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H105.805 REV 101/071
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00
-.
P 13858487
Certification Number
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.
~4't.. /?l ~444 <7 SEr 1 S J007
Local Registrar Date Issued
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REV 1112006
I PAINT IN
MANENT
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COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
(See Instructions and examples on reverse)
STATE FILE NUMBER
4. Date of 00a1h (_, day, lOar}
September 14,
2007
6. Date of _ (Monlh, da ,
1/11/1927
Altoona, PA
80
VIS.
Sd.FadlilYNamo(nnot_,glvesllaelafld_)
80. County of Ilealh
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()''""\ 0 ~q S-
1730
OO!her'Specify:
10. Race: American Indian, Black, While, etc.
~te
Cumberland Twp.
II.Daclldonr.UtlJaJ Kildofworkclone _of 1Ia.Oonotslale
KI1d of WOO< Klnd 01_' IndualIy
Brakeman Conrail
. 16. Oacadenl'. MaiIng _1_, clIy ,_, -, ,..-}
401 Valley St.
Summerdale, PA 17093
16. Father'. Name (Flrsl. midcle, Iaat. suftlx}
Dale England
208. ~. Name (Typo I Print}
Thomas England
21aMelhodof~
Select Specialty Hospital
12. Waa Dec8dont _ in !he 13. Decedenr. E.....llon (Specify ClI1ly highes1 grada completad)
u.Sgg~"O~ Etemenlary I TIndary (0.12) CoI1ege (1-4 or 5+)
=-""~ 17.. SIllle P A :: ~l 17c.119 Yes, Oecadonl lived in
Cumberland T_~7 17d.0 No,_llivedwrthin
17b. Counly Ae1uai Lin1its of
Ig. Molher'. Name IFilal, _, maiden aumame)
Margaret Oyler
2Ct>.lnfonnant'.MalIngAdth8sI_clIyl_,_,"'-)
306 Berkshire Rd. Mechanicsbur PA 17055
21c. Place of Illsposl1Ion (Name of cemetery, aemaIoly Of _place} 21d. l.ocallon ICIly ,_, slate,,.. code}
East Pennsboro
Top.
CIlyIBoro
Upper Allen 'lWp. PA 17055
. ~
Gate of Heaven Cemetery
29 S. F.nola Dr. F.nola, PA 17025
:
__ 2"26 """ be ~ by person 24. Time of Ilealh 25. Date _Deed (Monlh, day, year)
. "",,,,,,,,,,,,,,,,_, 2240 M. Septenber 14, 2007
CAUSE OF DEATH (see Inotructlon. and ..........)
It8m 27, Pert I: Enter Itle -.oLoltIllII- diseases, injuries, Of complications -Ihal ~recIIy ~ Itle _. OONOr enter _...... - aa ca_ anee1,
.- anaet. Of1llllllllcUer _lion wiIhOul showing !he elloIogy. UsI ClI1ly OM cauae on _ uno,
,Approximelein1elVlll:
: Onset to Death
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a.
Due to (or as 8 consequenc:e 00:
_ielconcI1Ione,iany,
IeIding to h cause IIst8d on Joe a.
Enter !he UNDERLYING CAUSE
=-~m~_!he
b.
Due to (or u a consequence of):
Due to (or as 8 consequence 01):
300. was an Aut_
petfomled'
d.
3lXl. Wefe Autopsy Ftndngs
A_PriorloCompIelion
01 Cause of Oealh?
3Uta_ ofOealh
DNalura/ D-
O_IOPendinglnvestigalion
o SWckIe D C<l<4d Not be Iletermined
M.
DVes ONo
OVes ONo
32d. Ttme of Injury
330. ~ (cIIeck only one)
=r.r.:"~==:"~Itte~ano:;"''':=h:~_~_~~~~2____mm____m D ~
:~~=~~;:"~...~~:~toto==_.___________________ 0
= =.= and 1",In-'lQotiOn, In my opinion, _ __ et Itte time. _,'" pIoca,'" due to Itte causo(s) afId...nner es etetacL 0
I ~.I1 .Pl.1 / II I
23b. LJcense Number
230, Dale SIgned (Mortlh, day, year)
26. Wes Case Referred 10 Medical Examiner I Coroner 101'. Reason Other than Cremation Of OonItion?
o Yes j[J No
Part It: Enter other fllMiIIrAnt rnndIIons CMtrb.1Iim ID d8aIh. 28. Did Tobacco Use Contribute to Death?
but noil9SUlli1g in !heundollyingcauaeglvon nPertI. 0 Yes OP.-y
o No D Unknown
2Y. II Female:
o Not pregnenl wllhin pasl year
Ol'tegnanlallimeofdeatll
D NOf pregnant but preglSntwllNn 42 days
ofdeelh
D Not pregnant, bul pregnant 43 days to 1 year
beloredea'"
o Unknown! ~ _n!he pasl year
32c. Plac& of InjufY: Home, Farm, Slreet, Factory:
0II'<e Building, etc. (Specily)
lh, day, year}
01
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