Death Certificate - Morrison, Roy Max_5/20/2019 Li "n' INDIANA STATE DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
Local No 000168 • EDR No 000000593699 State No 041688 C
1.DareoarCS Legs Name(Fast/Aida Lag) 1a.Maiden Name(1!female) 2.Sea 3.Tom Ot Death 4. Data Of Death QhtJDry/Yeaj
ROY MAX MORRISON • f MALE 03:15 PM 08/152 }
017 t-
S &cal Seery Number 8a. Age-Yrs 80.Ube 1 Yes 8c Urges 1 Mats ee.Urates 1 Dry 8e.Under 1 Has 7. On of BM.(NbaNOryWeer) B.antedate(City end Slag or Foreign Casey) S
0 Navin Home/Lag-fete Cara Fealty 3
0 Yes 0 No 10 Unbo n ❑Irgatiant 0 Emap®ty DePennvt DumeSae 0 Dee on Anmal 0 Other(Seery) r.II
11.Facial Name(If Not IrxGtat Give Shea erg Number) Lr
WATERS OF PRINCETON,THE 16EPj
12.Gay C Town Sea And Zip Cede 13.Canty Of Death 14.Mall Sane At Tare Of DeCh•
O Manisa O Mad,But Separated 0Sivorced
PRINCETON, IN, 47670 GIBSON.. 0%dosad 0 NesMarried 0 D"imo*n r
15:Stiviere Space's Name 15a Last Nene Bata First Macnage I 18.Decedents Usual Oatbam 17. Keg Cl BsvMBduaSY s
DORIS EVELYN MORRISON JAMES I LINEMAN SUPERVISOR TELEPHONE 1
18.Residence-Slate 18a Canty 18b.City Or Toll . S. I
INDIANA - GIBSON '- . PATOKA _
lac Steel And Nutter 18d.Apt No. 19e. Zip Code lef.Inside City Lie.?
211 SCHOOL STREET 47666 Ova ❑No
19.Decedents Eduratan A. Decadent Of Hwang Onpn 21.Decedats Race a
HIGH SCHOOL GRADUATE OR GED ....R„: ,
COMPLETED NOT HISPANIC White ._c '•' fL
22 Petards
Nana(Fast Midge last' 23.Pasts Nero(Fit Mdse,Last) :. 1'.,` � 23a Parente lain Name Before Fat Manage c
G
ROY MORRISON - CHARLOTTE PEARL MORRISON BARNES
24.hcbmaRa Name 24a Relatalsfp To Decedent 240.Mating Maass(Street And Nara,Cty.On.Ze Coda) t
TERRI HURST DAUGHTER 5136 SOUTH LAKE DRIVE, EVANSVILLE, IN 47715 . J
25.Place Of Osposi5m
25a Mate,Cl Oispmlm 250.Race Of Disposition(Nano Of Canadaty,Crenabry.Other Ptese1 25c Location-City.Town And State 1
0 Banal 0 Cremation 0 Daum 0 Eaaroner
0 Removal Fran State
❑orar(Seamy): OAK HILL CEMETERY PATOKA, IN -�•. `• j
28.Was Carver Contacted? 27. Name And WMlea Adams Of Fungal Fagg I'... 27a. Facaal Home License Nutter
it
❑Yes 0 No : COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671 .
27t.Signature Of tans Fatal Service Licensee: 27c.Liaane Nona(Of Liaeee)
MARK R.WALTER, BY ELECTRONIC SIGNATURE FD01013010 T T I
Cause ODeaCaused
(Sae Instructions And EnamTles)
enn ..> F 1 JLJ
28.Pet I.Enter The stain p Evens - act,Or Ventricular
!Nunes.Or Can i Vitiiora-That DirectlyThe Ca logy.The Dealt Do Not Enter Terminal Evan Oran
Aire As Cardoc Arrest, ves II
Nast,CVaevta Fbrtalion VrLtnout Shaving The Etbbgy.Do Not AbbadCa.Enter Only One Crum On OaCtn L
A Lae. Add Addti,rlM Lines 8 Necessary. •
Im medme Cause(Final Disease Or Condition Renting In Dean) A. DIASTOLIC CONGESTNE HEART FAILURE OF UNKNOWN ETIOLOGY MAY 2 0 2019
tot auras�e.ao is •
Sequeniaky List Condtions, If Any,Leading To The Cause Listed On B. wwlr r.rwwors
Line A. Enter The Underlying Cause(Disease Or Injury Tam Initiated
The Evan Restating InDean)Last C.
StiAt-7
want rA rape a '
•
D. GIBSON COUNTY a-UCiT TQ
Pan IL Eros OterSimvfanl Contexts CaMafmo to Death But Na Ranting In The Umefyig Cane Given in Pat I 29. Van An Autopsy P.nund?, i Oyes ®No
30. Were Autopsy Faking Avaiade To Gantlets The Case Of Dea? 0Yes 0 No
31.Did Tooaao Use Canines To Dear? 32.U Female: 33. Mesh Of Death
❑Yes 0 Pmoedy 0 No ®Iktvlwvn 0 ere-q.avan pea Ye. ❑Nye urea osae 0 a.N.-.a NV."Mn a Der.apace ®Natal 0 Homicide 0 Accident 0 Penang investigation
0.s fail-.a Nip 0°erste 1 is Ma Out 0,aese tangos net De Ns Ys 0 Birtle 0 Could Na Be Determined •
34.On Of Injury(Mortttajfear)., 35.Tom a bitty 30. Place Of hyry(EG,Decedents Horne,Cms:nclial Se,Resan*A V ceded Are) 37.INy Al V 1O? 1
❑yes ❑No j
r
38. Lennon Of Inuy-Sate Sea Cava Town - .381x Sea a Nance . 38c Apt.In. 38d.Zip Code
.
39. flesasne Hoe Is s)'Oraasred - O Tsasfpma� .s��seedefr i
CJ^-�Om-A-an i
3
41.Signature,Of Person Cetera Cane Of Death: .- - - 42. (Chad( ry farther(Chad(C Cm) q
JULIE K.GERHARDT, BY ELECTRONIC SIGNATURE - - - - 0Castling Plryddan 0 Carr 0 Heam'Dyer
43.Name,Address And bp Con Of Penal CeUyig Cane Of Dears : - - - .. - _ M. Liaise Nanhe 45. Data CtetSed
JULIE K.GERHARDT ,600 MARY ST.,EVANSVILLE,IN.477.13 - 01057271A 08/24/2017 i
48.Adonmal Funeral Serb P ovide - ?Ja
r
ka
�� t 3
L
ire Si*natured. ne et no Hough Cater - ----- -- - 49RegistrarRegissr Only -Data mN Flee(MDsy/Ye):
i
BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE - - AUG 25 2017 .
AMENDMENT TO CERTIFICATE Op DEATH(ENTRY OR ORIGINAL) r .
-. te‘.( - OL\-Lk 310-Q000. 24.6 -o20
26- 04, -2�-30b -000. 626. -C�2o
Slab Form 53395 ATTENTION ESTATE:Ito Social SemetY I is bong requested by this store agaty in order Inn"?resPonsi 3CY. Daaossre a vvUsday ad Ulna"I berm Penalty(a reheat
WARNING• ORIGINAL DOCUMENT HAS A MULTICOLOREDBACKGROUND
BACKGRND ON SPECIAL WHITE SECURITY PAPER AND THE GREAT SEAL OF THE STATE OF INDIANA COI BACX THAT t
TURNS FROM ORANGE TO YELLOW WHEN RUBBED ORIGINAL DOCUMENT_HAS A HIDDEN VOID ON FRONT THAT APPEARS WHEN PHOTOCOPIED. 3