Death Certificate - Marvell, Charles E_8/15/2019 141&�n • INDIANA STATE DEPARTMENT OF HEALTH 0 A
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) CERTIFICATE OF DEATH
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,i Local-No 001414 EDR No 000000720199 state No 033693 b
1.Decedents Legal Name(Firs,Made,Last) Is. Maiden Name Of female) 2.Sea 3. Tune Of Death 4. Dare Of Death(MaeeeDelewea4 Ns
CHARLES EDWARD MARVELL MALE 07:12 AM 07/07/2019 4
5. Saul Seamy Number 6a.Age-Vrs en. Under 1 Year Bc Under 1 Math 8a. Under 1 Day 6e. Under 1 Has 7. Date of Beth (MalNDayfrear) 8.Butlylars(City and State or Foreign Canby)
10.If Death Occated M A Hospital. 10a.If Death Ceamad Somewhere Omer Thai A Hospital
0 Hospice FeWy 0 Decedent Haute ❑Nursing Hante./Latg-tens Care Fanny :el
❑Yes 0 No 0 Unknown 0 lantern 0 Emergence Deparunent Ougatem 0 Dead to Ames' 0 Other(Specify) Al
14,
11. Fealty Name(If Not Manna,Give Street and Number)
LINDA E.WHITE HOSPICE HOUSE D
12.Cory Cr Star.And Zip Code 13.Canty Of Death 14. Mental Stets At Tine Of Deal j
0 Mauled 0 Mauied,But Separated 0 Divorced
EVANSVILLE, IN,47710 VANDERBURGH 0 Wdowed 0 Never Maned 0 Unknown
15. Svviwg Spouse's Name 15a.Last Name Before First Marriage 16. Decedents Usual Ompaoon 17. Kurd Of BusiessendusEy :74-
BETTY E.MARVELL KNIGHT LOGGER LOGGING
18.Residence-State lea Canty lap. City Or Town 45'
INDIANA GIBSON PATOKA
18c. Street And Number 1841. Apt No. 1Be. Zip Code 181. Inside City Limits] Tf(,
3662 WEST 250 NORTH 47666 0 Yes 0 No 30
19.Decedents Edtvom 20. Decedent Of Hispanic Cain 21. DecadWaRare j-
9TH- 12TH GRADE; NO DIPLOMA NOT HISPANIC White 1-1
22.Parents Name(First Midge,Last) 23.Parents Name(Firs, FirstMiddle,Last) 23a.Parents Last Name Before First Marriage j?
D
ELDON MARVELL NORA MARVELL SPEIGHT
24.Inbmarts Name 24a.ROW/castle To Decedent tab.Malang Adorns(Street And Nannbd,City.State,Zip Code)
•
BETTY E MARVELL WIFE 3662 WEST 250 NORTH, PATOKA, IN 47666
25.Place Of Disposition
25a.Medial Of Dispoamn 25o.Race Of Disposimn(Name OI Cemetery,Crematory,Other Place) 25c-Leman•Cory,Town,And Stare
0 Bona/ ❑Cremation ❑Canaan❑Emananers
0 Removal Fran State
❑Omer(Spedty): OAK HILL CEMETERY PATOKA, IN
26.Was Coroner Cote:ad? 27. Name Am Complete Address Of Funeral Fedsay 27a. Ftneral Horne License Number I
❑Yes 0 No COLVIN FUNERAL HOME INC,425 N MAIN ST.. PRINCETON, IN 47670 :.L'-- 1
27b Sgnlet...Of Indiana Fisted Service licensee' 2)c - Of ):- t t •
RICHARD DEAN HICKROD, BY ELECTRONIC SIGNATURE FDO10 15 {
Cause Of Death (See Instructions And Examples) _ Approximate
- 28.Pant.Enter The Chain Of Events -Diseases,triunes,Or Complications-That Deedy Caused The Death.Do Not Enter Terminal Events - - - - Interval Onset t
Such As Cardiac Mesa Respiratory Arrest.Or Vermtiar FiMTaticn Without St.,.:y The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death -
A Line. Add Addaccal linen If Necessary. / AUG 1 5 2019
Immediate Cause(Penal Disease Or Condition Restitung In Death) A ACUTE ON CHRONIC HYPO%EMIC RESPIRATORY FAILURE h" -:2 --.11 DAYS •
o..eroA.A ta..a+a ore ..
9 B. PNEUMONIA r-. WEEKS' A
Seque al),List Conditions, If Any,Leafing To The Cause Listed On w m to rA cw�a,.e oa
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, e E The In Deg Cause(Disease Or Injury That wawa GIBSON: - YI. ,L'IiOR ?
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, The Everts Resoling
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Part 8.Ender Omer$irntcent Conditions t:OmllbllMld to Deal But Not Resulting In The UMeyvg Cause Given In Part I 29.Was An Autopsy Pertonmad7 Yes 0 No q
CHRONIC OBSTRUCTIVE PULMONARY DISEASE.ASPIRATION RISK 30. Were Autopsy Fa Avalade To Compieeind Cauu Ot Deal'! 0 Yes E1 No l g.
31. Cid Toeaam Use Connate To Deal? ' 32. If Female: 33. Mather Of Death 1 0 ono P,ati Van VW V.v Poor*mo o.a Mt 0 N .. e.Ppe.Vac two abC 0Naaaal❑Homicde ❑Adam ❑Penang
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❑Yes 0 Probatly 0 No 0 Unknown e.Ppyn e.Pep.aaDon T.t 'I'm Dr ❑u ., Pnpr4ys1em.
Pair red ❑Suode 0 Could Not Be Determined jlm
34. Data Ce Injury(MontvDay/Year) 35.Time Of Inryry 38. Place Or MPay(E.G.,Decedent's Home,Cons:Acton Site,Restaurant Wooded Area) 37. Injuy At Wen? G
:d
❑Yes ❑No
38.'Lannon OI Injtay.Sate 38a City Or Town . 38b. Street 8 Number 38c Apt No. 380. Zp Code
39.Describe How Injury Occurred 40. If Tratepaatim Injury,SpeOly: Mower) v
Cla..c...e fP.w lJ°a°,
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41. Stpneare.Of Person Cartryeg Came Of Death 42.Center(Check Only One) 1
APRIL MICHELLE-SIMMONS TOELLE, BY ELECTRONIC SIGNATURE 0 CeNyug Physician 0 Coroner ❑ Heat OS ar
43. Name,Address Mn Zip Code Of Person Cetfyeg Cause Of Death 44. License Number 45:Dab Certsec
APRIL MICHELLE-SIMMONS TOELLE , 600 MARY ST.,-EVANSVILLE, IN 47747 02003410A 07/10/2019 I5
48.Addhedal Funeral Sends Provider ' A.'ekes: A
49 Signature • a. atre Local Hewn 49. For Registrar Only -Dab Fled(MavDayNea): �'
ROBERT KENNETH SPEAR;,VIA ELECTRONIC SIGNATURE JUL 11 2019.,; , I I,\ . •AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) j
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State Form 5 ATTENTION ESTATE:1tx4t)L'iel-AnanWISis beiry Sainted by Ittis state agenry in order to pursue responsibility. Disclosure is voluntary end there will be no penalty for refusal
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VOID ON MFRONT THAT APPEARSD THE GREAT SEAL OF THE STATE OF INDIANA WHEN PHOTOCOPIED. ON BACK THATia
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