HomeMy WebLinkAbout11-18-08 IOS.ROS REV (01/071
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 14809582
Certification Number
ITEM # ,~
sxotn.D ~ tis Foj,i,ows:
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. NOV ~ 5 ?DDe
Local Registrar Date Issued
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REV 11/2006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS D
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PRINT IN
uNENr CERTIFICATE OF DEATH O '
;K lNK (See Instructions and examples on reverse) STATE FILE NUMBER
1. Name d Decedem (First, middle, last, x) 2. Sex 3. Social Securtty Number 4. Date of Deam (Month, tlay, yeaq
~Fy ~ jr ~T ~- A/1~ ti~ Male 209 - 12 ~ 7835 Nove r 8 , 2008
5. Age (Leal &rmaay) Under 1 year Urxler 1 8. Dale of Binh (Momh, day, year) 7. Birthplace (City and state or ro ' count) Ba. Place al Deam (Check Dory one)
Moraha a» Hours Wmxae Hospital: Omer:.
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1927 Harrisburg
February 26
Pa ~,
81
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6b. Counry d beam 8c. Ciry, Born, Twp. of Death Sd. FaciYly Name (If not insthutlon, gNe dreel and nutrt6er) 9. Wes Decedent of Hispanic Origin? •.No ^ Vas ~ 10. Race: American Indian, Slack, White, etc.
DI Y•+, spedry taboo, (spedM
Cumberland East Pennsboro Hol S irit Hos ital Mexicen,PUenaRican,etc.) White
11. DecedanYS Usual tbn Kntl of work tlone most d wpk~ Ida. Do not state red 12, Wes DeceGd ever In me 13. Decedent's Etlucedon (Specify only hghesl grade completed) 14. Madlal Status: Marne0. Never Monied, 15. Surviving Spouse (If wile, gwe maiden name)
King of Work KiM d Bueirreu ! t t U.S. Armed Fomes? Elementary /Secondary (0-12) College (1 d or 5.) Widowed, Divorced (SpedM
- Su ervisor ew Cumberland Arm 4X1Yee ^Na 10 Widowed
16. Decetled's Meiling AGress (Street, c /town, state, zi coda)
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• Decedent's pa Did Decedent
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DecedenlLNedro rwp
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3520 September rive .
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Tow~slip?
Pa 17011
Hill
• Cam t7b. county Cumberland 17d ~ ~
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18. Father's Name (Flrsl, mdme, lest, sudix) 1S. Momer's Name (Flrel, mMde, meitlen surname)
Harr H. Dittman Helen Ho
20a. Informamb Name (type / PrinQ lob. InhxmanYs Mailing Atltlress ISreet dry /town, slate, zq code)
Betty Brubaker 1303 Kelton Road Hill Pa 17011
- 21a. Method d Dispcenian ^ Cremation ^ Donalbn 21D. Date d Disposilron (MOmh, day, Year) 21c. Place d Dispositlm (Name of cemetery, crematory or other place) 21tl. Locadce (CNy /town, state, zp cotle)
[~ Banal ^ Removal from Slate ~ Wp Cremetbn or Dotrtlon Autlgrtred
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^ aher. ~ hyYledkelExaminerfCoraner'1 ^Yee^Na November 12 2008 Rollin Green Cemete
pnaaxe ref a n acting as such) 22b. tiCe1169 Number 22c. Name and Adtlreas d Fadliry
. ~ 011654-L Myers-Horner Funeral Home Inc 1903 Market St.Cam Hill Pa 17011
CorrpMa Items 23ec ody when aNrying elerod. (SIWWre end tltb)
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23e. Tome beet d my ro~+dg+, deem occunetl al iM lk 23b. License N
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m~er 23c. Oete Signed (Month, day, year)
phydtlen M not aveYada at tlme d deem to J
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carlily cause of asset. • v'•r 1
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Itenre 2426 muss be conpleted W person 24. ilme of Death 26. Dale Pronounced Dead (March, day, year) 26. Wes Casa Refenetl to Medal Examiner /Coroner for a Reason Other Than Gemetion or Donation?
who pronounces dxth. ~z~}} (~
I V 1 ~ M. i ~ ~ '~~ ^ Yes ^ No
CAUSE OF DEATX (Sire instnacllone and axempbs) r ApproxYnete mtetvd: Pen II: Enter Omer ' 26. Dro Tobacco Use Candibde to Oeelh?
Nem 27. Pen I: Enbr me chin d events - dieeeeee, Iryurlee, a mrrpYcetrone - met dreary ceased dre deem. DO NOT emer temrktal events such es cemlec arrest, r Onael to Dean hul rrot resuding In are unGnying cause gNen in Parl I. ^ Yes ^ PmbeNy
reepirelory erred. a ventligdal fi6dledon widaN showiry the etidogy. UN any one cause on each Imo. ^ No ^ Unknown
aelEgATE CAUSE (Fetal disease or r
taMNm reeultlrg h deem) r
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.1 , If Female:
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Due (or es a of): r
CD/I D pregnant w
n pest year
^ Pregnem el time d deem
SequendaM Yst Nrtdltlors, d any, p. i
Ieedrq ro the Huse Ided m Yoe e. t
Due m (or a conserJUe oQ:
n ^ Not pregnant, but pregnant within 42 days
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events rewltlng in deaml sT•
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D ^ Not pregnant, Dd pregnan143 days to 1 year
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e. r ^ Unkmrm it pregnant wi1Nn me pest year
30a. Wee an ANOpry 306. Were Auropy Flndings 31. Meurer of Deem 32e. Dale d Injury (MOmh, day, years 326. Describe How Iryury Oceunetl 32c. Place d Injury Home, Farm, Sueel, Fadory,
Perbmted7 Available Prior to Completion
of cause d Deem?
^ Natural ^ Homkide Office Budding, etc. (Speciy)
^VBS ~No ^Ves ^ No
^ Acddent ^ Pendrg Investigetron
32tl. Tme d Injury
32e. Injury at Work?
321. II Trensponedon IrMury (Specify)
32g. location of Injury (Street, dry /town, wale)
^ Sddde ^ Could Nd De Detandrwe ^Ves ^ No ^ Diver / Operetor ^ Passenger ^ Pedestrian
M Other - Spedty.~
33a. Cerdfer (dreck ony one) ~ 33b. Signetu end role d Certifier
• Candylrtg phyMChn (Physiden ceniryng cause d seem w+wn endlwr physitlen has prmartced seem and cernplded Hem 23)
To uts best d my krrowiadge, Gem occurrod due to the uuse(q sne mariner w ambd_ "' _ "" _ """""""""""' ^
• Pronoundng sM aNlying phy+klen (Physiclen both prmanctng Gem and cendying to Cause d Gam)
^ 33c. Ucense Number 33d. DaN Signed (Monet, Gy, year)
- _ _ _ - _ _
To tlu hest d my knoMMge, Gam attuned M dta time. Gta, and place, end due to Hie utw(sl+nd manner ae states _ _ _ _ _ _ _ _ _ _
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On the bash d exsminedon and! or Ime+Bg+tron, In my opidon, Goth occurred et dw time, date, and plea, end due to me auae(sl and manner as ststad_ ^
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I dl I I I I 3B. Dale Fled (MOnm. Gy, Year)
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