Death Certificate - Horrall, Mark_3/29/2022 I II
x -:4 INDIANA STATE DEPARTMENT OF HEALTH
1 t , et.,. CERTIFICATE OF DEATH
0
local No 563 EDR No 000011220641 state No 2021-076651
1.Decedent,*Legal Name(First.Medea.Last) la.Maiden Name(alsmab) 2 Gender 3. Thal Ol Death 4 Date Of Death(Monti sy/Yeet)
t,?j Mark Wayne Morrell Male 09:38 AM 12/27/2021
Princeton,Indiana
9. Ever in U.S.Armen Forces? to.1r Death Occurred In A Hooper*: 1pe.*Death Occurred Sornew tece Other Then A Hospital
.41 CI meows Facility 0 Decedent's Home Cl Rasing lbaWLang-dune Care Carey �I
Q Vad ®No CI Unknown ®,patient CI Emergency Department Outpatient Cl Dams on AreWa 0 as.,($,Abolyl
11.Fac rdy Name(If Not Institution.One Street and h.er bar) Good Samaritan Hospital
R2..City Or Town.State.And Z.p Code 13 Comfy Ot Death 14.Merest Status N Time Of Da th
Vincennes,Indiana 47591 Knox Stained CI Md,arre BUSeprated Cl Divorced
®Widowed p never Mama* p Urencwn
15.Survtvup Spouse's Name lee.last Hams pallor.First Merrleg. 18. Decedents Usual Occupation 1 17.KKK!OI Business/Industry
Peggy Morrell Unknown Farmer Agriculture!Livestock
18.Residence-Saw 1ae. County 1ab Cap Or Tone
tN Gibson Hazleton
1 tAc Sewn And Number led.ApL No. 18e. Zip Code taf. Vgide City Lines?
8177 N US 41 Highway N 47640 ❑veil ®No
u 19.Decedent's Education - 20.Decadent Of HoParc Onpn 21.Decedents Retie
Unknown Not 3panistvreepartic/Latino When
r 22.Prams Name(Fast.Mddle.Lash 23.Parents Han*(Feast.Meddle.Last) 23a.Parent's Last Name Seines FIre Manage
Chester Wayne Norm)! Sandra Sue Honall Null
24-Wdxmax's Hams 48 Raeaaro onp To DecedentAddress 246.Mtutnp Address(Street And Number.Cis,Stills,Ztp Dada)
Mark Morrell Jr I Son 8177 N US 41 Highway N.Hazleton,IN,47640
_ 25.MOO*Of pp�tton
25e.Method rill Disposition 25b.Piece Of D:apoeiton(Name Of Cemetery,Cremsiaty,Other Pleas) 25c.Location-Coy.Town.And State
fa Burial CI Cramatnn Cl()punier+Cl Entombment
Cl Remove From Sure IOOF Cemetery Hazleton,IN
0 Other t
28.Was Coroner Contacted' 27. Herne And Complete Address Of Funeral Facility 27e. Funeral Finny License Number:
Doyle Funeral Home 520 S Main St,Princeton,Indiana,47670
CIYes ®No L.. FH10400010
27b-Signature Of inden.Funeral Sence Licensee' 27c. License Number(Ot Licensee):
tBartMt 4'V Do _- Electronically Signed FD28500009
Cause Of Want(See M1Mruedone And Examples) N(PWonirris/s
2e-Part I.Enter The Chain DI Fanoty -Diseases. Or Mtic l ar Cation t •That Directly Caused The Death.rDoe Not Enter Terminal Events Interval:Onset
Such . Cardiac Arres.onai sfRespiratoryN sorry. Or VeranCtNar Fibrillation Without Showing The Etiology.Do Not Abbreviate.Enter Only One Cause On To Death
A Line. Add Add.iwnal Lutes If Necessary.
Immediate Cause(Fatal Disease Or Condition Remitting In Death* A. Covid-19 with weakness and a fall 2 days
.__...
sequenhary list Conditions. n Any.Leading To The Cause Laded On
B Multiple hemorrhages of the brain due head trauma 2 days
line A. Enter The Underlying Cause(Disease Or Injury That initialed w.i,eo a.arree. ce a).
--_-
The Events Resulting In Death)Last C.
• __-_ Dwain ra.A.At c..se.ter on.
D. _
Pail It,Enter(S5 areecont CsendKevns Ctabbwnni r to tau aT+But N riser-Reg-ii -Underlying Cause riven inPart I 211. was An Autopsy iverfYea gg No '
• respiratory failure requiring mechanical ventilation 30 wan Autopsy Finding AveKibte To Cettpieb The Game Of Death? CI Yes CI
No
31 Did Tobacco(Jae Cor8rtbuts To Dealt a '32. *Female
Cl not na.arstewm__m--an--e.--77 at aewas�ee rmerew.orome rill Strata t-tomic
Cl Yea ❑ProWabey❑No ®Otoa....n.. 0 nee re,.eeaea+.ra�aepie. , some •rop.,we.rlaPow year Ifl Natures Cl Homicide AeaddM Cl Pending le'araaspetioef
�'1 �[�Suicide Cl Covet Nat Re D.ItvrtRnad
34.Dale Of Main,(Month:Day/Yea r) 35. Tens Of Injury (E.G.(Ea Dyads a Hans,Cantu ction Stec Restaurant,Wooden Ares) 37. tnlwy At WO*7
❑Yes ❑fin
3a.Location Of injury-Stab 38e.City Or Town 1Y1 AR 2.9 S aZ2 t a Number 38c Apt.No- 384.Zap Code
39.Despite How usury Occurred
° jam,/ 40. If TrenspaWOOn Merry,Specify:
491fmtfs7l rRt cedltrtngCoos.0 bdam: Gtr "SO aguNTYA►.►D'r0 a2. tiear a(Check exwayissempeass een❑a...a. ❑o...er..w
El cttonically Signed MI certMra Physician Cl Coroner Cl Head+Oxeoer
43.Name Adana And trim Code Of Person C.Irylag Cause Of Defter: 44. Ucenee Number 45. Dare Certified
Harold.Hcbard 520 S.7th Street,Vincennes,IN 47591 01034822A 01/01/2022
46.Ada.0444 Funeral Serve..:_Prov,;er: 'Akaa-
48.SypNCwem Lome wean 0theer 49. For RepaWar Only •Dam Feed IMonttvDeytYearl.
'Wan CD-.Stewart Electronically Signed 01/04/2022
AMENDMENT TO CERTIFICATE OP DEATH(ENTRY OR ORSOM IALa
Stay Pwm 53395 ATTENTION ESTATE:'The Social Security et is being requested by see state moony in order to pursue responsibtlety. Diadoeure to voluntary and were w7 be no penalty for refusal.
WARNING. TTURNIS FROMC•RANGE TO YELLOW WHEN RUBBED.ORIG NALO DOC EME T HAIS ASHIDDEN'Iv OP
DPON FRONT THARTEAP EARS WH NE HOTOCOPIEDIANA ON BACK THAT