Death Certificate - Norrington, Earl_1/19/2021 w;f`1r_�-ar...,....ye>,rs,rre s.,nt:.�-11,Q�m ahy+. �'17ifgfr�';+e'�17A:lli - • • ■ - �-5 T' :7;1 "'9 r �n
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� ' ''� INDIANA STATE DEPARTMENT OF HEALTH
; ,p• S CERTIFICATE OF. DEATH -RESUBMIT
Local No 000093 . EDR No.000000783565. - State No 030359 : 0
t - 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)
�\, EARL RAY NORRINGTON MALE 09:00 PM 05/30/2020 _'
6 5. Social Security Number 6a.Age-Yrs 6b.Under 1 Year Sc. Under 1 Month 6d. Under 1 Day Be. Under 1 Hour 7. Date of Birth (Month/DayNear) 8.Birthplace(City and State or Foreign Country)
t> . 68 Months .Days Hours - .Minutes OAKLAND CITY,IN
9. Ever in U.S.Armed Forces? 10 If Death rlrrt rred In A Hospital. 10a. If Death Occurred Somewhere Other Than A Hospital
r ❑ Hospice Facility Ei Decedent's Home 0 Nursing Home/Long-tens Care Facility
f' ❑ Yes 0 No ❑ Unknown ❑ Inpatient❑ Emergency Department Outpatient ❑ Dead on Arrival ❑-Other(Specify)
11. Facility Name(If Not Institution,Give Street and Number)
'309 SOUTH DONGOLA ROAD
G;// 12. City Or Town,State.And Zp Code ' 13 County Of Death 14. Marital Status At Time Of Death
t- ` -
0 Married Married,But Separated ® Divorced
ci- OAKLAND CITY, IN,47660 GIBSON 0 Widowed ❑ Never Married ❑ Unknown
I 15. Surviving Spouse's Name 15a.Last Name Before First Marriage 16. Decedent's Usual Occupation 17. Kind Of Business/Industry
C MECHANIC AUTO SALVAGE' •
18. Residence-State . 18a. County . I 18b..City Or Town
• INDIANA GIBSON - '` OAKLAND-CITY . . ;
,i 18c. Street And Number 18d. Apt.No. 18e. Zp Code 18f, Inside City Limits?
s- 309 SOUTH DONGOLA ROAD 47660 ❑ Yes 0 No
it.... 19. Decedent's Education 20. Decedent Of Hispanic Ongin 21. Decedent's Race `, ,
HIGH SCHOOL GRADUATE OR GED _
r ' COMPLETED . . NOT HISPANIC . ., . ' White . '
p A 22.Parent's Name(First,Middle,Last) 23 Parent's Name(First,Middle,Last) 23a.Parent's Last Name Before First Marriage
j EARL DAVIS NORRINGTON - ANITA LOUISE NORRINGTON BOLIN _
Q 24.Informant's Name 24a.Relationship To Decedent '24b,Mailing Address(Street And Number,City,State,Zip Code)
BRIAN NORRINGTON SON • ' 430 SOUTH LINCOLN AVENUE,OAKLAND CITY, IN 47660 • -
25 Place Of Disposition -
a 25a.Method Of Disposition 25b.Place Of Disposition,(Name Of Cemetery,Crematory,Other,Place) 25c.Location-City,Town,And State
0 Burial 0 Cremation ❑ Donation 0 Entombment
• ❑ Removal From State i . -
• 0 Other(Specify): CUP CREEK CEMETERY-- •. PIKEVILLE, IN .
• 26.Was Coroner Contacted? 27. Name And Complete Address Of Funeral Facility v ' :, 27a. Funeral Home License Number.
® Yes El No CORN-COLVIN FUNERAL HOME, INC.;323 N. MAIN ST. PO BOX 278, OAKLAND CITY, IN
47660-0278 . FH19400002 ' •
27b.Signature Of Indiana Funeral Service Licensee: 27c. Ucen cerise
JAYANNA WEAVER, BY ELECTRONIC SIGNATURE FD21805� -{
Cause Of Death'(See Instructions And Examples) 11 j J Approximate •
28.Part I.Enter The Chain Of Events -Diseases,'Injuries,Or Complications-That Directly Caused The Death.Do'Not Enter Terminal Events Intervals Onset
Such As Cardiac Arrest,Respiratory Arrest,Or Ventricular Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Additional Lines If Necessary. �� 0 21
• Immediate Cause(Final Disease Or Condition Resulting In Death) A. ACUTE MYOCARDIAL INFARCTION MINUTES
Due to(Of A.A Consaquanu Of)
T Sequentially List Conditions, If Any,Leading To The Cause Listed On B .
(^ Dui b(Dr As A Cw qu.nn OQ 'I7 /J �//�-_'L
(': Line A: Enter The Underlying Cause(Disease Or Injury That Initiated ����KALC W.J/Y�Lr�•
f1�
The Events Resulting In Death)Last C CIC3SON COUNTY AUDITOR
Dua'to(Dr A.A Gorse qucno DO '
o. . - - .
N Part II.Enter OtherSionificant Conditions Contnbtrtine to Death But Not Resulting In The Underlying Cause Given In Part I 29.Was An Autopsy Performed? ❑ Yes ® No
F` 30.Were Autopsy Finding Available To Complete The Cause Of Death? ❑ Yes ❑ No HYPERTENSION,DIABETES MELLITUS,CHRONIC OBSTRUCTIVE PULMONARY DISEASE .
p� 31. Did Tobacco Use Contribute To Death? 32. If Female. - - " " 33. Manner Of Death: .
A ❑ Nat Pregnantea,en Past Year ❑ PngruriAt Tana Of Oaaln'❑ Not Pregnant.But Prognem n So a7 Dmor o..u, IN Natural 0 Homicide 0 Accident 0 Pending Investigation
0 Yes IR Probably❑ No 0 Unknown ' l .
',/{ 0 Na Pngnart,as Pregeam u Day.To 1 roar aeon seau, 0 univ,otrn V Pregnant Mar Th.Par Year 0 Suicide 0 Could Not Be Determined
34. Date Of Injury(Month/Day/Year) 35. Time Of Injury - 36. Place Of Injury(E,G.,Decedent's Home,Construction Site,Restaurant,Wooded Area) 37. Injury At Work?
- ❑ yes ❑ No
,r 38. Location Of Injury-State 38a. City Or Town 38b.'Street 8 Number - 38c. Apt.No. . 38d.Zip Code
,`/ 39 Describe How Injury Occurred ❑ If Transapt❑dorr
P.Inry❑pecity:
n❑o ( )r -/ -
I~. 41.Signature,Of Person Certifying Cause Of Death:, ' ' 42. Certifier(Check Only One) '
;U MISTY G. HOKE, BY ELECTRONIC SIGNATURE , ' ❑ Certifying Physician . Coroner ❑ Health Officer - '
k 43. Name,Address And Zip Code Of Person Certifying Cause Of Death- . - 44. License Number 45. Date Certified
`n7 MISTY O.HOKE ,203 S. PRINCE ST., PRINCETON, IN 47670' - 06/02/2020
46 Additional Funeral Service Provider. . ' ' . ' ' 47. •Akas:
P
•;\ 48. Signature of Local Health Officer . , 49. For Registrar Only -Date Filed(Month/Day/Year):
. BRUCE BRINK JR,VIA ELECTRONIC SIGNATURE , l ' JUN 08 2020
- 'AMENDMENT TO CERTIFICATE OF DEATH(ENTRY OR ORIGINAL). ,
' 49:06/04/2020 . -
; 22-Middle:RAY -
'..\\ )\ --- 1 LA - * •-..- LACD"- -s. 000 . ' ,,_>- .---,. . 00,/ , , . . .
to
State Form 53395 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,
WARNING: TURNIS FROMCORANGE TO YELLOW WHEN RUBBED.ORIGINAL DOCUMENT HAS A HIDDEN VO DP ON FRONT THAT APPEARS WHENEPHOTOCOPIED. I BACK THAT