HomeMy WebLinkAbout05-15-07
H105.805 REV 1/05
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.
~frl~-
Fee for this certificate, $6.00
Local Registrar
p
13354857
MAY 1 ~ 1007
Date
TI'BM ,
~HnUl.f' RRA n AS FOLLOWS:
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1 PRINT IN
MANENT
ICI<INK
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
(See Instructions and examples on reverse)
-,~
82
May 18. 1924
7. .
3. Social SecufiIy Number
205 - 12 - 7997
Sa. Place of Death ChecI< on one}
Hospital: Olhec/
o I"""*,, 0 ER / 0ulpeIienI 0 DCA [B'Nursing Home 0 Residence OOlher. Spodfy:
g. Was ~ of HlspanIc 0ri\In? J:iI No 0 Yes '0. Race' _Indian, -. White, etc.
I" yes, Ilp8Cily CIilen, (Speci/)\
Melllcan, Puorto Rican, etc.} whi t e
14.~~~~_, 15.SuMvingSpouse(lIwffe,g;,emeidenneme)
1. Nome of OecedenI(FIr1l, middle, last, sufIIx}
Ann L. Boust
5, "'1' (lat Ilitlhdey) U- 1
VIS.
6. Dale of Ilirth Month, ,
81>. County of Death
Cumberland West Pennsboro Twp. G"
11.0ecedenf'UoueI of_done"""ol IIe,Donol_
KlndolWoll< KInd 0/1lusi1eu IInduslry
Re istered Nurse Healthcare
. ,6.-.r.MeiIing_ISboet,cily/_,....., zip code)
290 Center Road
Newville. PA 17241 17b,CounIy
16. Felher'. Nome (FIraI, middle, last, sufIIx) 19. Mother', Nome (FIraI, middle, meiden """"",,)
Donald Jose h Gensemer Florence L. Folmer
20a 1nItllmenI'. Nome (1Wle I Print) 2(I).1_'IlelIInlI- (S1reoI, ciIy ,_, -, zip code)
Chuck M. Boust 290 Center Road. Newville, PA 17241
21e.Me4hodofllispoeition IXIcromeIIon OOonallon 2'b.Deteol~(MonIh,dey,yeer) 2kPlaceollllsposllion(Nomeol_,aemetolyor-place}
. 0 _ 0 _fromSlale Wu~"--
o 0lher.Speci/y: I by_EumlIl8f/Coronor? lEIVesONo Evans Crematory
~ 228. perIOO acIIng as such) 22b. Uc:enII Nt.rnber 22c. Name and Address 01 FadIty
~ FD 013 340 L Parthemore FH & CS, Inc., P.O. Box 431, New Cumberland, PA 17070
238. To the ~ knowledge, deelh or:cuned at the line, dele erd.t"" slaIed. (Slgneblrl and,.., liIIe) \
/'jIl~<-~/ E LL~C:U K-tJ
_ 24-26 musI be CXlI1'4lIeted by pe!lKlIl 24. Time of De8lhPrf'? ~ "n ~l.<1 'f 25. Dele - Deed (Ilonlh, <ley, yeer)
__doe... 3';/!?I'M. {Y\tt! ~ d-OC?
CAUSE OF DEATH (See In_ one!. )
Item 27. PIlItI: Enlerthe~--,......' or~-lhetdlec:1ly<:aused lhedeelh. DC NClTentertem1inalevenls such ascaldacenest,
..,pratoIy anesI, or _, _ _ ohowIng the ~.lisl only one cause on eech ine.
==~=l~ . CA.Wl~~AAjlU\ (lu..Jo:A
Cue 10 (or es a ooneequence 01): -t- _ I J :. ^.. .
b. ~/U.o-:..t'lO/1~ Vr.1.Df'u,AAI\ ~
Due to (or as a consequence 01):
Widowed
0ec0den1'.
Aduat Residence 17a. Stale
[);d~
Uvelna 17c.K] V.._Uved" Upper Frankford
Townel1Ip? 17d.O No, _ Uved_
AcIuel'--ol
Twp.
CIIyIIlolO
2'd.lor:alion ICIly ,_, _, zip code)
Schaefferstown, PA 17088
231>. Lk:onee Number
I2NI'I1.:3j D I- ~ ,)CJb'l
26. WIB Case Referred to ~I Exarninel'1 Coroner lor a Reason Other than Cremation or Donation?
OVes [lliIo'"
Part U: Entefotherllloiflcanl.cordtknoontrb.Jllv:JtodeattL
butnoc resulling" the underlying cause given In Pe'l.
ApproJdmeI1I.....el:
OnsalloDe8lh
28. Did Tobecco Use CootrI:Ue 10 De8lh?
o Ves OProbebly
ijJ..H60-
~.".:
[lJ"NoIpI9!J18Il' within pest yeer
o Pregnenl el time ol doe&.
o NoIpl8gll8Il.,butp!8!JW1lwlthin42deys
oIdoeth
o NoIpl8gll8Il.,butpl9!J18ll143deyslo'yeer
---
O_'JI'8lllI8fllwllhinthepeslyeer
320. Place 0I1r1jurf Home, Fann, Slreet, Fac1o<y,
Qftlce Buiding, ate. (Specify)
_1Isl~,''''I,
IeeihtofwClll.llltlilledonlinea.
Enter itIe UNOER\.Y1NG CAUSE
=-~m~u.-
c.
Due to {or as a consequence 00:
300. Wes en_
-
o Yes ui' No
d.
3lM>.WeIe_Flndings
A__Io~
01 Ceuee of Deeth?
OVes ONe
31. ,.".. 01 Oeeth
8' Netutel 0 Hon'kide
o Accidenl 0 Pondng IIMl91igeIlon
o SUckle 0 Could NoI be lJetermlned
32d. Tone 01 tr;uIy
M.
33e. Ceo1rtlerld1eClloniyone}
. CertIIyIng ~ (PI1ysicien cet1ifyIng cause 0/ _ _..-. physiclen hoe pronounced <leeth erd oompleted Item 23)
T.... beetofmyllnoolodge,_oc:curredduelolheCllll8(alandmanneresetaled...- - - -- - - - - - - - -- - - - - - -- - - - - - -- - - --
=-=~=;="~"::'~~Iolo==manner..___________________ 0
. = =..= and I.. "-1lgetIon,1n my opinion, _ _ at the time, _, and~, and due to the CIIlI8(a) erd manner es......... 0
36.FIogistrI(,
~
1"'<1 / I ~ I /1/
; <ley, yes~
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