Death Certificate - Hornby, Dale_4/11/2013 �t -ryA� I U I J4 CI U
//a ,at INDIANA STATE DEPARTMENT OF HEALTH
(;�2I CERTIFICATE OF DEATH
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;rfe�� Local No 000154 EDR No 000000310984 State No
1.Decedent's Legal Name(Firs,Medde,Last) la. Maiden Name(If female) 2.Sea 3. Time Of Dead. 4.Date Of Death(Meat/Day/Year)
DALE ALAN HORNBY MALE 01:46 PM 03/03/2013
❑Hospice Facility ❑Decedents Home ❑Nursing cmell Iemt Care FaW
❑Yes p No ❑Unknown p Inpatient ❑Emergency Department Outpatient ❑Dead on Amvat ❑Other(Speay) g y
11. Facility Name (If Not Insttudon,Give Street and Number)
DEACONESS GATEWAY
12.City Or Town,State,And Zip Code 13. County Of Death 14. Mahal Steams At Tone Of Death
NEWBURGH, IN, 47630 p Married❑tamed,But Secaratea ❑Divorced
WARRICK ❑Widowed ❑Never Mamec ❑Unknown
15.Surnring Spouses Name - 15a. (II Wde)Gie Maiden Last Name 16. Decedent's Usual Occupation n.Kind Of Business/industry
SHERRY LEE HORNBY SORRELS
COAL MINER MINNING
le.Resldnce-Bute 18a. County 180. City Or Town
INDIANA GIBSON FRANCISCO
16c. Street And Number
18.c. Apt No. lee. Lc Code 151. Inside City Limas?
312 EAST VINE STREET - PO 25 47849 0 Yes ❑No
19. Decedent's Education 20. Decedent Of H6spanic[Ingo 21. Decedent's Race
ASSOCIATE DEGREE(AA,AS) NOT HISPANIC White i
22.Fathers Name(First.Made.Last) 23.Mother's Name(First,Meddle,Last) 23a.Mothers Makin,Last Name
VIRGIL HORNBY IRENE HORNBY HOLDER
24.In;cements Name 24a.Relationship To Decedent 24b.Mailing Address (Street And Number,City,State,Zip Code)
SHERRY L HORNBY SPOUSE 312 EAST VINE STREET APT PO 25, FRANCISCO, IN 47649
25a.Method Of Disposition 25.Place Of Disposition
250.Place Of Disposition (Name 01 Cemetery,Crematory,Other Rxe) 25c.Location-GIy,Tpwll,And Sate
E Burial 0 Cremation ❑Donation❑Entombment
❑Removal From State
❑Other(Specify): VEALE CREEK CEMETERY WASHINGTON, IN
26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility
27a.Funeral Home License Number:
❑Yes p No PEMBERTON BRADLEY FUNERAL HOME, P O BOX 247, MAIN STREET, LYNNVILLE, IN
2Tb 47619 FH19800018
- Signature Of Indiana Funeral Service Licensee: 27c. License Number(Of Lcensee)
ROBERT LELAND STEINHAGEN, BY ELECTRONIC SIGNATURE FD21200011
Cause Of Death (See Instructions And Examples)
28.Part I.Enter The Chain Of Events •Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Apery al:On
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology. To eat Onset
A Line. Add Additinal lines If Necessary. 9 oqY Do Not Abbreviate.Enter Only One Cause On i c Death
Immediate Cause(Final Disease Or Condition Resulting In Death) A. MYOCARDIAL INFARCTION
n,i rem,e,a caew,,
.. .,,09 1246AM
Sequentially List Conditions, If Any,Leading To The Cause Listed On B,
Line A. Enter The Underlying Cause(Disease Or Injury That Initiated ea el°"'w^•,.•t•on
The Events Resulting In Death)Last C
Dv*eta. rew.e•• •on
D.
Paton.Enter other$krtficaraCocioons Cpnedetnc to Death But Not Resulrg In The Undedyng Cause Chin In Pan I 29. Was An Autopsy Perleaned4
❑Yes p No
HYPERTENSION 30. Were Autopsy Finding Available To Complete The Cause Of Death?
31. Did Tobacoo Use Contribute To Death? 32.It Female: ❑Yes ❑No
33. Manner Of Death:
0"go.,,.ww .a..n. ❑ .^,.tart...we.. ❑ .w w ^• e..n.^ ,we...r own www p Natural❑Homicide Accident
0 Fencing Investigation
❑Probably y❑No 0 UnFnov.n
❑'.•ne,.w+ae.rn.r.nn o.•le 1 n..B.a..o..e ❑w.,e.,sn.e„,ww.Tn.e•a Year 0 suicide❑Could Not Be Determined
34.Date Of Injury(Mon•NDaynYear) 35. Time Cf Injury 36. Peace Of Injury(E.G.,Decedents Home,Conviction Site.Restaurant.Wooded Area) 37. Injury At Work?
❑Yes ❑No
-
38.locason 011njury•State 38a. City Or Town 35o. Steel Number 38c.Apt No. 138d. Zip Code
3g Describe How Injury Occurred 40. If Transpcne✓pn Injury,5
❑0...rte..ie ❑o.rs. LJ'.e u 0..., ,
41. Signature,01 Person Certtyi g Cause Of Death:
JERRY L LIKE , BY ELECTRONIC SIGNATURE 42 Certifier(Check Only one)
p Certifying Physician 44. ip ❑Coroner ❑Heath Cerurir
43. Name.Address And Zip Code Of Person Cereyvg Cause Of Death" 44.License Number 45. Dale Ceniied
JERRY L LIKE , 110 W.SYCAMORE ST, ELBERFELD, IN 47613 02000254A 03/11/2013
46.Addvpnal Funeral Service Provider.
q. 'AiaS:
48.Sg:uYre oI Local Heath Officer • 1 149. For Registrar Only -Date Filed(MonT/DayfYea,
RICKY B YEAGER,VIA ELECTRONIC SIGNATURE MAR 12 2013
AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)
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ATTENTION ESTATE:The Social Security:is being requested by U -.-- , , -.
is VOIDIFALTERED'/RiERASED`NOTeV•LI NLE 4''EYI ^r1 :' r_ . I, 1 .'1;tau LI"I