Death Certificate - Sollman, Herschel_7/6/2012tnni;r.�nnn:�aucoainm:mirmis�cmyr.uaua•r.c�uvannn
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INDIANA STATE DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
EDR No 000000259491
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764281
O5/05/2012
�. ama �eanry w.ru�er w. ye - rrs eo. unaa i rrar x unmr i�wx:m ee. unec i oaY �. �� ��r r. oam ot ew. I�w�aYnerl e. BiaWm IGry ana Str.e n
Foexsi 10. Ii DeY.li Otiurte� In A MoSp�al: . I Oa. If OeYJf OcCUrteO Swne�Mert ONer Than A Mosq�al
❑ Hosptt Faod3y ❑ DKeOmfs HOme ❑ Nursvg HprcRwglcm Grt Fatity
❑ Yes � No ❑ Un'enwm � Inpaxnt Q Eneqenry �epr:�ent W:paxni 0 �ea0 m Am.al � pN�� (S��y)
FORT
607E SOUTH SQ WEST
�9. DeceOenYSEWO�m
HIGH SCHOOL GRADUATE OR GED
� Bunai � Crertawn Q Dona•.ion Q En:onammt
� qerqrdl Flotn StY.e
O �+P+ Isoeayk
26. waz Comner ConqctKt 11. Name M�
❑ Yes � No crnncu
Wi7fCa
POSTAL
2d. Pan I. Entu T1ie Gain Of EveMS - Diseasas. Iryvnes. Or Comptirations - Rw� DirMty CauSeE TM Oea:R Do Nol Enter Txminal EvmS
$�cti'AS CarEiac h�res�, Respra;wyMest, Or VenVicWar FDritlaGOn Wihwt Stw�rrig The Etidogy. Do Not AEEreWa:o. Entel ONyOne Ca�se On
A Line. ACd AEEi6ndl LinES I( NEC¢SSary.
Immetlia:a Cause (Final pisease Or ConO:uon ReSWtlng In peaL�) /. RESPIRATORV FAILURE DUE TO PNEUMONU
.�o...re....+.ors
Sepuenualry Ust ConOi;ions, if My, Leaeinq To TTe Cause listea On 0. GOION MA55
Line A En;er The llnEerlyi(g Cause (Disease Or In'ryry T�at kJ:iatea °' `� �� �`°°�P�`
Tlie Even6 RrsW:ing In Dea:�) Lazt C.
a..,�a�.•� .
D.
� MameO � MameO. BN SeOara:W ❑ DM1wcM I
❑ Wqw.eE ❑ Nevc NameO ❑ Unknv«n
❑ Y¢s � No
Appm�dma;e
Interval: Onset
io DeaN
. ..,......0 .,. .........�.. y ...� r , y _............. _.. . .._.._..,. �-. ._....,.. ❑ Yes � No
�RI Cli� ANEMIA YJ. tVert �,:sy FhCr9 4valatls T^_ u.-^y1eL• Ta Ca�rse CY O�aTi � YC ❑ N<
31. Dq ToOacoo Use Cm}iOUR To Dea�? 32. I( Fem2�e: 33. Mimtt Of 0laT:
❑ v« ❑ arotatN � eb O UnF+awn O••^•a.+..c..,...... ❑ w.w+.� r a o..w ❑�..n.w. e..n.w+w.�.: e.n a>..� � r�r.uni p iawnioae ❑ �cvamt ❑ v«q'v+v inveso3asn
p„�A.md..+.:..�5,.,.,�e.«.c..., ❑�..a.».,�.....,.�,......�. ❑suioxOc«nenaeeoeimewea
31.Da�eO(Irthiry(AbnpvDay/Year) 35.T e0flnj�ry 38.vlare011ry�ry(E.G.,DercEmhMpne,CrnswWm5l�e,Reswrzn4WOaEetl/�rea) 31.InjuryAtwon?
❑Yrs ❑No
L
Su
(7/OS)
ESTATE:Tha
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CaMl�
stete agmcy in orCer to Wrsue respmsi�5ry. Oistlosure is vMmtary aiM Nere wiP Ee ro oenatty