Death Certificate - Hardiman, Mark D_12/27/2011INDIANA STATE DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
EDR No 000000235185
10.IIDeaTOmneElnAHaspW' t0a.IlDeaJ�OmmeESOmeM�e�ep�,IfyTl�ar�qHOSpitel
❑ Yea � No ❑ Unk�w.vn ❑ Iripepmt 0 Emerpency pe�wwvnent Ouqeuem � peap on nmval ��� Faatiry ❑ DeceOerp� Mame ❑ Nun'vq Momertsptertn Gee Faofiry
0 oe,�, �s�nr
11. Fe�ry Nama (II Nd Irtrt^.fva4 GM SYeet azq NwnEe�
DEACONESS HOSPICE CARE CENTER
4��Q%
952 NORTH SDO WEST
is. o«ne�r: Ea�raoo�
HIGH SCHOOL GRADUATE OR GED
f:7•\1
� a.ai p uom.un, p oon.x� p em.on�omem
❑ Rmiwal From Sb:e
HILL CEMETERY
❑ Yes � No
�
• � • • �
• .
❑ MarneEO Martia0.9n5epxa:ea � Di+ace0
❑ Vr50owE ❑ NevatMameE ❑ UnYnwm
❑ Yes � No
wuu v� �eam �xe �mwcums nna uampiol Fpp(n�vna:e
2B. Pan I. Entar The Cna'n Of Evenu - Oivases, 4purres, Or Complicatiom - Tt�at Dvaciy Caused Tha Oeatrt Do No� Emer Tem�vul Evenu In:ervat Onsat
SuU� As Cardiac Mest, Respira:ory Mest, Or VeMrcWar FiOriilatim VJ��M�t Snw"vg Ttie Etblogy. Do Na ADbeviata. Emer ONy One Ceuse On io Deatn
A Line. ME AEtlitmal Lines If Nacessary.
ImmeCia:e Gause (F�al Diseasa Or CorNition ReuCaq In Deatti) A PANCREATIC CANCER ONE YEM
a�o r.. n rwe� or�
Sepuercialy List CanC:tims, tt Arry, Leaaing Ta TTe Causa listetl On B-
Line A En:er TM UnEeryir�g Cause �Disease Or Vyvy T1at Inrtia;eC bj° ��"�ONO °'
The Even:s Resu:tirp In Deat�) Las� �
w�a...�.�..a�e
D.
❑ Yb ❑ PmEady � No � UnYip.m
Yas � No
p».»�w�ro.,•..•.., ❑�o�.+un�..ac�.m ❑..n.r.a.n.w+�..com«o..� I� Haaiai O nor.vaoe ❑ ncoam ❑ Faav+cimesecria+
fl.+a.w..wn.o.+awr.rai�.rr.we� flv�w..,�aRr++w.�m.e..v... fl5iioaef'7CaeaNaBeb:emYnea
VIA
❑ Yes ❑ No
Ip�i:.�.ac.:.� On�'s:'d..s"a.. Qa.�.nr.�m
Cm:��fier (CherkONyOre)
CaMtrwPMVdv� C7 Cumer . ❑ Hea1�0��
i
139.5 ATTENTION ESTATE' The Sacial Saartity k is beinp requesteC Gy Nis stete agercy in oNe� ro purs�a �esponsibi4ly, piscbsure is voNntary aM Nere will De no pe^aly fw teNSal.
IVRA-20
(7lOS)
1 1 ' I I' 1 1 1 I: I'