HomeMy WebLinkAbout06-12-06 (3)
HI(J:;.~O:; REV l/fl) fl d . h
This is to certify that the information here given is correctly copied fro~ an original certificate of death dul~. I e WIt me as
Local Registrar. The original certificate will be forwarded to the State VItal Records Office for permanent flhng.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00
~ ~ G>~'~J
Local Registrar
p
12497809
MAR 2 8 2006
No.
Date
r-'~..)
::-:--:-")
.,
".-....l
o
III
:>
~
~
. I"',)
Hl05. 1 <3 Rev. 2117
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEAlTH. VITAL RECORDS
CERTIFICATE OF DEATH
TYI'l!IPlIINT
IN
P_NT
RACllINK
NAME OF DECEDENT (FItII. Middle.l.u)
\\'\U t It. T
sex
..~
I.
-(1.01I_ _'YeAR
<:;If - ! ....
0\0 v... :
COUNTY Cll' lleRH
IIIRJHPt.ACE JCiOy "'" .
"'01 FCQlgI'I CDurwy)
PA
G..nl:a-Ia-rl
..
DECeDENT" llCCUPOnoN
~.=..:::.a:= :::.I...mor
I Pa::ka:- " Fl:x:x:l rrmJfatl.ltirg
DeCEllI!NT', --"ISO'" CI>fbMo. _zv~ DECEDENT"
~
AElIIDENCE
-
on~1idet
_1TArUI._
--.-
--
,.. Wicbve1
17',~ .....__ I.a..a:-
SUWIVING SPOuSE
(II wM. lJf\IemMIM netneJ
I.
Xl Beaver Pad
lL 0ripIill , PA 17011
-~.,-("",._l..o)
F. Oals
-(T~_
Fdnrd J. ~ Jr.
METllllOOF~
_0 =~",-o
I
.....
G..nl:a-larl
"...
...--.
...................0
f-~
.-
'--
: onuI and...
.
I
'S" 06
No%-.
""'"'---...........
nol:~In...~__...InPAFlTI.
DUE lO{Ofl All A COHSElXJENCE Of),
E
DUElO(lJRAIlACONSEOUENCE 0F)0
WEN' AU10HV RNDIHGa
AUllUkE PAIOA 10
CONPlE11ON (WCAUSE
Cll' IlERH?
UANNER 0# OERH
ORE Of INJUAY
1.......00y._1
TIME Of INJURY
INJURY M weAK7
DESCfU8E' HCMIINJUAV OCCURRED.
fa
o
o
Could not btI dIIl..-m/ned
o
o
o PLACE OF INJURY. AI home, farm, .;.... fadory. omc. U.
---
....
... 0 NoD
-
-
-
-
--"'"
....0
No~
~
~
l!l
~
I
_.
ClIIITIOWIICt.*..., _
.Cl!ATrtINQ PHftICIAIrI (PtlYK*'~ '*'-101 ca..t..... anoIher phyIictM has prOAClUl'lC8d deIIh ana compItt~ n.n 231
1it..............~.....OClCUIl'ed.........~..)aftdmliflfte,.................; ,..... ._................. ..... ................
...
'~AHOCBrrrf""PHYSICIAN(Ph)'SIClMboftDlOl"lOUnC1nOdOI'l.nd~ lOcaus.otdQlh)
To......... Of my 1uIowItdtt. dN1ft DClCUI'I'IcI at........ dati, Ind~. aM due 10 the ClUH(a) ........nMf'......... . . . .. . .. . . . . . . . . . .. . . . ..
1011:\. 1\ {'J 01
...