HomeMy WebLinkAbout12-04-08 OCA~...F.~~CaI~T'RAR'S CERTIFICATION OF DEATH
WARa~'N~i;, leas,illegal to duplicate this copy by photostat or photograph.
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l=ee fur this c~rtifirate. $6.00 ~; Q ~ This is to cer~il}' that the inti7rmation here given is
~~~~ ~~~ -~ ~~ correctly copied from ,.(n ori~~in~ll Certificate of Death
duly filed ~~aith me as Local Registr~u-. The original
~~fl~~~ ~~ ~ ccrtifir_ate u,~ill hr~ ~iyrwarded to the State Vitn]
e v~,t ~ Rcct~~ )t~ficc for ~ennancnt filing.
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Certification Number ~ Lo ~ Registrar Date [s~uled
H105-143 AEV 118006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
TYPE /PRINT IN
PERMANENT CERTIFICATE OF DEATN "
BLACK INK (See instructions and examples on reverse)
STATE FILE NUMBER
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1. Name d Decedem (first, mitltlle, last, sdik) 2. Sex 3. Sodel Security Nunber 4. Dare d Death (Month, day, year)
Grace Marie College Female 168 - 24 - 2889 September 8, 2008
5. Age (rest Birthday) Uwkr 1 year Urger 1 day 8. Date d Birth (Month, day, year) 7. BiMplece (City end stale w laegn country) 88. Place d Death (Chatty only one)
wrxhs pen twum sa„ures Hospital: Omer:
79 ym. 10-10-28 Mt. Joy, PA ^Inpatiam ^ER lOdpalianl ^DOA (?Q Nursng Home ^Residence ^fAher~SPedIY:
fib. County of Death &. Cay, Born, Twp. of Death Bd. Faality Name QI nd instiWSOn, gWe street ant number) g. Was Degetlanl of Hispanic Orgin? ®No ^ Yes 10. Race: American Intlian, Bleck, Whfle, arc,
gf yes, specify Cuban, (Specily)
Adams Franklin Twp. The Village of Laurel Run Mexican,PUedoRican,etc.) White
11. Dacedenl's Usual Occu lion Kind d work tlorre d u' most d work life. Do not stale retired 12. Was Decedent aver in The 13. Derstlem's Education (SpeciFy only highest grade comp leted) 14. MarBal $Ia1uS Martial, Never Marked, 55. SunNirg Spo use (II wife, give maiden name)
Kind of Wont Kintl d Business /Industry U.S. Armed Forces? Elementary /Secondary (0-52j' Cdlege (1.4 or 5+) Wb°~' Div°rced (Spea!}vj
Homemaker ^vea ®NO 12 years Widowed
16.Decetlenl's Mailing Address (SUeel, dry Mown. sUte, zip code) Decedent's
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PA Live in a t7
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Shi ensbur , PA 17257 .
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18. Father's Name (Frs1, mMdk, lest, su8u) 1g. Mother's Name (First, mitltlle, meklen sumerre)
O. Merle Gutshall Ada Snyder
20e. Inlamant's Name (Type / Pant) 206. Idortnant's Meillrg Atltlress (Slree6 city /town, slate, zq cede)
Cathy M. Parson 179 Stony Point Ave., Shippensburg, PA 17257
21e. Method of Disposition ^ Cremation ^ Donation 21 b. Date of Disposition (MOdh, day, year) 21c. Place of Daposdbn (Name d cemetery, crematory or other place) 21d. Location (City 11own, state, zip code)
[~ Bwi,» ^ RemwalUOmSlate WesCromatfonorponationAWhodzad
^ Other - Speedy: i by MMkal Examiner /Coroner? ^ Yes ^ No 9_11_ 08 S Tin Hill Cemeter
P g Y Shi ensbur PA 17257
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22a. Signature d F Senke ~ (01 person u such) 22b. License Number 22c. Name arM Adtlress d Fedhy
~ D-012984-L Fogelsanger-Bricker Funeral Home Inc., Shippensburg, PA 17257
Complete ttems 23a~c oMy when certiryag 23s. To the best d my knowledge, death oceunetl al lime, date antl pia slated. (Signature Idle) 23b. License Kanter 23c. Date Signed (Month, tlay. year)
physican is not availade al time dpeeth to 1%'~
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Ikms 24-26 must be carpktetl by persm 24. Time d Death 25. Dal renounced Dead (Monty, day, year) 26. Was Case Aetenetl to Msu4cal Examiner /Coroner for a Reason Other roan Cremation or Donation?
wlw prorxwncas death. 3 0 A M 8 ~ p Q ~
v ^ Yes ~ No
CAUSE OF DEATH (See instructions a examples) r Approximate ntenal: Pal II: Eraer other sippilranl rxxrtlaions coot brdn t tle Ih, 28. Did Tobago Use Comribme to Death?
Item 27. Pan I: Emer the chain of evanu - dseases. iryuries, or complications -that tirecity caused the death t>D NOT eniw lermklal eve nu such as cardiac arrest, Onset to Death bd rot resWling h the rxMerying cause given in Pad I. ^ Yes ^ Probedy
respiralay anesl, w vedriaAar librelalion without showing the etiobgy. Lisa only one reuse on each Ime. r~~
^ No tyUnknown
IMMEDMTE CAUSE Final diseases I
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cond8xm resuttirg k death) ~. a r r lL 7~ ! : J"Ci'(Y ~
r ~ 29.NFar,de:
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Due l01or as a consequence ol):
_ Nd pregnant within past year
Segpemially N51 conddbns, d any,
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~eMnq b the rouse Ns1ed m line a.
Enter the UNDEflLYING CAUSE Due 1° (or as a oonseque~e o11: ~ ~T~~ •~ ^ Not pregnant, bm pregnant within 42 days
(dsease w injury That initialed trre c
events resulting m death( LAST. ,
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_ of death
Due ~° (or as a emsequerrce of): ^ Nd pregnant, but Dregnent 43 tlays to 1 year
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^ Unknown a pregnant within the past year
30a. YYas en Autopsy 30b. Were Aukpry FinNngs 31. Manner of Death 32a. Date d Injury (Month, tlay, year) 32b. peswibe How Iryury Occurred 32c. Platy d Injury: Fbme, Farts, Sired, Factory,
Pedomxd? Avacade Prkr to Compid'ron
~watu2l ^ Hwnidtle
^ Odice Building, etc (Spa lily)
of Cause d Death? L-
^ Yes ~ ^ Yes ^ No
^ Accident ^ PerWing lnveslvgafion
32d. Tune d Injury
32e. Injury d Work?
321. X Tranalx'Mlion Inryry (~IYI
329, Location of Injury (Street, csy 1 town, stale)
^ Suicide ^ Could Not be betermined ^ Yes ^ No ^ DrNer / Opembr ^ Passenger pedeslden
M Oltler~ Speedy:
33a. Gaudier Id1ecN only one) 33b. Sryyulure eM Title d Cerlif r /~ ~
• Certiryfng physklen (Physkien cendyagcause d tleath when erwtft to physician has ponaxrced rledh and compiled Item 231
To the Reel of my knowledge, death ocwrretl due to the cease(s) and manner es atetetl_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ /
• Prorwurrcing and certdying physielan (Physician both pronourxrng dedh a~ certtlying to cause d tleaNj
To Ise oast °t my knowledge, death atoned at the Time, date, end place, and due to the cause(s) and manner as Mated_
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ 33c. lirense NwnMa 33tl. Darr Signed ( onlh, tlay, year)
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• Netlical Examiner/Coroner D
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On the basis d examination and! alien, in my tlea occunetl et the Ume, date, and place, antl due to t he cause(s) end manner as elatetl_ ^ y
Nnme ant Atldress of Person Whe Cc
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istrar's Sknature and D' of F (M Ih
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v Diaposiion Permit No. 0076300