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Death Certificate - Scott, Mark_10/2/2019 5 'r; >7�._;" .Qt^ .. •' rff �'�.4 !' CERTIFICATE OF DEATH a'If ,7T,`� C�N �'`7S`77-- ``Fill F-''aN INDIANA STATE DEPARTMENT OF HEALTH 0 7j I CERTIFICATE OF DEATH "' Local No 000628 i EDR No 000000731513 State No 044814 1.Decedent's Legal Name (First,Middle.Last) I 1a. Maiden Name (II female) 2.Sex 3. Time Of Death 4. Dale Of Death (Month/Day/Year) MARK KEITH SCOTT MALE 03:18 PM 09/13/2019 5. Social Security Number 6a.Age•Yrs 6b. Under 1 Year I 8c. Under 1 Month led. Under 1 Day Be. Under 1 Hour 7. Date of Birth (Month/Day/Year) 8.Birthplace (City and State or Foreign Country) 10.If Death Occurred In A Hospital: 10a. If Death Occurred Somewhere Other Then A Hospital j0 Hospice Facility El Decedent's Home ❑Nursing Home/Long-term Cara Facility 0 Yes ®No ❑Unknown ®Inpatient ❑Emergency Department Outpatient ❑Dead on Arrival ❑Other(Specify) 11. Facility Name (If Not Institution,Give Street and Number) DEACONESS GATEWAY 12. City Or Town,State,And Zip Code ' 13. County Of Death 14. Mantel Status At Time Of Death • I ❑Married❑Married,But Separated ®Divorced NEWBURGH, IN,47630 WARRICK ❑W4dowed 0 NeverMenied ❑Unknown 15. Surviving Spouse's Name 15a.Last Name Before First Marriage 16. Decedenrs Usual Occupation 17. Kind Of Business/Industry I I FACTORY OPERATOR MANUFACTURING 18.1 Residence-State 18e. County 18b. City Or Town INDIANA GIBSON PATOKA 18c. Street Arid Number 18d. Apt.No. 18e. Zip Code 18f. Inside City Limits? l P.O. BOX 18 ❑Yes 0 No d 47666 t 19. Decedent's Education 20. Decedent Of Hispanic Origin 21. Decedent's Race ) 9TH- 12TH GRADE; NO DIPLOMA NOT HISPANIC White 22.Parent's Name(First,Middle,Last) 23.Parent's Name(First.Middle.Last) 23a.Parent's Last Name Before First Menage THURMAN SCOTT BETTY SCOTT SINKHORN 1 24.Informant's Name 24a.Relationship To Decedent 24b.Mailing Address (Street And Number,City.State,Zip Code) BETTY SCOTT MOTHER 801 HART STREET, PRINCETON, IN 47670 25.Place Of Disposition 25a.Method Of Disposition 25b Place Of Disposition (Name Of Cemetery,Crematory,Other Place) 25c.Location-City.Town,And Slate ©Bunel 0 Cremation ❑Donation❑Entombment D Removal From Slate ❑Other(Specify): MAPLE HILL CEMETERY PRINCETON, IN ., 26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility 27a. Funeral Home license Number ❑Yes ®No COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671 27b Signature Of Indiana Funeral Service Licensee: 27c. License Number(Of Licensee): JAYANNA WEAVER, BY ELECTRONIC SIGNATURE _FD2r95 , Cause Of Death (See Instructions And Examples) Approximate 28.Pan I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-Thal Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Nol Abbreviate,Enter Only One Cause 1LED To Death A Line. Add Additional Lines If Necessary. Immediate Cause(Final Disease Or Condition Resulting In Death) A. CARDIOPULMONARY ARREST 12-24 HOURS i wemlaA.Aemn.w.^'-op OCT 01 2019 B. HYPOTENSION Sequentially List Conditions, If Any,Leading To The Cause Listed On 12-24 HOURS Line A. Enter The Underlying Cause(Disease Or Injury That Initiated a•'•(Or tiAc..,.w,r�oq. - The Events Resulting In Death)Last C. SEPSIS 12-24 HOURS y Cu.. la ru A.A e,,.ee�Bon. d D. ADRENAL INSUFFICIENCY " SON COUNTY AUnITOR 12-24 HOURS Part II.Enter Other Significant Conditions Contributing to Death But Not Resulting In The Underlying Cause Given In Part I 29. Was An Autopsy Performed? ' ❑Yes ®No y 30. Were Autopsy Finding Available To Cumpiete Tie Cause GI Death? ❑Yes ❑No GENERALIZED DEBILITY 31. Did Tobacco Use Contribute To Death? 32. If Female: 33. Manner Of Death: 1i ❑,ei Plear.,.valAn P.e v... 0 nreIrsn M n,r,.or DeeM ❑Co.P,.0,ne.Cur PreCeImI W 5n.2 Dar.Or Deem ®Natural❑Homicide ❑Accident ❑Pending Investigation i ❑Yes ❑Probably®No 0 Unknown N„Plearura.ea',rape,]a Dar.To I rear e.mre Deem ijnuec r in Pu�W cam„me Past year ' 0 ❑ 0 Suicide❑Could Not Be Determined 1 34. Date 01 Injury(Month/Day/Year) 35. Time Of Injury 38. Place Of Injury(E.G.,Decedent's Home,Construction Site,Restaurant,Wooded Area) 37. Injury At Work? ❑Yes ❑No 11 - 38 Location Of Injury-Stale 38a. City Or Town 38b. Street&Number 38c. Apt.No. 38d. Zip Code 7 39. Describe How Inju rred 40. If Transportation Injury,S ecity 1 ❑orr oPeramr ❑P...erpn �PeeetlrYn ❑Offer isrevry7 J 41. Signature, Of Person Ce ing Cause Of Death: 1 42. Certifier(Check Only One) TABASSUM PARKA , BY ELECTRONIC SIGNATURE ®Certifying Physician ❑Coroner 0 Health Officer 1 43. Name,Address And Zip Code,I Person Certifying Cause Of Death: 44. License Number 45. Dale Certified d 1 TABASSUM PARKAR ,600 MARY STREET, EVANSVILLE, IN 47747 01065454A 09/16/2019 y 46. Additional Funeral Service Provider 1 - 47. 'Akas: 48 Signature of Local Health Officer 49. For Registrar Only -Dale Filed (Month/Daylyear): RICKY B YEAGER,VIA ELECTRONICISIGNATURE SEP 16 2019 p AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL) � i 1 1 C) -0 -'k,--• D-L-J\ -.3 0. - 000 OR `-) -doQ_O State Form 53395 ATTENTION ESTATE:The Social Security 8 is being requested by this slate agency in order to pursue responsibility. Disclosure is voluntary and there will be no penally for refusal. 1i IA fit,w 11 IL 1 Pt. ORIGINAL DOCUMENT HAS A MULTICOLORED BACKGROUND ON SPECIAL WHITE SECURITY PAPER ANTI THE(;RFAT SPA! (1E TRF CTATF nF ttuniArue not oerir rear