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HomeMy WebLinkAbout10-14-08 ,,,t ~„~ P_I-,~_-~-~., - - ~-~ ~~ This is to certify that this is a true copy of the record which is on file in the Pennsylvania Division of Vital Records 1n accordance with Act 66, P.L. 304, approved by the General Assembly, June 29, 1953. WARNING: It is illegal to duplicate this copy by photostat or photograph. I ~~,~~ ~ .an ~~ C Frank~ropoli ~= Calvin B. Johnson, M.D., M.P.H. r~ Secretary of Health State ~e~'spr•ar o ~'~ x.5692 No. c-4 CEP 2~ .~ corrected item 3 ` ^~ ~4454~ H10YPE 1PRINT INS per fd, 6-2O-OSC"~MONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS_ ~ PERMANENT CERTIFICATE OF DEATN ~ BLACK INK (See instructions and examples on reverse} STATE FILE NUMBER ~" N T ^~I z 0 U D 0 a z 1. NamedDecedent (First inidde, last sudix) Deloris V. Watts female 3~~17( -/{()-7381 4. Dat dDeath (Monty, day, year) } ^~ (~ W 5. Age (Last Birthday) UMer 1 year Under 1 day 6. Date of Birth (Month, day, year) 1. Birtfg4ace (City and shale a kx eign country) 8a. Place of Death (Check Doty one) 84 ~°^~ °a~ "°xs "aa"" October 18 1923 Mechanicsburg, "°~"~ 01heL yre, , Inpatient ^ERIOutpatieM ^DOA ^Nursinglbma ^Residence ^OBzr-Specify: 8b Ceu of De th ~ l ~ d Bc. C , Bao, 7w . of DeaN ~ t PP b 8d. Fadtiry Name Qf not mstiNtion, give street ant niariber) 9. Was Decedent of Hispanic Origin? ~ ^ Yes 10. Rare: American Indan, Black, While, dc. ~ j0 ~ °iN~'~n l~cdN um er an oro as enns y '~ ~ Vllhite Mexican, F1arto Rican, etc.) 11. Decedents Usual lion Kind d work d ate dur most d tile. Do nil state retired Never Marred, 15. Surviving Spouse (d wife, give maiden name) 12. Was Decedent vet in the 13. Decedent's Eduwlion ( 'ry Doty hghest grade canpleted) 14 Mahal Status: Marrw.d HonliilICer ~ U QYes Fo~ Elemenhary4Secondary(D-12) Ill Cuaege(l~l«5+) ~Gsw W p VUrCe((] ~ a ,I~,ed ~' I tawm, stale, ~ code) ~'evv+ J~~• ~ ~ PA ~ Decedent amp en Decedents Decedent Lived in Twp { Yes Slate ~ m a 17c Adual Residence 17a Mechanicsburg, PA 17050 . . , , . Um er art T0? 17d. ^ i nt~ivedwBNn b ~a . County 11 ~ Imo 'e.FadareNamelFirst,middle,last,w8ix) John Earl Wise 'g.Mo7araNamelRrst,middle,maidenaumame) Edna Stone 20a lnromanra Name (Type! Prkd) Nancy L. Watts 20b.IMamaMs Ma"~7~~~~1`~m~~itbrive Mechanicsburg, PA 17050 2f a. Mailed d Dleposiibn ^ Cremation ^ Daation 216. Date d Dispositiat (Month, tlay, Year) 21c. Place d D'sposhion (Name of cemetery, crematory a oilier place) 21d. Locdim (City I ksm, state, zip code) ~ ^ RemovallromStale j WasDremdion«txndlortAUMaized April 29, 2008 ST. Paul's Lutheran Church Cemetery Enola, Pa.1T025 ^ ONer - ~ ~ by kkdial Exandrterl rkr? ^ Yes ^ No ~ 22a. ' of Funeral adkg as such) 2ffi. ' Norther D 01266 L 22c Name ant Addr d F ~' e uneral Home In 37 Ea t M d i St t M h i b PA 17 55 ' - 2- , y c. s a n ree ec an cs urg, 0 h 23ac aYy when certityiig 23a. To the best my knowledge, death owxred d the time, date and place stated.lSyaWre and tide) 23b. license Number 23c. Dale Sgned lam. ~Y~ Y'~) pAysxdan is riot availade at time d death to cemfy pose d death. ~ hems 2426 must be cmpleted by person 24. Tina d DeaM ~ 25. Date Dead (Month, day, yearf 26. Was Case Referred to Medical Examiner I Coroner for a Reason Olhar than Cremation a Donation? who pronounces deaN. h I V r ~~ ` M. O ^ Yes ^ No CAUSE OF DEATH (See instruttlons examples) , Appro~arate interval: Part II: Enter dher simficanl pnAtions coMnbdinq to death 28. D'M Tabaaa Use CmaidAe b DeaYl? Item 27. Pad I: Eller the n -diseases; iry'udes, a pmplireliars- tl,at dmctly caused the death. DO NOT enter tem0nal ever~k such az prtiac artesl r g5el b DeaM bd not resulting n the urdedyiog pose given in Part I. ^ Yes ^ Probably respiratoryarted,aventriwlarftbnllationwidaWshowingtheatiabgy.lislaMyarecauseoneachWre. i ^No ^Unkrgwn MMEDUTE CAUSE IFinal)disease or n~, ( rG ~ ctrdaun r m death ~~~fQ L H•2~ G~ r .~ a 29. U Female. i ^ ~ Due to (a az a censequerxxi oQ: ~j ,, rT ~i i Sewer~ti'aIH list condiGora, tl any, b. ~,ynn ~'~ ~/ ~ S ' /~j"v ~-! C aC•]/~~, ' ' n with awl ~~ ^ Pmq~M at tirne of death Ieadaq to the pose fisted m line a. Eller hie UNDERLYMG CAUSE Due b (a as a consequence ot): ~ ~ ^ Nil pregnant, but pregnant w9hn 42 days ' (disease or injury Nat kutiated da °. r lti d M aBT ~ d death events resu ng m ea ) • Due to (a az a consequence oq: i ^ Not pregnant. dd pregnant 43 days W 1 year betae deafh • d- r ^ Unkrawn q pregiam within the past Year 30a. Was an ANapsy 3°b. Were ANapay Fsdings 31. Mamer d Death 32a. Date d Injuy (Month, ~y, Year! 32b. DeV'aw Injury Occurred 32c. Place d ~: fbme, Farm, Stad, Faday, Perbmad? Availade Pda kr Completion ^ NaNrd ^ ftomicide orwe aiair~ ~~ l~'hl d Cause d Death? ^ Yes ^ No ^ Yes ^ No ^ AaideM ^ Pendrcig Investigation 32d. Tine d Injuy 32e. Injury d Work? 321.8 Transporlatitn Iriay (Speciy) ffig. Locatbn of Injury (Strad, dh I faun, stale) ^ Suidde ^ Could Nd be DdertMried ^ Yes ^ No ^ DMrer! Opereta ^ Passenger ^Pedestdan M Olher- 33a. Cer6far (dads atiy one) 33b. file d Certifar , ' CedBykg physiden (Ptrysician certitykg pose d death when andher physidan has Wawunted death and mnpleted Clem 23) ,gyp To thebestdmykrawkdge,death«cumedduetofhepuse(s)andmanneraastated_________________________________ ^ • Pranourxdng amt certifying phyaidan {Phyddan lwth praaunckg death and car8lyirg b pose d d~1h) ^ 33c. Licence Number 33d. Dde " ed ( , Ypr) / ' To the bedolmykriow4edge,deaMOaurreddthetime,dek,endplate, andduerotheausela)andmannerasagted__________________ A. !f ©~ ~, /~ L y ff/ 7 / • MedkdEzaminerlCaorrd On the basis d exmninatlon and I «investigatlon, In my aplnan, death otturred d the time, date, and plxe, arM due to the teasels) ant manner as stated_ ^ 34. Name and Adtlress of Person Who Carpleted Cause d D eaN (flem 27} T I Print 35. R i r' ~ ature ~94~stnd u r ( r•1 ~ ~ ~ ! ~ ~ ~ ~ ~~ ~ 36~ate Fded(IAOlith,pAy, ~ r I J 1 7 1 , A C/{~/~ ~ . s~ // v' yh ~~iT tl - . 3 1 G T 0 ~ Dispos8bn PertMl No. ~~ y .J ~~ ~yV\r-