Death Certificate - Scott, Mark_9/16/2020 •
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r 40-:.-a�, INDIANA STATE DEPARTMENT OF HEALTH .
�'`r w `p'j CERTIFICATE OF DEATH
�r 044 814
't-°i� '� Local No 000628 EDR No.000000731513 State No
0 , ; 1.Decedent's Legal Name(First,Middle,Last) la. Maiden Name (If female)' - ' 2.Sex 3. Time Of Death 4. Date Of Death (Month/Day/Year)
}} � MARK KEITH SCOTT _ . _ _ _ MALE 03:18 PM
I&( 64 Months Days Hogs Minutes . , GIBSON COUNTY, IN
9. Ever in U.S.Armed Forces? 10.If Death Occurred In A Hospital: • • 10a. If Death Occurred Somewhere Other Than A Hospital
- ❑Hospice Facility 0 Decedent's Home 0 Nursing Home/Long-term Care Facility _
i rG. 0 Yes El No 0 Unknown El Inpatient El Emergency Department Outpatient El Dead on Arrival - -
( El Other(Specify) '
n 11. Facility Name (If Not Institution,Give Street and Number) - .
is DEACONESS GATEWAY
It r- 12.City Or Town, County
State,And Zip Code - 13. Of Death Time
14. Marital Status At Of Death '•
N.S 0 Married❑Married,But Separated ®Divorced
' r. NEWBURGH, IN,47630 WARRICK 0 Widowed 0 NeverManied El Unknown
�V 15.Surviving Spouse's Name 15a.Last Name Before First Marriage • 16. Decedenrs Usual Occupation 17. Kind Of BusinessAndustry
7� FACTORY OPERATOR MANUFACTURING
r�,,; 1,8/Residence-State 18a. County _ 18b. City Or Town - ,
t_ INDIANA - GIBSON ' PATOKA
{`(t,' 18c.Street And Number 18d. ApL No. 18e. Zip Code 18f. Inside City Limits?
P.O. BOX 18 . - ❑Yes ❑No '
��1�t - 47666
j�'kr'" -19. Decedent's EducaLon 20. Decedent Of Hispanic Origin 21. Decedent's Race
,y _ t
- . 9,TH-12TH GRADE; NO DIPLOMA NOT HISPANIC . lWhite
I`��j 22.Parents Name(First,Middle,Last) 23.Parent's Name(First,Middle,Last) 23a.Parent's Last Name Before First Marriage
Oi THURMAN SCOTT BETTY SCOTT= SINKHORN
024.Informant's Name 24a.Relationship To Decedent 24b,Mailing Address,(Street And Number,City,State,Zip Code) • •I -
QBETTY SCOTT MOTHER . 801 HART STREET, PRINCETON, IN 47670
'25.Place Of Disposition • . .
CC 25a.Method Of Disposition 25b.Place Of Disposition (Name Of Cemetery,Crematory,Other Place) 25c.Location-City,Town,And State
®Burial ❑Cremation 0 Donation❑Entombment - -
OEl Removal From State '
❑other(Specify): MAPLE HILL CEMETERY PRINCETON,IN
♦Ci 28.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility, . 27a. Funeral Home License Number.
W . -
ICC ❑Yes ®No
W COLVIN FUNERAL HOME INC,425 N MAIN ST., PRINCETON, IN 47670 FH83005671• -
I- 27b. Signature Of Indiana Funeral Service Licensee: 27c. License Number(Of Licensee):
JAYANNA WEAVER, BY ELECTRONIC SIGNATURE - . FD21800025 - -
l!. Cause Of Death (See Instructions And Examples) Approximate
•
,"26.Part I.Enter The Chain Of Events -Diseases,Injuries,Or Complications-That Directly Caused The Death.Do Not Enter Terminal Events Interval: Onset
CI Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death .
OA Line. Add Additional Lines If Necessary.
> Immediate Cause(Final Disease Or Condition Resulting In Death) A. CARDIOPULMONARY ARREST .
12-24 HOURS
ouq to for As A consequence oft'
•
SequentiallyAny,Leading B. HYPOTENSION
Se uentiall List Conditions, If To The Cause Listed On 12-24 HOURS
iii Line A. Enter The Underlying Cause(Disease Or Injury That Initiated -
Due to A.A Consequence oq:
fir` The Events Resulting In Death)Last I ry •
�� C. SEPSIS 12-24 HOURS
1 - Due to(Or Aa A Consequence On'
r9�g( D. ADRENAL INSU FICIENCY
4 12-24 HOURS
• Part II.Enter OtherSignificant Conditions Contributing to Death But Not Resulting In The Underlyin .Caause Given In Part I'' 2?..Was An A opsy Performed? ❑Yes ®No
Ri'. 30 Were At'itoos' Finding Available To Complete The Ca'Ise Of Death? •
h\ GENERALIZED DEBILITY - ❑Y'es i]No
e 31. Did Tobacco Use Contribute To Death? 32. If Female: 33. Manner Of Death:
❑Nol Pregnant Wahin Past Year Pregnant At -trot Pregn re.. _; ag Days of Death El Natural❑Homicide ❑Accident ❑Pending Investigation
�� ❑Yes ❑Probably®No ❑Unknown ...���®®®```nnn'''
9'`:_ ❑Not Pregnant,But Pregnant ay ays To f year Before palq Onknown If nt W. a Year ❑Suicide❑Could Not Be Determined
34. Date Of Injury(Month/Day/Year) 35. Time Of Injury J 86'. PI a 'Inju ( c.,.. .Home,ConsWctio Site,Restaurant,Wooded Area) 37. Injury At Work?
1tf��'.• ❑Yes ❑No
Pr. 38. Location Of Injury-State 38a. City Or Town ' 38b. Street&Number 2020 38c.Apt.No. 38d.Zip Code , ,
0 • SEP 1 6
„ t 40.,If Transportation Injury,S ecify:
l 39. Describe How InjuryOccurred ❑ r;.enoPerawr ❑Paasanger liPeaestrbn ❑other(sweaty)
rh 41. Signature, Of Person Certifying Cause Of Death: 644
,,c 42. Certifier Check Only One)
p TABASSUM PARKAR, BY ELECTRONIC SIGNATUR C,IRSON COUNTY AUDITOR ®Certifyi Physician 0 Coroner 0 Health Officer -
1 43. Name,Address And Zip Code Of Person Certifying Cause Of Death: 44. License Number 45. Date Certified
}YI
is TABASSUM PARKAR , 600 MARY STREET, EVANSVILL IN 47747 01065454A 09/16/2019
I' 46. Additional Funeral Service Provider \ 47. 'Akan:
48. Signature of Local Health Officer. - 49. r egistrar Only -Date Filed (Month/Day/Year): .
,(4 RICKY B YEAGER,VIA ELECTRONIC SIGNATURE SEP 16 2019 .
4t AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL)�.l
O' '., . - 1,D ,--\ )„....,.._\ \ , ..---. WO --COI . -9-7(14 __oD,\- -____
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r.• State F�o�rm53395 ATTENTION ESTATE:.The Social Security#is being requested by this state agency in order'to pursue responsibility. Disclosure is voluntary and there will be no penalty for refusal.
)r - _ ••AR N I N-a TTURNIS FROM ORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUMENT HAS ASHIDDEN VOID PON FRONT THAT APPEARS WHEN PHOTOCOPIED.IANA ON BACK THAT