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H105.805 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.
No.
,~/Jl~
Local Registrar .
Fee for this certificate, $6.00
p
13354581
MAY 0 8 2007
Date
Q
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COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
(See Instructions and examples on reverse)
.-,
.,
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I REV 11!2006
IPRII'ITIN
MANEI'IT
ICK INK
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STATE FILE NUMBER
o
. 16. D.-nrs Maiing -... (51..... cIly flown. stat., z~ code)
483 Woodcrest Dr.
chanicsbur PA 17055
16. Falhor', Nome (FIrst, mIdcIe. lest, suIIlx)
12. Was Decedent ever In the
U.S. Armed Forees?
OYee
Decedenf,
ActueI Reeidence 17.. Slat.
13. Decedenrs Educallon (SpeciIy on~ highesl grade compleIed)
EI."'iil Secondary (Q.12) College (1-4 or 5->)
4. Dale of Death (Month. day, yeer)
2512 Ma 2,2007
1. Nome 01 DecodenI (FIrst, _, I"', suIII,)
Lillian A. Wallower
5. IqJ (Last Blrthdey)
96
6. Date 01 Birth (Month, . year)
7. Birthplace (City and slBl. or
Yrs.
Apr. 23,1911
Arendtsville,PA
DOIher . Speclly:
10. Race: American lndia11. Black, While, etc.
(~
wnlte
8b. County 01 Oelllll
11. Oec9denrs Usual
Ki'ldofWOf1t
Mechanicsburg
_01 1IIe.DonolsIB~reti
Ki1dol_11ndusIry
8d. FdIy Nome (11 nol_, give _I and..-r)
Seidle Memorial Hospital
14. Marital Status: Married, Never Married,
W_, OMlreed (Speci/)j
widowed
17b. CoooIy
PennsYlvania
Cumberland
DId Decedenl
Live In a
Townsh~?
17c'j;es. Oecedenl Lived In
17d. ,_UYed' .
Ai:ttJltUmltsol ~echanlCsburq
TW!l.
City I Boro
Calvin Orndorff
19. _', Nome (ArsI, _, maiden sumeme)
Emma Elizabeth Schlosser
2Ob. Inlolmenf, Ma1Ing Address (Slreet, cIly 1_, _. Z\l code)
12 Nature's Crossing, Enola,PA17025
210. P1ace 01 Dispor;tion (Name 01 cemetery, Clemaloly or_ ~ace)
Rolling Green Cemetery
21d. locat1an (City f_, sIBle. zip code)
Camp Hi11,PA17011
20&. tnformenfs Name (Type I Print)
22<. Name and Address 01 FaciIIy
Musselman FH&CS,324 Hummel Ave.,Lemoyne,PA17043
23b. lioense Number
23c. Dale Signed (Month, day, year)
Items 24-26 m... be oornpIeled by person
. who pronounces deBth.
26. Wu Case Referred to Medical Examiner I Coroner lor a Reason Other than Cremation or Donation?
DYee DNo
Due to (or as I consequence ot):
I Approximate inIervat:
I Onset to Death
I
I
i / n-,tJ.,/t,
I
I
I
I
I
I
I
I
I
I
Part II: Enter other sianiflcant condtions conbibtiino 10 0MItI,
but nol resulting in Ille undertylngcause!t<on 1\ ParI!.
Due to (or ee a consequence 01):
Ar;/;. IITA/
bTO /l-SVj)
att! ~vA r 1~~/r~
28. Old ToI>acxo Use CootribuI. to Dealll?
o Yes D~
[B"No 0 Unknown
29.11_:
I3"NoI pregnenf within pa~ yeer
o Pregnant at lime 01 dealll
o Not pregnant, but pregnant within 42 days
ol_
D NoIpl81jIl8I1l, but pragnent <3 deys 10 1 yeer
beIore_
o Unknownipl81jll8l1l_lhepeetyeat
32c. PIaee of InJury: Home, Fatm, Slreet. FadOlY,
0ft1ce BiJldng, ate. (Sped/y)
~~~:'~\d~
a.
_lialconclllons,i8IYY,
Ieadino to the cause IisIed on Ine 8.
EnIef!he lINOERLYING CAUSE
~~~~~
b.
d.
DYee ~
:lib. Went ""- Rndngs
Aval1eble PT1o< to Completion
of Cause of Death?
Dyes DNa
31. MeMerol Dealh
q:(Nalul8l D-
O _nl 0 Pendilg Inveeligellon
o Suicide 0 Could No! be Detemined
32d. Trme 01 Injury
32g. Location oIl~ury (SIreel. c1Iy Ilown, sIB~)
3)a. Was an Autopsy
PerIormed?
M.
35. RagisIrer'
~
1c11/ 10(1/ I"" I
DI,,,,,,1ion Permll No. L5 / / L 9 :f E-