HomeMy WebLinkAbout06-23-08 OCAL REGISTRAR'S CERTIFICATION OF DEATH
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Fee for this ccrtihcate. $(,.f)(l
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Certification tiumbcr -----
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113 REV 11.2006
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PERMANENT
BLACK INK
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'This is to ccrtif}~ that the information here given is
anrecUy copied from nn original Certificate of Death
duly filed with me as Local Registrar. The original
certificate will he forwarded U> the State Vital
Records Office f~tr permanent filing.
Local Rer~istrar Date Issued
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH ~
(See instructlone and examples on reverse) STATE FILE NUMBER
1 Nano of Decwknl (fxsl, coddle lass. sunaj 2. Sax 3. Sucal Secunly Number 4 Data of Death (Month, day. yeah
~ 5 ~_ -~ ye o.tia ~. y/I c~79 -2. - 17f3 3 S o
5 Age (Last Bdhday) Uwler 1 year Under I day 6 Data of Birm (Month, day. year) 7. &rlhplace fCky ant stale w lanai n country) 3a Place of Death (Check o one)
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MonIM DaYS Maws N,nutea
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Yra . /`• ) 7/z / r ) ~(/ t ~' L~J InWlrYnl ^ Efl / OulVatwnl u DOA " NurYUg Roma ~~ Noa,danra (7Olher Spac,ly.
Bb County of Deam &. City, Boro lwp. of Death Bd. Facility Name (n not mslaulxw, give seeel and N 9. Was Decedent of Mispanec OnginP ~ No ^Yes 10. Race. American Indan, Bach, wrma. ex.
~ (II yes, specify Cuban,
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II Daedenfs Usuxl Occu -Iron 'N,ntl of wolA tl onz duns moss cal woekin bee Do ,w1 sale retired 12 Was Decedent aver in Uw 13. Decerknl's Educatio (Specify Doty hlgnesl grade canp eletl) t4. Manal Salus. Maned, Never Masora, l5. Survivug Spo use (If wrle. give maiden name)
K,nd of Wolk Km
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of Business i Inquslry US. Armed F
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ces? Elementary (Secondary f0-12) College (1-4 or 6+) Widowed, Divacad (SpBCiM
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t6. Deced¢ is Maeng Address ISteeeL cdY / town 1 te, rip code) Decedent's p Did Decadem ,},,, ~ j f
Pfd Live n a
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/-~ ~~ L~fNS F G~• 17c.{y Yes. Decedent LiveO n
Actual Resilience 17a. gate
Twp.
Townanip? '
r 1 L _ V / "~ t7b County [ (~ x'17 ~, [~ 1~~.,~ 17tl. ^ No. Decedent L,ved w,min
Actlul Limits of CnV ! Bao
18 Falt~el s Name IFi151. meddle, last. SuU,x1 19. Mother s Name (First m,tldle, maiden sumamel
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20a Inlormanys Name (Type r Print) 200. Inbmlanl's Ma,ing Address ($Ireel, ci /town stale, zp code)
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21a Method Disposn,on ^ Crenalial ^ Donation 210 Data of D,sposilan (Month, day, yeah 21c. Place of Disposition (Name at cemetery, crematory a oUar pears) 21d. L (Clry I morn, scale z,p coda)
Burial ^ Removal from SLdO I Wu Cremation w Donation Aumorn•d
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~~ - S{Iewly, Oy Madkal Eaaminar I CaoneR ^Yes ^ Nu ~ (y { / I L ;~ (
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22a Syyature such)
as 220 License Number 22c. Name ant Address al Facily Ay
Nei I TU rrA1 omens ~N~.
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Complete s 23ac only when cenilymy 23a Tome best of my krwwkbge, deem attuned at ale IYIIe. (fate aid place staled. (Spnalure and title) 23b. icense Number 23c. Date Signed (Mmm, day, year)
physic is rid avaa0le at time of death to /)
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ca cause of deem. (
Items 2a26 ewsl 0e completed by pzlstn 2e. Time of Deals 25 Date Proreaxwed Dead (MOnm, day, year) 26. Was Case Relarred to McMral Eaaminer /Coroner for a Reason Omer lgan Cremaaon w Donation?
who pronounces aealh a ~ (x / V M j ~ A(.'. ^Yes ^ No
CAUSE OF DEATH (Sea Inssrueelona end axampke) r Appozimate interval'. Pan II'. Enter doer ' laDCdW. 2B Did 7abacco Use Canllibde m Deam?
hem 27. Pan L. Enter Ina SOilO of events - bseases, mrynes, or wmplicat,ons - Ifal tireNy caused Ne death. DO NOT enmr terminal events such as cardac anesl, Onset to Deam but cwt resunky in Ua IrMedymg cause given a Pan 1. ^Yes ^ Predady
resgealory anesf. 01 venbicalar libnllatwn wimow showlrg the elwlogy. List Dory one cause m ea,3i lira. ^ Wa ~'~Llknow
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IMMEDIATE CAUSE IFrnal msease a . I /~ (
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COrlNlion resWkrlg in deals) _~, a_ /•~
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ins
Dlie to (or as a conseq op: I
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~ d pregnant co
pass Yeaz
^ Pragnam al Ivlle d dean,
Sequentu-Ny E51 conbkon5 g any b e
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leafing b tla cause NSIed m Gne a.
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consaqu xe d). ., 1 ^ p,agnant Dui praryNnl wlllxn J2 days
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Ne B,e UNDERLYIN
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(0sease w kwxY That uuliated U,e
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Due to (or a coraequerca oQ: ^ Nol pregnant, bW pagrant 63 tlaye to t year
Oelore Oeatl1
d. ^ Unknown p pregnant w,eun ma Pact war
30a Was an Auopsy 30b. Were Autopsy Findings 31. Mamler of Deam 32a. Dale of Inpuy (MOnm. y, war) 320. Describe Ikrx Inryxy Occuned 32c. Place N mNry- Ilorree, Farm. Street. Factory,
Perbrmad? Ava,LrLle Pnoi lu CwIWWIUm I~
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of cause 01 Deam? ,
L~1'r'°I°'al ^ lWrnede
[ J acc,0em ^ Periling lnvesbgalan 32d. Tine of Ilpury 02e. kljury at Work? 721. ll7mnsponatbn Injury (SpeoM 32g Location of llljlxy (Street, coy' / lows, sale)
^ Yas [~Rlo ^ Yas [JAIo
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^ Dr,ver I Operator ^ Passenger ^Pedeslnan
^ Saatle ^ CuWd Nul ce Deieim,rred ~
Olher~ Specryy:
33a CeNlar (ched oNy anal
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MOWkdga, death occun•d due to LM cause(s1 and mama, w alalad_ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ u -
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ewg death and cedilymg to cause of deatl,l
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on dx orate ol.xammabnn and / or myeshgauon, m e..y opinion aaam ottarrea d Lila came Bala, ana pinta, ana dDa to Irre tae,Ne) and manner a stelae. ^ ,,,_„ -
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