Death Certificate - Simon Jr, Eugene John_4/28/2017 ..././..«-..r w..air-......a,u- aetNAr-.Y 4:r^-Sy.-, IN 4Craa7r:¢c.1V U _ .Y .,.. -allt 1rdl eii...f .- 3 -,i-,.•
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1, -1 Decedents legal lame l(FYSL`MiOme;Last!l i lla%JIN Vr.....'�tlr l,), I[N e: Ma�fMName:ry b7: ! 2"5a:i 7 fade of fasa a•rte De DeaA:(MOnwDryttsar j
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r EUGENE�JOHN'SIMON;JR .ei�, itrt, i6 }Da ihn, ,�.: Arr., ✓m.. MALJwn12:07rPM., :"\D2/23/2017�.`.�:4
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g'i 1O!ItDeam Occurred In A'Hospial K(i S -tga.l•Dea,n Oscdrre05 e2O er Ra 'A'IhspUl rt, P I
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�\ 22.Parents Name FnL-P.;dde;Lest �,1 / s/..'%' fr f ( ) ii�`!,i) I Manwge,
1 1(vr � 1 I /' i y /' t / %'3 / I?1'?arems Name FYS4'N+OUe Lazt i' / 23a Parenra Lau Naroy Be'orl FUZt
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c Ii EUGENE JOHN SIMON SRI i,•ih t?It is idllil' /III10%.! ! / EONAApA%S MO'N\ t Al iiMfi".-i 1 WEBER %T iJ' II
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MARGARET(ESIMON�: „ -.ail. �d11i!Elj- SISTER i.: , r itl 42798 S SOUTH�450 W ROAD WEST%HAUBSTADT•,IN'47639�iih 1 .4
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! 2Th Signature Of Indiana Funeral Service LicenseeE
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I�/ANDREA LYNNNINCENTI BYtELEcTRo NIc sl GNATURE;: I I 4lI i& l ilh? FD2i4000O5!I iIi1nfircA : I 1
\` T� "\Cause Of Death Sea Inswttipns And E am lea .la \
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j rSutlihs Cardiac Arrest Resp,Ia ary Arrest Or Ve mwla Fbrilia'ori W 6ioul Shots ng The Euolagy:Do Not Abb eeaidl Enfant)*One Cause On �/ I i 1E:7..1�I' C�� s �io DeaUi Q/'11I
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4nmaQate Cause(Final dsease Or Cond ton Resulting In Oeatn) i A �iRESPIRATORY FAILURE / ii s''.,,:alt. / I r3;9.:;;.:;-'
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I39 Desame HowlelucY Occurred_ 't ejJ tr- V \� Vr,r�i:(•4t r% -: t` 4o of Trans,o:aoonL.R,ns f, ∎/aii IG" I:
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•...• L41 Signaye :Of pawn Centying Cane Of Death r4p MJJIr/�k#IL1444.t Y/,V;r ` 1tr .' 42 Cei.ae tCneatonYOne!! � Fn/-r4W.E%,cIIfIF/�1�,'p/1
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