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rl105.805 REV 1/05
This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing.
WARNING: it ISdiUega.l. to duplicate this copy by photo~tatOtphotograph.
E-11931532
No.
.~Ji;.~
Local. Registrar
Fee for this certificate, $6.00
OCT 2 2 Z005
Date
Rev. 2/87
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEAlTH. VITAL RECORDS
CERllFICA lEOF DEATH
STATE fiLE NUMBER
C)
S;o
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:~.:;! ~-~~> M
'-:; :0
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SEX
2Female
76
S.
COUNTYOFDEATH
VIS.
BIRTHPlACE (Citylnd
SIBle or F~COunlry) l408PITAI.:
amp Hill,PA 1"9dW1XI
7. . ...
F"'CIlITY NAME (If notlnatllutlon, give a:reet and nlllnber).
I
~FE
RACE . Indian, Biaek. White, al .
(SpeclfyWhi te
10.
: Cumberland
lb.
DECEDENT'S USUALOCCl/P"''fJON KIND OF BUSINESS IIHDllSTRY' .
l.,..:::.r~~~l . ..Commonwealth6t
11Fersonnel · Annalis. 1b. PA
, D~CE. DENT'S ~U!IY ~~S (Sml. C..~ /Town,. Stala. ZIp Code) D. EC. .EDENT'S
':l0 N. l:ltn St. .. ACTUAL .
. RESIDENCE
Lemoyne, PA 17043 (Slelnsliil~
16.' Qn otIler sid.)
FA THER'$ NAME (F\rSt, Middle, Last)
1..
INFORMANT'S NAM~ (T~
2o..Raymona H. Bowers
METHOD OF DISPosmON
Burlll 0 C~D8IRQVal fn)m SIBle 0
0tMr (SpecIfy)
FllNERAL S E l N EE OR PERSON ...CTING AS SUCH
MARITAl ST"'TUS.M8rri1d,
N~~~,
1married
R
15.
SURIIMNGSPOUSE
(KWife..lPv*m__l
mondH.
17c, 0 Yes, dlC8dlnt livid In
twp.
LemOyne
citylboro.
17043
PLACE OF DISPOSITION- HlIlla of Cemetery,CremllOry
or Other Piece
2~~n-O-Li te · crematory
~E AND. ..... QP. RESS OF ~1J.n:.s
~~ss>~.J.man 1'.t1&L:
lICENSlO NUMBER
IG
(Month. DIY. "'aar)
23b. 230.
WAS CASE REFERRlOO TO A MlOOlCAl EXAMINER /CORONER?
28. Yes -"0(..41 No 0
: ApproximIII Oth8l' s1gnlfic8nt conditions contrillUlIn\llo d8llh, but
, intervll between not r.sulting In the undIriylng ClulI!Iglven In PART I.
: onset end delth
,
24.
21. PART I: E_'" -.Inju.... or com....-.. which coutH ... dtath. Do not
U.t Oftly OM _ on ...h .....
IMMEDIATE CAUSE (final
di$eMe or condlllon
resulling In delllh)-+
I.
=:.~=::e I..b'
ceuSl. Enter UNDeltlYJMG .
CAUSE~ or injury c.
thIIlnillltlld even..
.....tIIng on delth ) J.A8T d.
WAS AN AUTOPSY wERE AUTOPSY FINDINGS
PERFORMED? AVAILABLE PRIOR TO
COMPlETION OF CAUSE
OF DEATH?
Yes 0 No
YHD
MANNER OF. ~~
Netu"" .. .&:3'"
AccIdant 0
o
Homicide
Pending Investigation
Could not be d81ennln8<i
DATE OF INJURY TIME OF INJURY INJURY AT WORK? DESCRIBE HOW INJURY OCCURRED.
(-.... Day, Y-l
o
o ~DNoD
o 30& 301). M. 3Oc.
~~~(=Y - Athome.""", amt. r.ctory, oIlIc8
3Oe.
No
2ft
33.
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