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HomeMy WebLinkAbout0430 4].6~353 r THE HEALTH AND HOSPITAL EORPORATION OF MARION COUNTY ~ DIVISION OF PUBLIC HEALTH F~E ~rwo oo~.u?Rs 1641 C11Y-COUNTY BUI4DING - INDIANAPOLI3. INp. MYM~[R iNOTO~iTA1~ YAW CCRTItriED COPY Q!r RBCORD OR DEATH O!r 5 Charles Robert Ro~ers oATt OF OtA1H Se_ptember S, 1977 NAM[ OF DEC~AtE~ PLAG[ OF OEATH, GOUNTV__ MARION CITY. TOWN, OR LOCATIOI~t I~ianapolis~ Indians ~r ~~~e~ ~ a aa~. ~ WID0IM~D ? N[Y[A MA110. O 7~3O~iH9S . 82 - I MOR CAt~ MM. I NIN. SEti Ma le yAR~~~p j~ p~ypR~=p QDATR OF OIRTFI ~GE FATHER'S NAMRCeOrge ROgCrS uOTHER'f MAIDEN NAME $~fie ~We C8~Y1 _ ~Kn~v~~ nTwu« CAUSE OF DEATN ~ ' T PART1. IMMEDtATECAUSE ~A)~Uit3~J.C' pulmonary emboli ~ TS co~w~nor+s. ANY ~E To ~e, and cardio enic shock 8 hours WNICM •IV[. RI~[ TO II~OVt GYSt tA) . . RATINO TNt YNDiN• ~r~Ma twu~t uK• DUE TO ~c~_Severe congestive heart failuse OTH[R ilOH111CAN7 CONDI~IONi GONTIII~VTINO TO OtAT11 ~t~T MOT RLLAT[O TO TN[ T[11M1N41 OIL[Afi COMOI~IOM 01V[N IN ?A11T 1(A) PART~~ Complete heart b2ock aith pera~, pacemaker renal insufficiency DAT[ OF BURtAt 9-~"1977 CEM[TERYW83h117gtOT1 PBr~C BBSt ~~Tior~ Indianapo2is. Inciiana CERT. NO. OR f~_.._ Patricia K~ Hendershot, M.D. VOL ANO PAGE DEAT/i CERTIFIEO iY OATE FILED 9_~_!~~ NOT VAliD UNlESS MA~Hit~t~ ~IU.MBE~ED 9-8-197~ AND SIGNED WtTH MUETICOLOR RlSBQN o~Te ~ssueu - ~ . Nurrse~eco B. Pardue ~ CIERK. ~ O ~~ry~t~ . TIRU I ~ - . - ~ ~ . _ . _ • ~ ~ - i ~ ~ i . _ . . , _ . ~ ' ' ` _ , " t D. ~l` ~ i . ~ t~ 11 . - .a p„~~ - ~ Yh~~M~ . ~ E ~ ' " f 1 - S ~ i . ~.~:L ~.:\.i .L~r. ~ ' ST WCIE COUN11r Fle. ~ P.GCER ?Ot'RAS ~ f _"4C ' .;UIT !'CL}R ~ ' ~ ~ S_~ 11 4 ioPH'?8 ~ ~ ;a K ~ ~ 416853 ~ ~ _ a ~ . ~ - ~ ~ ~ ~ . ~ ~ ~ ~94 43~ _,t' ~4G~ P f . - - - - - - - ` ~ ~ - ~ ~ ° : ; j . ~~s~ti . .F _