HomeMy WebLinkAbout08-20-07
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
\N r...nNlNG' it n, illegal to duplicate this copy by photostat or photograph.
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2; 2007
RECORDED OFf'ICI': OF
REGISTER or; \\lLLS
2007 AUG 20 PM 3:31
CLERK OF \
~ :)RP~L\NS' COlJRTAf-~':'
CL\IBf"..RL\ND CO" P.\
H105.143 REV 1112006
TYPE I PRINT IN
PERMANENT
BLACK INK
COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH' VITAL RECORDS
CERTIFICATE OF DEATH
(See instructions and examples on reverse)
STATE FILE NUMBER
1. Name ot Decedent (Fil1il, middle, last, suffix)
3. Social Security Numbef
201 _ 16
2367
I' Cumberland
5. Age (last Birthday)
6. Dale of Birth (Month. day, year)
Other
82
Yffi
[jlnpalienl DER/Outpalienl DooA DNursingHome DResidence DOther.Specily'
9. Was Decedent at Hispanic Origin? []eNO 0 Yes 10 Race: Americal1lndian, Black. White, elc
(II yes, specify Cuban, (Specify) White
Mexican, Puerto Rican,elc.)
14. Maritai Status: Married,NeverMarrie<l,
Widowed. Divorced (Specify)
Widowed
ab. County of Death
Kind of Business/Industry
Sales Dept. Store
_ 16. Decedent's Mailing Address (Stree\, city Ilown, stale, zip code)
2100 Bent Creek Blvd
Mechanicsburg, PA 17050
Decedent's
Actual Residence 17a.$talll
PA
Did Decedenl
Live in a
Township?
17b. County
Cumberland
17,.Dyes,o"",,,,'''''. Silver Spring
17d. 0 No, Decedent Uved wlthln
Actual Umits 01
Twp.
City/Bora
19- Mother's Name (First, middle, maiden surname)
Esther Myers
'ib2'!r'"'A\'rtn'g'ny("lTith~y~"tft:kbersburg, PA 17201
16. Father's Name (First middle.last,sullix)
William Merle Stoops
2Da.lrl100nanl's Name (Type / Print) James D. Cullings
I
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nc.
o
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22c. Name and Address of Facility
Carlisle, PA
. ~
23b.licenseNumbel
23c. Date Signed (Month, day, year)
26. Was Case Referred to ~ical Examiner I Coroner for a Reason Other Ihan Cremation or Donahon?
Dyes ~
Approximate interval:
OnseltoDealt1
If Female:
Not pregnanl within past year
o Pl8Qnant allime 01 death
o Nolpregwrnt, but Pllll1'anI within 42 days
oIdealh
o Not pregnanl,bul preglllJ1l43 days to 1 year
before death
o Urlkoown II pregnanl within lt1e past year
32c. P\ace of InjUry: Home, Farm, Street, Factory,
QfficeBuilding,BlC. (Specify)
=~~~:~~~ ~~"tf!)diseas~
\/)
~l.
SequenliaNy li61 conditioos, if any,
~~o~~~~~edc~u~r: a.
~~~~~~h9~nl~ai~rx~+~
Due Ie (or as a consequence oil
d.
DY"~
oVes DNa
31. Manner 01 Dellth
~ral 0 Homicide
o Accidenl Dpendinglnvesligation
o Suicide 0 Could Not be Delennlned
32d.1imeofln;ury
329. Locatlonot Injury (Streel,cily/IOWfl,state)
3Oa. Was an Autopsy
Perlormed?
3Qb. Were Autopr;y Flndings
Available Prior to Complelion
of Cause or Death?
M
331. Certifier (check ooly one)
Certifying physician (phl'Sician certifying cause of death wnen aoother physician has pronounced death and completed Item 23)
To the beltot my knowledge, death occurred due to the cause(s) and manner a! ltated-_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - - -- - -- - - - - - - - - 0
Pronouncing and certifying physician (Physician both prDf'lOUncing death and certilying to cause ot death)
To the best ot my knowledge, death ocC1.lrred at the time, dele, and place, and due to the cause(s) and manner as staled- - - - - - - - - - - - - - - - - -
Medical Examiner / Coroner
On the basil of ell'lminatlon and / or investigation, in my opinion, death occurred at the time, dale, and place, and due to the cause(s) and manner 8S stated.. 0
tman
35.R
~
lei II lril 110 I
43
Disposition Permit No.