HomeMy WebLinkAbout05-16-08
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LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
P 14394478
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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.
fee for this certificate. SfJ.OO
Certification Number
',~. ~~~~p 15/2008
Local Registrar Date Issued
,10
H105-143 REV 1112006
TYPE I PRINT IN
PERMANENT
BLACK INK
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COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
(See Instructions and examples on reverse)
1. Name ot Decedent (FIrst. middle, last, suffix)
Top.
Martha B. Markley
4. Date of Death (Month, day, year)
March 13, 2008
5. Age (Last Birthday)
12. Was Decedent ever in the
U.S. Armed Forces?
o Yes IJb;o
Deoedenf,
AclualResideoce 17a.&ale
PA
6. Dat~ 01 Birth (Month, day, year)
9;124/1925
82
00lhe' . Spec;~.
10. Race: AmefIcan Indian, Black, While, etc.
fflte
V~.
ad. Facility Name (If not iostitution, give street and number)
Thornwald Home
Bb. County of Death
\ . Cumberland
13. Decedenfs Education (Specify only highest grade completed) 14. Marital Status: Married, Never Married,
Elementary I Secondary (0-12) College (1-4 or 5+) Widowed. DIvon:ed (Specify)
12 3 Divorced
Did Decedent
live in s
Township?
most 01 1Ile.00notstate
Kind of Business I Industry
11.Oecedent'sUauaI lion
Registw~d
. 16._I's MaHklgAddl'" IStreel,cilyl_, state, zipcalol
442 Walnut Bottom Rd
Carlisle, PA 17013
16. Father's Name (FIrSl. middle, last, suffix)
Walter BarriCk
17c. 0 Yes, Decedent Uved in
17d. ~ ~~tofUvedwithln
Carlisle
C'nmberland
17b. County
C<lyIBoro
19. MoIheI"s Name (FIrst, mldcIe, maiden surname)
Pearl Kramer
2Ob. Informant's MaiHng Addr8s& (Stnlel, city I town, stale, zip code)
100 Brandywine Ln. Ickesburg,
'tJpp~~t"an'tt'&~~h
Cemeter
208. Informant's Name (Type f Print)
Shaune K. Markley
c
3
00
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I ApproxImateinlerval:
: Onset 10 Death
~I
,
~oJtyft.-.
tft~t..:.
21a. Method of DispOSillon
e PA 17241
23c. Dale Sigled (Month, day, year)
hems24-26mtJStbecomp4etedbyperson
who prtlfICU'IC8S death.
Part I!: Enterotherdmlftr.anloonllllonsmntribullrMJtod98lh
butnol resuIlIng in the undllI1ying cause giv9n in Part 1.
28. DidTobacco Use Contribute to Death?
DVes 0--
~ No 0 U"known
29. It Female:
l4 Nolll'99"'''"",,"pestyea'
o PregrIar1l.ltimaoldaa~
o NolP'8ll"''',bul-""willlin42daY'
ol_
D Nol_bul-""<I3daY'tolyear
bafuoedaa~
o U"known W -"""'" '" pest year
32c. Place of Injury: Home, Farm, Street, Factory,
Olllao.....og,all:.(~
CAUSE OF DEATH (See Instructions and examples)
tlemZ7. Partl: Enterlhe~-liseases, injuries, orcompllcations-thal cirecIIy caused the deaIh. 00 NOT enterlerminal events such as cardiac arresl,
_"'Y'_"'_'ild'tioo""""'~~OO_""
~=~=~~ a. U'-
Due to (or as a consequence 01):
_ial_, I any,
IeatinatotheCllUllJlistedonllnea
Enter !he UNDERLYIfG CAUSE
="'~=~~
b.
Due 10 (or as a consequence 01):
Due to (or as a consequence 01):
d.
308. Was an ALiopsy
--
3Ob. Were ~ Flrd1g8 31. Manner of Dealh
~:~~~ ~NabnJ D~
0- oPel1dlngI""",gatioo
0- DCooklNotbaDel.......
M.
oVaa ~No
oVaa oNo
32d. Tme 01 Injury
321. WT_tioo1,*",,(SpecIfy)
o Drivar lOpe"", 0 P8aseoga< DPedaalrla"
oOthar._
33b. Signature and TrtIe
32g. location of Injury (StIMl, cily f kMn, stale)
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33a.Ce<lllie<lcheckoolyooo)
c.tlfytogp/lytlcion(__....olclaa._'""""_has_claa~'""_ltam23) ~
To IN belt of my 1mawIMgI, deIth 0CCtItf'8d dutlo the C8UIl8(s) II1CI manneI' as stated.. _ _ _ _ _ _ _ _ _ - - -:- - - - - - - - - - - - - - - - - - --~
:=:.-==.~~~;:::~and~~=toto=~~a~mannerll statecL___ ___ _ __ _ __ __ __ _ 0
==== IIInd lor investigalion, In my opinion, dIattl occurred at the time, date,and place, and due to the cause(s) and manner as sl8tecL 0
33c. Ucense Numbel'
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34. NameandAfldress~f~rsClI').....WhoComple~CauseofDeaItl (Item 27) TypefPrint
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