HomeMy WebLinkAbout01-16-07
H105.S05 REV 1/05
This is to certify that the intormation 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.
13UL4757
No.
~l'?'f~
Local Registrar
Fee for this certificate, $6.00
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JAN 0 9 2007
Date
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PElPAINT IN
oRMANEHT
ILACK INK
,. Name of Oecedent (First. middle, Iasl) 12. Sex ~13. Soc~1 Socu,;ly Nurrbe< I' Daleo' Dealh (Mo,". day. yearl
Janet J. Murphey Female '360 - 18 - 5585 January 7.2007
5 Age (laslbirthday) 6. Under 1 vear Under 1 ds 7. DateolBirth Month,ds, ear 8 Birtholace rcilv and slate or bre '" I Sa. Place of Death Check anly one
80 I Months Days Hours, Minutes j D b 13.192~ Chicago.Ill I ~OSPital: I Other: X Residence
Vrs, ecem er o Inhalient o ERIOolnslienl o DOA 0 NurSina Home o Other"Specjfv;
. Bb. County of Death Be_ City, Boro, Twp. 01 Death I~' Fa;~Na;~~:~rtu;':~I'eela'd'Urrbe'l 9. rSN~ec~en~~ ~1~::s~~O~1:~uban, 10_ Race: American Indian, Black, 'NMe, elc
(Sper:if;j
York Etters Mexican, Puerto Rican, efc.) White
.
It Decedenl's Usual OccLj)8tkm Kind of work done durin erosl of workino life; do nol slate retired 12. Was Decedent ever in the US 13. Oecedenrs Education eciry on~ hiahesl orade oorroMfed ... Marital Status: Married, Never married, t5 SUNiYino Spcmse (!I wife, give ma.den name)
Teach~J:!oIW"k lG KindOf~in~nduw Armed F01? I ElementarylSecondary (0-12) ! 4 College (H or 5+) WKloW<d~""<rc (S~
reenW1C on o Yes No 1 owe
. 16. Decedent's Maifing Address (Slreel, cilyll.own, slate, zip code) Decedent's Pa Did Decedent t7c.M MonroE"
717 Oak Hill Drive AclualResidenc8 lla.Slale live in a Yes, Decedent Lived in Twp
Townsh~?
. Boiling Springs. Pa 17007 Cumberland 17d.O No, Decedent lived w~hin
17b, County Aclusllitrits ot City,{Joro
18. Falher's Name (First. n-idd!e, IaSl) " ~ "I- " Mother's Name (First, middle, maiden surname)
William Johnson Irene Honsaker
208_ Informant's Name (Type/print) 2Gb. Informant's Mailing Address {Street, cily..1o~n, slale, z~ Code}
Diane M. Land 1744 North Adams Street Pottstown.Pa 19464
21a_ Method of Oispos~ion 21b. Dale of Disposmon (Mon/h, day, year) 21c, Place 01 Dispo~ (Na~ of cemeleJt.cr8mal~ or olhe, place) 121d. Locat", ICity"". stale.,~ code)
. o Burial d{ Crermtion o Rerl'Xlval from Slale o Donation January 10.2007 Hollinger.,6\ematory Mt Holly Springs.Pa
o~;
. t!2I. ~al Service Uce~e (Of Pzacting as such) 122b~~~~;7~L 1 "c. Name BOd Address 01 Facility ... 1903 Market Street
. ,,7~L. Myers-Harner Funeral Home Inc Camp Hill. Pa 17011
CorrI>I.ele n... 23a"C.O'''''''''' cero~inq 23a. To Ihe basI of my knoWledge, dealh occurred allhe time, dale and place slated. (Signature and title) ~. Lie.ensa Number 23c. Dale Signed (Monlh, day, year)
phYSICian is not available attirne 01 dealh \0
certily cause of death.
. Ilems 24-26 fTkJSl be CO"llleted by person 2' Time of Death 125 Dale Pronounced Dead (Monlh, day, year) 26. Was Case Referred to II Medical Examiner/Coroner'i'
~ who pronounces death //: .yO hZ M p)6 Yes o No R.HI!
CAUSE OF OEA TH (See Instructions and examples) Approxima.teintl;lrvel' Part II: Enter other sic:mil\canl condilions contrihutina 10 death, 26. m:l Tobacco Use Conlrbute to Death?
~em 27. Part I: Enter Ihe ~ - diseases, ;n~ries. or co"lllications -thaf directly caused the death. DO NOT enter terminal events such as cardiac arrest, onset to death but nor fawning in Ihe underlying Cause given in Part L DYes o Probab~
respiratOl)' arrest, or lIentri:ular fibr~lation without showing the efiology:OO NOT abbreviale. Enter only one cause on a line. o No o Unknown
IMMEOlATE CAUSE (Final disease or J'I! J?I /tS'jtrfJ.:.... ~--rv"cIh'Z"'J rvo ,'A,1 .t.....ull/G 29. If Female;
cood~lon resu~ing in death) ~ a. . o Not pregnant within past year
Due 10 (or as a consequence o~. o Pregnanl allime 01 dealh
Sequentialty Iis1 cond~ions, if any, b. o Nol pregnant, but pregnant within 42 days
. leading Ia /he cause lisled on lile a Due 10 {or as a consequence on: ofdeatl1
Enlet the UNDERLYING CAUSE
. (disease or injury thaI initialed the c. o Not pregnant, bul plegnant43 days to 1 year
events resuning in death) LAST Due 10 (or as a consequence oQ; beloredealh
d o Unknown if pregnanl within the past year
308. Was an AulopSy 3Ob. Were Autopsy Findings 31. Manner of Death 32a. Date 01 Injury (Month, day, year) 32t>, Descrbe how Injury Occurred: 32c. Place of Injury: Horne, Farm, Street, Factory, Office
Performed? Available Prio, to Cofl1lletion o Natural o Homicide B<iiIiing. etc. (Spoc1j1
of Cause 01 Death?
o Yes j( No DYes o No a Accidenl o Pendin{llnvestigalion 32d. Time 01 Injury l32e. "~~ al Worl<? 321. If Transportation Inj1Jry {Specif)'l 32g. location (Street cityrtown. mte}
o Suicide o Could Not Be Determined DYes DNa o DriYer!Operator o Passenger
M. o Pedestrian o OIher - Specify:
J3a. Cel1:ffJer (check only ons) ;;rr;::\J..l
Certifying physk:lan (Physician certifying cause of death wtlen another physician has pronounced death and completed Item 23) <:: flj
To the best of my knowledge, death occurred due to the cause(s) and manner as slated .................... ..................... .............. ............ ............ ...... ..............................0
Pronouncing and certifying physician (PhYsician both pronouncing death and certifying 10 cause of death) 3~urrber ........ 33d_ Da!&SiQjIMonlh. day. year)
To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner as stated .................... ...................... ............. ....~ MD OJ07a7& //6" '2.00'/
Medical examiner/coroner " Na;!fnd~ Person Who Co~d ca,use of Death (1Iel!l27) Typ~rint
On the basi$ of examination andlor Investigation, in my opinion, death occurred at the time, dale, and place, and due to the cause(s) and manner as stated ........0
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V See instructions andexao)' les on reverse)
COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH STATE FILE NUMBER
o ItJ~~O 7
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