HomeMy WebLinkAbout04-10-07 (2)
HIO:;.80:; REV 110:;
This is to certify that the information here given is correctly copied fro~ 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 filmg.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
No.
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Fee for this certificate, $6.00
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COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
(See In.truction. end exemple. on rever..)
STATE FILE NUMBER
H1Q5.143 REV 11/2006
TYPE I PRINT IN
PE_NT
BlACK INK
l......."'_(FWsI._,Iasl,_1
Velma A.
5 Age (laslBirlhday) :
CI Dateof~(MonItl, , r
( andlllleOf
85
Oct 29, 1921
Bangor Maine
.. CounIy '" Dealll
Cumberland
11.OecedenfsUsull most 01 1te.00nolstatef8lir
KindcfWortr. KindolBuiineS$/1ndusUy
Homemaker Own Home
. 16. Oecedenc's UaiWIg Address (&reel, city I kMn. stale, ~ code)
513 Bar.ry Court
Mechanicsburg PA 17050
'I. Fa.....', Name (Firs!, middIe,last, suffix)
Roscoe Arnold
o Vos J8tio
Docodenr.
Aca!aI Residence 17a. Slate
14. Marital SIaIu&: MalIiecr. Nt'ltr MaltiecI,
-,-(~
Widowed
".. Courly
17c.!il Yes, Decedent Uvedin
"d.n- No. DecodenILNod....
",*",LiriIs'"
Hampden
T"l'
COy/Bow
2OiIInformard's Name (Type (Prinl)
Lee A.
19.__.......(,...,_,__1
Anna Belle
211>._sllailng_l_dIyl_,_,,.._1
2219 Peony Court Jamison
2".PIace"'~(l'OIme"'_._"'_plocol
Rolling Green Memorial
Buchanan
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PA 18729
21d L..-(COy 1-. _, ,.._1
Pa k Camp HIll PA 17011
22c. Name and Miress of FaciIIIy
MYERS FUNERAL HOME 37E MAIN ST MECHANICSBURG PA 17055
23b. Ucense Number
23c: 0... SIgned t-, day, -'
25 0aI0 _ Dead <_, day,...1
1/', !S"" ........\...."','-C \9 ';lM>7
CAUSE Of' DEATH 1_'0_ ond "_1
1lem21. Part t Eme. lie rlIiIUllntilll- diseases, f1juries"Of compIicalions - ftallirec.1y taU5id IhI dealll. OON01 enIef lerminal evenls SlIdl as caJOic arrest,
respiraloly arrest, Of yentficlJlaf ibriIalion wiIhoot showing the ebOOgy. Us! only ooe cause on each line.
~~cI::~I""::'. P\'1tU.\li-1{l(,t(~
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s._'~_,'any, b L.-Ive..-- r~; ILA>"<...
r= ~"':ldcA~ a Due 10 (or as a con&equ&nee 01):
=~":.=I'"
1lems2H6mtJ5iblil~bypef5Oll
whoprorlOUl'lC8$deattI.
26. Was Case Refefred to Medical Examiner I Coroner for. Rea$Oll 0Itler Ulan Cftmation or Donation?
OVe. Jiil'o
........--
Onset to Oealh
Part.:E,*",oUlIf~oondlIianlta'llIiMJtiMlod8alh,
bulnotresullinginh~QJijse~InPartI.
28.D;d T-.o "'" CooIriOule.. 0eeIIl?
Dves OP""""'!I
ONo~
29.~....
[J"1iQcPf89'\al'llwillWlpasl)'Nl'
o Pregn...e/...."'_
D No! Pf8lJlOUll, bUt prl9Wll wiIhln 42 days
"'des"
o NO<.._,....._""""..,...
Woredllall
o Unllnown If pI&gIWlI ~iUwllNI past 'jUf
32c. AKe d 1niufY: tbnt, F;um, SIteel. Faaory,
OIiceBolding.elclSp>cilyJ
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Due 10 (or as a consequence 01):
d.
o Yos 0'"
o Vos Ul!P"
31, Manner of Oeith
~;'e1 D-
0""..,' 0 P"""",,to,,_
o Suoode 0 Coold Nol be 0._
32d.fmecflnfulY
329. L..- "'..." (5IreeI,,,, /-,-1
30&, WasllllAtAopsy
Pel1onr.ed?
3Oll.WereAuklpsyFIndings
AvailabklPrioffoComp6e1ioo
c4CaWi801 Oealh?
M.
33a Colnitier (chedt CI1Iy ooel
Certify... ph,siciM (Ph~liIC.an cWyiog cause 01 dealh when anoIher ph}'SlClafl has p'llOOUrIl;ed dealh and ~ lIem 2:3)
Totht beslof m.~..... occ:UMd dut 10.... ClUM(a) Hd......ner II aII&ecL.................................... _....................... _............................
~~: ~=~saa;::..:.~~~~~~~.:::~to..:=~::,manner IIItIIecL ___ _ _ __ __ __ _ _ _ __ _ 0
MedicM EumiMr I Coroner
On.... but. of ...amiRaliot't end I Of "'IItsUgahon, VI. my opInion,..ttt ocwnlKl at the time, dU, and pIKe, and due to... CIUH(I) and nianner IIItItecL 0
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