HomeMy WebLinkAbout03-24-08
HI05.805 REV 101107,
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00
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14124987
Certification Number
This is to certify that the information here given i:
correctly copied from an original Certificate of Deatl
duly filed with me as Local Registrar. The origina
certificate will be forwarded to the State Vita
Records Office for permanent filing.
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Date Issued
Local Registrar
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Hl05.143 REV 11,2006
TYPE i PAINT IN
PERMANENT
BLACK INK
COMMONWEALTH OF PENNSYLVANIA' OEPARTMENT OF HEALTH' VITAL RECOROS
CERTIFICATE OF DEATH
(See Instructions and examples on reverse)
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CAUSE OF DEATH (See Instruction. and examples)
Uem 27 Part l: Enlef tha ~~ ~ diseases, illjunes, 01 complications -that difectly caused !he death_ 00 NOT enter terrrunal events such as C<lldiac arrest
respilalory arrest. or V9f1tOcular librihation wilhoul showing the etiOlogy. list only one cause on each line
I Approximate inltirval:
: Onset 10 Deatl'l
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Due to (Of as a consequence of)"
Sequen~a~ list condrtioos, it any,
leading 10 ltIecause .sled on kne a
fmer tw UNDERLYIHQ CAuSE
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Due 10 (Of as a consequence o~:
OI.IEI to (01' as a consequence of):
JOa_ Was an Autopsy
Perlormed?
3Gb. Were Aulopsy FiIldngs
Available Prior 10 Comple\lon
01 Cause otOealh?
Jl. UaM&r 01 Dea!b
l':5-~tlJral DHomiclda
o Accidenl 0 Pending Investigaboll
o Suicide 0 Could Not be Determined
..
32f./I''''''''"''''''''Ini"'YISpociIy)
o Driver I OperalOf 0 Passenger DPedes.trian
Of.., . Sp<<i/y.
33b. Signature and Tille~oI cer1i1iet
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DVes
B<lo
32d Time of1rlJuI'j
33a CMilier (check only one)
Certifying phws1clan (PhysK:ian cenltymg cause ot death VrhtHl another physlUan has prOllounced death and comp:eled \110m 23)
To lht be,tot my knOWMdge, death occuned due to the cauH(s) and manner.. silled.. _ _ _...... _ _ _ _.. _ _ _ _.. _ _ _.. _ _ _ _ _ _ _ _ _.. __
~~ol~OU::~~"'~~ :=J::::C~:~:~~ :~:~l,~~~n;=~:~~~~ot':::~:~~ manner.. staled_.. _ _.. _ _ _.. _ _ _ _ _ _ _ _.. 0
~:.aI ~:~':7:~~O:: Ind I Of Investiiation, in mW opinion, death occurred at the time, date, and place, and due to the cause(s) and manner.. staled.. 0
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Part II: EoteJ other siCll'liflCanl concilions contribulina 10 deaIh,
but not resulting in Ihe under1ying cause giVlKl in Part I
28 Did Tobacco Use Cootnbute to Oealh?
o y" DP'''''''''
o No 0 Unknown
29 It Female-
o NoI:Pfegnant WltrIn past year
o Pr~nl athme at de~1h
o No! Pfegnanl. but preynant Wllhlfl 42 da~
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o Not pregnanl, bul pr&gnant43 days k> 1 year
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o l..Ioknownitpr~amwithifllhf;paSlr"'"
32C'=~::'i~)~eet,Fac1ory.
32g. Localion of Injury IStreet, diy/town. slaleJ
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