Death Certificate - Nixon, Melvin_3/1/2023 r 1 \� r ' ,ems ..`_ Sex h;,e-y:. -4,2 _ '- r ra ,: - .. ,.�r.v' -a,:... rr
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CiII;rI(1PI11 INDIANA STATEDEPARTIoillul , lgil liilli��ivTOF�HEA�TH4�4�Q2�"°�',;i„'_1,1 �T CERTIFICATE'OFDEATH ', _ I..:
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'111tiiiLocal No 000023' lin.11iil, EDR No 00001 806308 �,�!�IllililIllState No 2023 007179 (
T.Decedents Legal Name{First,Mtddie,Last) , 11 ill,' 1 a.Maiden Name(It female) 2 Gender 1,n:, 3:Time Of Death
87 Mordhs Days . Hours` ,1,+ i,-„inutes 1 1 -'
9 Ever U:S.Aimed Forces?, te.If Death Occurred la Hospital: Si "I,+,;ij�; 10a.if Death(TIT reed Somewhere Other Than A Hospital :1 E +,i '
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• I�� ill+� ❑ P ❑ i++ 66.I I, ❑HospiceFacility�®Decedents Home ❑Nursing HomeA.ong-termCare FaaFrty -
+ - - � _ i i IN �dIu„ '
®Yes ' No 0 Unknown Inpatient Emergency Department Outpatient 0 Dedd do+Arrival !+"'
II m+i1* iii,t lilii, ❑other(specify) I I+�+�' ;;i
r' ''... 11."Facility Name Of Not Institution,Give Street andNumber) illj!'yill , I
w;"ll,,„I,1 I' 114 E Truster Street h1,1,1u,'
a 12.City Or Town,State,And Tap Code II11�11!)1 41m1!If.: 13 County it De�a;{h,,, 14.Marital Status At Time Of Death
! 1!1 l 1 ®Married❑Married,But Separated 0 brvorced
Oakland City,Indiana 47;66ii, ''' Glb'!' Ill -
6Lo, Ui, 0 Widowed 0 Never Married ❑Unknown
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15 11Sur`;1yingg;Spouse's Name - " 15a.Last Narpe;Before First Marriage 16.Decedents Usual Occupation ,1({i i;117.Kind Of Businessindustry , l
I'll 1.:
h iJII( Chapped! ' Coal Miner ; 1 Mining :;
;Myrna Nihon I q 1) I, I:", 1
r I'III'1 II 18."Residence-State 18a.County i! ' li,,1ill" 18b.City Or Town al'
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ff.: i111 +IN 1i1 !;, IIf 11,,NhI. Gibson - 1 11 Oakiand,Dity ,,i n1, !„
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r. 18c.Street And Number + I i I, + IC• I l t,1' 16d.Apt.No. 18e.Tip Code 16f Inside City,Limits?
114 E TruslerStreet I I ''" / 476601 ❑Yes°❑No
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,! ;19.Decedents Education j,l i+" 20.Decedent Of Hispanic,Origin J ',,,,,I„ 21.Decedents Race ''i -
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I1' P 044i it 8th grade or less Not Spanish/Hlspaniu/LeUno White
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0 I,I ln' 22.Parents Name(First,Middle,Last) 1 1..,J(I 23.Parent's Name(First,Middle,Last) "'!I(1 I 23a.Parent's Last Name Before First Mardage-
,1 Hershel K Nixon I,'ull,:,, !''' Imogene Nixon li:,"',dirt �I l:, Powers
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24.Informant's Name +" '';i i!�' 24a.Relationship To Decedent 24b Mailing Address(StreelAnd Number,City,State,Zip Code) ,
Myrna Nikon ,,"II,IEI'III II'I„ Wife 114 E TajsIer Street,Oakland City,IN,47660
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• 25.Place Of DislbsNdh •
25a Mdtiiod Of Disposition '',,,,Itt, 25b.Place Of Disposition(Wane:OflCemetery,Crematory,Other,Place) 25c.Location-City,Town,And State 'a
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r Btldati 0 Cremaepnq❑Donation❑Entombment i,l 'll l r>
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1 l❑flotrova)From State Montgomery Cemetery Oakland City,IN - r
r i II D,Other(Specity): .t
r 'il,a, '.26.Was Coroner Contacted? ^I 27.Name And Complete Address DiiFuneral Facility I l 27a.Funeral Home License Number:
Corn-Colvin Funeral Home, 1,!;li;i„ FH19400002
El Yes al No 91U`to111 Iliac.323 N.Main St. Po Box 278,Oakland City,Indiana,++47660''1
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27b.Signature Of Indiana Funeral Service Licensee: - I i ".I,--^_ 27c.License ce :
layanra htar�ft , nu, Eleetronte8ltySigned e FD21800025
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ll 1�,11 '! - tit I, i!ill I Cause Of Death(See Instructions And Exa pies) Ii. Approximate
, I ill 28.Part I.Enter Evnts-Diseases,In uries,The Chain Ofe Or Complications -That Directly Caused The Dea b.Do Not Enter Terminal Events I . I1 interval:Onset
','I Such As Cardiac Arrest,Respiratory Arrest,Or Ventrcular Fibrillation l(thQut Showing The Etiology.Do Not Abbreviate.Enter Only One Cause n To Death
,:,,ill,,',,!:;, Aline."Add Additional Uses If Necessary. .; ' I
i1 ,, 11 p,l BLACK LUNG DISEASE ,1 - years
t immediate Cause(Final Disease Or Condition Resulting In Death)III A. o io to a e te...�"....on^ ''�����77777
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Sequentially List Conditions, if Any Lea Iditig i o The Cause Listed On B. �141+f 1 Consequence `(T
a; L ne A 'Enter The Underlying Cause{D cease Or Injury That,nit cited 1' 'I I '°�l
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The`Events Resulting In Death)`L;ast III. ,n,' 711` 4
I flii,oa litl, ii Postal 'U
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n j Part Ili Enter Other$/sndicant Conditions Goniributino to Death But Not Resulting In Tlie Underlying Cause Given in Pant 29.Was An Aulops P'Y l 4ed%� , ,'.0'Tres ®No
i 1 Ii'I i,i� - 30.Were Autopsy Finding AJa1 a T3 fete The Cause Of Death?
CHRONIC LYMPHOCYTiC LEUKEMIA �/" p ❑Yes 0 No
I_„'' 31.Did Tobacco Use Ccntnbute To Death? 32.If Female: :I' 1',I Ill, ' 33.Man�nier.Ot net • --
cf; ' �': ', ,, ❑Now winsid wMnp..ivev ❑weyn.m.r rave oroam ❑r,wrr an.etampreyn iwm 42 Drys or oath ®Natitrallj Ho I de ❑Accident 0 Pending Investigation
1F • ❑Yes ❑Probably 0 No ®Unimow,,y,I ❑Nv�, Pregnant ❑unnownap,eg awmnth'''Nlnermvea 0 Suicide 0 Could Not Be Determined 1
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6 34,Date Of Injury MonthtDa 11'ea ' 35.Time Of Injury 36.Place Of Injury(B.G Decedent's Home,Construction Site,Restaurant,Wooded Area) 37.injury At Work?, -
J !ry{ 9�Il�iilil`Il "u° lI4lI� �I"''I' ❑Yes (.I❑No
olil0igill li,_198.Location Of Injury State:(i`' 38a City Or Town I.,! ?II! 38b.Street&Number 1 BBc.Apt.No.- 38d.2p Code
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nY r II 11'1 li n v.,,, .i;' '
Ill , i 40.If Transportation Injury,Specify: •
l 39.Describe How Injury Occurred 1'1;Illi Ih 11I d
Gill, ❑m e)rope ern ❑pwe qe ❑peeeasn❑oa a tspeeart •
L' 41.S,ignature,Of Person Certifying Cause Ofceath: '- li '1!„ 42.Certifier(Check Only One) ' 1.1
Ik, iifelly Lee 2fekhel6ech Il Il i iill:;' Electronically Signed II I' (Certifying Physicla;l ❑Coroner 0 Health Officer '•i
43.Name,Address And Zip Code Of Person Gasifying Cause Of Death: I', ,III',' 44.License Number 45.Date Certified .
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�' Hoii Lee Heichelbee�T,p O'°Box 266-1020 W.Morton Street,Oakland City,IN 4766Q,�1"! I'I 02003241A • 02/13/2023,,''
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46 Addrtiosial Funeral Service Provider, I p 9:�IIj,U;':' .. 47 Alms ii j ,:'
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t, 'III ligh it - 11 1+. 49. For Registrar Only Date Fiiedl(MontluDayJYear): '
48'Signature of Local Health Officer: •• y11 i, �rin r 3111, I y,;;:" Electronically Signed ,NI II I I I �" 02t1412023
f I p AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) I fl'
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� G ORIGINAL D,Q.CUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITESCO,I'}'RITY PAPF�R AND THE GREAT SEAL OF THE STATE OF INDIANA ON,BACK-THAT
VI(�RN�i'�i_1�• TURN$1=ROM ORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUMENT.fiAS+A'HIDDEN VOID ON FRONT THAT APPEARS WHEN PHOTOCOPIED. , !,