HomeMy WebLinkAbout04-17-07
H105.805 REV ]/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 is illegal to duplicate this copy by photostat or photograph.
No.
~~~~
Local Registrar
Fee for this certificate, $6.00
p
13523714
~f,
)., 00 7
Date
:x"& ~ If: f ~~Odfj 'j!
Jc)hN . O/et"Sf/
R,I(.
(")
~O
:'c=-:J:J
..:,J-o
T-rO
....,,~h:;
'-/) ~
_QO
_ )"-~Il
.~c
::0
'T] -4.
)>
r--.:>
c::::i
=
.......
>
-0
:::0
-.l
::2
-""
w
.::-
~
~
;t
COMMONWEALTH OF PENNSYLVANIA 0 DEPARTMENT OF HEALTH 0 VITAL RECORDS
CERTIFICATE OF DEATH
(See instructions and examples on reverse)
aQS.143REV 11."2006
TYPE I PRINT IN
PEAMANEHT
1llACl(N(
!
Twp
COj/llo<o
D'es DNo
31. Mamer of Death
_NaIUla! OHoo1icide
0-1 DpB<lding11WeSliga\i<ln
o 50_ 0 Coold... bo D,'o"n,ned
23<:. Dolo Sipd _, de" ,..,1
RN ~O~\<tOL V'''(I~U-.... \~ ,.9.0011
26. Was Cue ReIemtd 10 Medc:aI Ewriner I Coroner tor. Reason Other IIan Cren\alioll OJ 00nIIi0n?
DYes fijlNo
Approxima1e n.v8l: PIIt.: EM oUler sicwliicant cmdIIim& conIdUi'lo: 10 dMII\o 21. Did Tobacx:o Uu ConIti:lJM 10 DeaIh?
Orisotlollea~ bU....~~..'""""'Ying.....givon.PenI. 0 YM DProboIlly
~No 0"""-
29." Female:
0...1"_10......,,,,
o P_"Iime~"'''
o ...,,_, buI 1"_........."
~-
D NoI:pregnant,buIpregnant43daysM)ly..
.....-
D_w__...........
32<:. PIece ~.........., Fantl, SlrooI, F-.,
Olke BUldOg..... I_I
25. Dolo P.......... Dood 1_, dey, you)
A... (Y\0J\.0h \'-\ ~OO'I
CAUSE OF DEATHC_ __.... .'_1
l181n 27, Pan t: Enlir" ~ - diseases. iI1uriN, 01' COII'IpIicalion -1haI dinJdIy caused Ihe dlNih, 00 NOT enIef temlnaI events such as caniac arresI,
respiralol'y wrest, Of \/enlficular librlalion without ~ ile eliology. List Ofiy one cause on,each h.
~=~=...~ .
COR.ONItR.Y A Il.Tfi.Jly V' SoB/HE'
Duo 10 lor... cooseqoenc:e oil. A/'/ ~
b. CD,,,&~sllv(; HYrIl-T rAtLIJ(fi,
Due 10 101 as a consequence 01):
$eQueoIiaIvtslcondtUoos. ~ any.
INtino 10 ... WlUW IiQed onQ a
Bier hi lII:IEAlYIG CAUSE
L=-~~~LIi~
Due to (or as a consequence (1):
d.
301. was an Ar.ltopsy
P_1
3lI>. Wtie """"'" f'rdings
AvailablePriorIO~
01 Cause at 0eaIh?
DY" ~No
32d. Tlmltoflr*-'Y
33a c.mier I""'" """ onel
. =:::.."J::~:*~ca::.~...w:.aoo:;-.:=~~_~~_~~~~~...._.._____________ 0 ..
. ::=:.:=~.::::=::.:..~:~.:::tk).:=~~ thinner .ullled.......... ___ _...... ___...... 0
. IIHlcII e.......... I Coroner .
On the buIt of examinItion and / OIIn"I'Ugation, In my opinion, dulb OCCUl'~ at the lime, da", and pIIce, .nd due 10 the cause(.).,;d manner 11....._ 0
M
32f. KT'_lion..... I_I
o !loW" I """... 0 Pa_ 0-
0lheI-_.
33b Signa/uIoandT"~CeItiMI
J2gl<lcelion~.....(_,..,,_,.....)
330. Lkenae_
!;;
~
'g
~
!
I!.olr.