HomeMy WebLinkAbout02-27-07
HI05.805 REV 1105
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 is illegal to duplicate this copy by photostat or photograph.
P 13106001
No.
1"",11111"'",,,,,,,,1',
11111~~\.i" OF PEl'--.
l'l ~ r;::---~.;,-.,..,.
~~tr.. ~~... . ~\
~~I _ ,':' - \7?~
~~I ~- .-., - _ 11:e~
~....~.., I~~
~ *~>:.,.,/ *~
\~~. CO -0. '..' .0 /~i
\. ~,., /,~/
""-----:?1"fEN1 ~~~,lltll
"""'"o,/ufltJJ11J,,11
~Ip~
Fee for this certificate, $6.00
Local Registrar
FEB 0 2 2007
Date
3 +t
___iiHOllLI11lliAD..ASJ:<OtLG.W:i
/97- 22 -cc~9
-_~))li"i-7Ziz-(;... .
___...3
.----"--=
.-...._1
REV 11/2006
PRINT IN
\ANENT
;K INK
1130-440
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CORONER'S CERTIFICATE OF DEATH
(See instructions and examples on reverse)
r,)
_I
I2wrv frl ~
-C!
N
U)
STATE FILE NUMBER
19 Andes Drive
4. Date of Death (Month, day, year)
January 22, 2007
,. Name 01 Decedent (Rrst, middle, last, suffiX)
Ruth
5. Age It.st Birthday)
J
Irvin
6. Dale of Birth (Month, day, year)
80
y...
Nov. 23, 1926
&:I. Facility Name (If nol institution, gNe street and number)
ResidenCE! DOther. Specify'
10. Race: American Indian, Black, White, ele
( Specif0
white
12. Was Decedent ever in the
U.S. Armed Forces?
Dyes ~o
Decedent's
Actual Residence 17a. State
13. Decedent's Education (Specify only highest grade completed)
Elementary I Secondary (()"12) College (1-4 or 5+)
12 1
14. Marital Status: Married, Never Married,
Widowed, Divorced 1Specif0
widowed
17055
17b. County
P;:>nnl'lylvi'lnii'l
Cumberland
~ ~t 17C~ Yes, Decedent Lived in Up)> e r
Township? 17d. 0 No, DecedentlJv9d within
Actual Umitsof
Allen
Twp.
Ci1yIBoro
Peter C. Musselman
19. Mother's Name (First, middle, maiden sumame)
Alic S an ler
2Ob. Informant's Mailing Address (Street, city I town, state, zip code)
24 Conway Dr.,Mechanicsburg,PAI7055
Bonnie Trusch
21b. Dale of Disposition (Month, day, year) 21c. Place of Disposition (Name of cemetery, Cf&!!1alory or other place)
Evans Cremation S2rvice
21d. location (City I town, slafe, zip code)
Leola,PA17540
22c. Name and Address of Facility
Musselman FH&CS,324 Hummel Ave.,Lemoyne,PA17043
23b; License Number 23c. Date Signed (Month, day, year)
Dyes DNo
31. Manner of Death
~tural 0 Homicide
D Accident 0 Pending Investigation
D 5o<ide D Could No! be Delo""med
26. Was Case Referred to Medical Examiner I Coroner for a Reason Other than Cremation or Donation'
)!:1yes DNo
Approximate interval: Part II: Enter other ~itions contributina to death, 28. Did Tobacco Use Contribute to Death?
Onset to Death but not resu~ing in the underlying cause given in Part I. 0 Yes 0 Probably
D No D Unknown
29.lf Female'
o Not pregnant within past year
o Pregnant at time of death
o Not pregnant, but pregnant within 42 days
of death
o Not pregnani, but pregnant 43 days to 1 year
before death
o Unknown If pregnant within the past year
32c. Plate of Injl.lIY: Home, Farm. Street, Factory,
Office BuildIng, etc. (Specify)
24. Time of Dealtl 25. Dale PlOllOlInced Dead (Month, day, year)
4:00 January 23, 2007
CAUSE OF DEATH (See Instructions and examples)
Item 27. Part I: Enter the ~ - diseases, injuries, or complications - that cIIrectly caused the death. DO NOT enter terminal events such as cardiac arrest,
respiratory arrest, or ventricular fibrillation without showing the etiology. Lisl only ane cause an each line.
~~A~~t~~~ d:~tW) dise~
a Gastrointestinal Hemorrhage
Due to (or asa consequence of):
Sequentially lisl conditioos, n any,
leading 10 the cause ~sted 00 line a.
Enter the UNDERLYING CAUSE
(disease or injury that initiated the
events resuhing In death) LAST.
b.
Due to (or as a consequence o~:
c.
Due to (or as a consequence 01):
d.
3Oa. Was an Autopsy
Performed?
3Ob. Were Autopsy Findings
Available Prior to CompIehan
of Cause of Death'
Dyes ~o
32d. Time of Injury
M
330. C,rtif.. (cI1ed< only one)
Certifytng physician .(Physician certifying cause of death when another physician has pronounced death and completed Item 23)
Tothtbe8tof my knowledge,death occurred due 10 the cause(s)and manner as stated- _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0
~;:u=~a;; ~~~~~~~=i:~~~~:~::~~a:~~I~=~~a~ manner as stated.. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0
Medical Examiner I Coroner 1'i7I
On the basls 01 examination and J or InY~lgetlon, In my 09tnlon, death occurred at the time, date, and place, and due 10 the cause(s) and manner as statecL JP"
Coroner
35. R
~
r's Signature and Dislrict~
/7) . '--%:? .4/1_
36.D,'1e lied (M!",~~, yeafl.,
I ~I /loZ 1/ j/ 1 /. ;::;S'>?I /
DI,co,Rlon P,,,,," No. Lf / /' i t /J _ .;-
33d. Date Signed (Month, day, year)
January 24, 2007
34. Na~rc"1l'!1~'fO't'.Wh~'r:f~ 01 ~~tl'mrb fP" I Prinl
6375 Basehore Road! Syite #1
Mechanicsburg, PA 70~0