home ❑Nursing Home/Lonerterm Care Facility
®Yes 0 No 0 Unknown I 0 Inpatient 0 Emergency Department Outpatient ❑Dead on Arrival '❑Other(Specify)
11. Facility Name(If Not Institution,Give Street and Number)
222 SOUTH SEMINARY STREET 13. County Of Death 14. Marital Status At Time Of Death
12.City Or Town.State,And Zip Code 0 Married 0 Married.But Separated ❑Divorced
PRINCETON,I
ON ®Vowed 0 Never Married 0 Unknown
N m7670 (GIBS 17. Kind Of Businessnndusby 15a.Last Name Betore First Marriage 16.Decedent's Usual Occupation
15. Surviving Spouse's eme
FACTORY WORKER MANUFACTURING
18a. County 18b.City Or Town
78-Resitlerxe-State
INDIANA I GIBSON I PRINCETON
18c. Street And Number
led.Apt No. I 18e.Zip Code 18f.Inside City Limits?
❑Yes 0 No
47670
222 SOUTH SEMINARY STREET 21. Decedent's Race
19.Decedent's Education 20. Decedent Of Hispanic Origin
ASSOCIATE DEGREE(AA,AS) NOT HISPANIC White z3a.Parent's Last Name Before First Marriage
22.Parents Name(First,Middle.Lest) 23.Parent's Name(First,Middle,Last)
ELIZABETH SILLERY MORSE
NEDEAN SILLERY 24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address(Street And Number,City,State,Zip Code)
MARY HURST I DAUGHTER 222 SOUTH SEMINARY STREET,PRINCETON, IN 47670
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 0 Cremation ❑Donation 0 Entombment
❑Removal From State
❑Other(Speedy): FOREST HILL CEMETERY GREENCASTLE, IN 27a. Funeral Home license Number.
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility
®Yes 0 NoFH83005671
COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON,IN 4 0Q Number(Ofucensee):
27b. SignatureHARD Of DEAN
Funeral Service Licensee:ELECTRONIC SIGNATURE 'F 1 215
RICHARD DEAN HICKROD, BYApproximate
Cause Or Death (See Instructions And Examples) `'� Interval: Onset
26.Part I.Enter The Chain Of Events -Diseases,Injuries.Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events To Death
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only OJI�Cause On
A Line. Add Additional Lines If Necessary. N 9 SUDDEN
Immediate Cause(Final Disease Or Condition Resulting In Death) A. CARDIAC ARREST 1«N�^Consequence n
(���� oli �? 10 YEARS
eg
Leadin To The Cause Listed On B. CHRONIC CONGESTIVE HEARR Sl ����o�.
L A. Enterlly List The Conditions, If Au 9
Line R UnderlyinggIDet Cause(Disease Or Injury That Initiated O 25 YEARS
The Events Resulting In Death)Last C. CORONARY ATHEROSCLEROSIS' o,retoCf elr
Part II.Enter Other Sionificant Conditions Contributint to Death But Not Resulting In The Underlying Cause Given In Part I - 29.Was An Autopsy/4 0 Yes ®No
30.Were Autopsy Finding table To Complete The Cause Of Death? ❑Yes 0-No
COPD,PAST STROKE,PAROXYSMALth ATRIAL FIBRILLATION,SENILE DEMENTIA 33. Manner Of Death: •
31. Did Tobacco Use Contribute To Death? 32. If Female:
❑Net Pregnant NV.Pa.Year ❑RegneMurime of Death ❑Not Pregnant.ert Puente...n..2 Data Or Deem ®Natural❑Homicide ❑Accident 0 Pending Investigation
❑Yes 0 Probably®No ❑Unknown 0 Not Pregnant.SO Pregnant o Den rot rear Dears Death ❑Unknown a Pregnant Wane,The Pan Year 0 Suicide❑Could Not Be Determined
InjuryAt Work?
34. Dale Of Injury(Mont iDaylYear) 35.Time Of Injury 36. Place Of Injury(E.G..Decedent's Home,Construction Site,Restaurant.Wooded Area)
❑,Yes ❑No
38b. Street&i4umber 38c.Apt.No. 38d.Zip Code
38. Location Of Injury-State 38a. City Or Town
40.If Transportation Injury, ec y=
39. Describe How Injury Occurred ❑Dm..rans« ❑P•lnjur j, v.a.rnan Qom..Isgrlry)
- 42.Certifier(Check Only One)
41. Signature,R.
Person WELLS
, BY Cause Of Death: . \ Ei Certifying Physician 0 Coroner 0 Health Officer.
WILLIAM re WELLS, Of ELECTRONIC SIGNATURE - -1 44. License Number 45.Date Certified
43. Name,Address And Zip Code Of Person Certifying Cause Of Death:
WILLIAM R.WELLS ,510 NORTH MAIN STREET, PRINCETON,IN 47670 01017790A 08/01/2017
47. •Akers:
46.Additional Funeral Service Provider
BITTLES AND HURT FUNERAL HOME - as- For Registrar Only-Date F (Month/Day/Year):48. Signature of Local Health Officer. . r`. '� AUG 01 2017
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE AAUG
TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
)�- /� o ? - 1/6/- 0o /, `ts5-- - o... �
State Form 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.
... APPEARS. .._ --i w..cov.t�BACK THAT
WAR N I N G a TTURNIS FROM ORANG TO EkLLOW WHEEN RUBBED.ORIGINALL DOCUME T HAIS AS IDDEN VO DPON FRONT THART PEAR WHEN HOTE OF INDIANA ONE w` ^ITT` '!'
