HomeMy WebLinkAbout04-09-09 ilO5,ky0~ 12GA' i01/I171
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, 56.00
P 15002551
Certification Niuzzber
This is to certify that the information here ~eiven is
correctly copied ti om an original Certificate of Death
duly filed ~~~ith roe as Local Reguu~u-. Thy orik~inal
certificate will he tol-~~,,~rded to Nye State Vital
Records Office fur permanent i~ilinr-
o`'' JAN Z Z 2009
Lora] Re~ristraa- Date Issued
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REV 11/2006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
PRIM IN
±ANENr CERTIFICATE OF DEATH
_
..K INK ^ /~ ~j ^/
(See Instructions and examples on reverse) STATF FII E NIIMBFR .~~ ~ / l l~1 ~ ~.~1-< 1
1. Name pl Decedent (First middle, last, su8ix) 2. Sez 3. Social Security Number 4. Dale of Death (Month, tlay, year)
Charles W. Fealtman male 201 - 16 1- 5804 January 18, 2009
5. Age (Last Birhday) Under 1 year Under 1 tlay 6. Dale of Binh (Month, day, year) 7. &nhplace (City antl slate or foreign coumry) Ba. Place of Death (Check only one)
84 Momhs oaya noun Minutes Hospital: other
yra October 29, 1924 Newport, PA r--,~'
^
^
LJ Inpafiant
ER /Outpatient
DOA ^ Nursing Home ^ Residence ^Other -Specify
Bb. County of Death 8c. City, Boro, Twp. of Death Btl. Facility Name (If not Instautbn, give strcet aM number) g. Was Decedent cf Hispanic Origin? ~f No ^Ves 10. Race: American Indian Black, Whu=. am.
Cumberland E. Pennsboro Twp. (If yea sPecity Cuban, iSpeciNl
Holy Spirit Hospital Mexican,PUanoRican,etc.) white
11. Decedenra Usual Occu Iron KiM of work done Burin most of workin life, Do not state retired 12. Wes Decedent ever m the 13. Decedent's Education (Speciy oMy Mghesf grade completed) 14. Marital Status: Married, Never Married, I6. Surviving Spouse (If wile, give maiden name)
Kind of Work Kintl of Business I Intlusiry U.S. Armed Fomes? Elementary /Secondary (0-12) College (1 d or 5+) Widowed, Dlvorcetl (Specif»
1 a ®Y~ ^"° 8 :Married Jennie C. Knaub
16. Decedeni'e Mailing Address (Street, city I faun, state, zip code)
1126 Fernwood Avenue Decedent's Did Decedent
Actual Residence na. state Pennsylvania LNema f7c. yes
Decedent Livetlrn Lower Allen
PA 17011
Cam Hill
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Township? 1'd.^No, Decedent LNed within ap
17b.000nty Cumberland
,
Actual Limos of
ciyiBdr°
18. Father's Name (First, middle, IaaL suffix) 19. Mother's Name (First, middle, maiden surname)
William Oscar Fealtman Sara Workman
20a. Informant's Name (Type / Pnnry 20b. InlortnanYs Mailing Adtlresa (SDeet, city /town, stets, zip coda)
Jennie C. Fealtman 1126 Fernwood Avenue, Camp Hill, PA 17011
21a. Methatl of Disposition ^ Cremation ^ Donaton 21D. Dale of Disposition (Hoorn, day, year) 21c. Place of GsposiDOn (Name of cemetery, crematory or Omer place) 21 d. Location (City I town, stale, zip coda)
® Burial ^ RemovallromState bYa~remaEbn na cnoreooeru~DOmed^rea^NO
^ Other - speciry: January 23, 200 Rollin Green Cemeter
$ Y Lower Allen Tw
p . , PA 17 O 1
22a, Signs o F I Serv~ a rrsee (or person acFnq as such) 22b. License Number 22c. Name antl Address of Faafey
~ ~ ~ Parthemore FH & CS, Inc., P.O. Box 431, New Cumberland, PA 17070
Complete It on hen cenilying 23a. To the hest of my knaMedge, tleam occured at tl1e time, date end place sqt . (Signature end title) 23b. license Number 23c. Date Signal (Month, day, year)
physican U rrot av at time of death to
cerljly cause of deem. `~
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Items 24.26 must be cornpMted by person 24, Time of Death 25. Date Pronounced Dead (Hoorn, day, year) 26. Was Case Refered to Metlical Examiner I Coroner for a Reason Other than Cremation or Donation?
who pronauncea tleam. L 13 U P M. ~r- ., M q :. I $ ~ ~: G c1 ^ yes ~No
CAUSE OF DEATH (See Inatruetlons antl examples) ,Approximate interval: Part II: Enter Deter w~anm m ,unit s cam ~ moo to deem, 28. Did Tobacco Use Coninbute to Death?
Item 27. Pen I: Enter the Blain of events -diseases, injuries, or complicaagns - that Erectly cauaetl me tleam. DO NOT enter terminal evens such as cardiac arasL r Onset to Deem but not resuNng in rite untledying cause gNen in Pan I. ^ yes ^ Probadry
reapratory aresL or ventricular fibneation withoN showing the atidogy. List Ditty one cause on each line. r
r
^ No ^ Unknown
IMTEe~~SM IFnm)dsease or ~ ~ ` ~Cs C i L
Bea
_~ a % x ~ r ~
29. If Female.
Due to (or ash nsequence off: r ^ Nol pregnam within past year
Sequemialy Nsl conddans, if any, b, ~
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m ^ Pregnant at lime of death
IeaWnq to
e cause
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ite a. Due to or as a cron r
Emer me UNDERLYIND CAUSE ( ~~^^a o~~ r NIN pr
^ egnant. but pregnam wimin 42 days
(daease a inNNryry mat mibaled the c r
avant resulNigln tleam) LAST. r of death
Due to (or as a consequence oQ: ^ Not pregnant oN pregnant 43 days to t year
r before death
d ^ Unknown it pregnant wimin the past year
tea. Was an Autopsy 30b. Were Autopsy Findrgs 31. Manner d Death 32a. Date of Injury (Monet, day, year) 32b. Describe Hmw Injury Ouuned 32c. Place of Injury'. Home, Farm, Slrael, Factory,
Pedortnetl? Available Prior to Completlon
®Natural ^ Homicide Office Building, etc (Specify)
of Cause of DeaM?
^ Ves ~ No ^Ves ^ No ^ Aooi°ent ^ Pending Investigation 32d. Time of Injuy 32e. Injury of Work? 32F, BTransponatlon Injury (Speedy) 32g. Location of Injury (Street city I town, state)
^ Suicide [] Gould Na be Determined ^ Yes ^ No ^ Driver I Ope2tor ^ Passenger ^Petlesinan
M Otlrer - Specify
33a. Certifier (check Dory are) 33b. S' nature and J' `engier -'
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• CeHitying physician (Pnysician cenitying cause of death when arrottrer physician has pronoumetl death antl cor~pleletl Item 23) ~ % / ~/~ r
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To me bleat of my knowledge, death courted due to the eause(sl and manrrer as efated_ .. _ _ .. _ _ _ _ _ .. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ '
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• Pronouncing and ceditying physician (physician both Dronouncing death and cenitying to cause of Beam)
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ed at the time
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and due to the ceuae(e) and manner as stated
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d 33c. License Number aid. Dale Signetl (Month, day, year)
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On the basis of examination and I or investlgetton, in my opinion, deem occurred at the time, date, end place, and due to the cause(s) and manner ae slated_ ^ (
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34 Name and Adtlre
o/myfeted Cause of Death tam 27) Type I Pnni
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35. Registrar's Signs a Distnm Num / 36 D Rled( th, day, year) ~
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REGISTER OF WILLS
CUMBERLAND
Estate of
CHARLES W. FEALTMAN
Barry K. Fealtman and Charles W. Fealtman, Jr.
(each) being duly qualified according to law, depose(s) and say(s) that
acquainted with
OATH OF NON-SUBSCRIBING WITNESS(ES)
COUNTY, PENNSYLVANIA
Charles W. Fealtman
Deceased
she / he /they was /were Well-
and am/are familiar
with the handwriting and signature of the decedent, and that the signature of
Charles W. Fealtman
to the foregoing instrument purporting to be the Last Will and Testament/Codicil of
Charles W. Fealtman is in his/her own proper handwriting.
e~.,+ ~
egnature)
6043 Williams Drive
(Street Address)
Mechanicsburg, PA 17055
(City, State, Zip)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this ~"~ day
of ~~ , ~~~
Deputy for Regis,,+.er o ills
~,
(Signature)
118 N. Locust Point Road
(Street Address)
Mechanicsburg, PA 17055
(City, State, Zip)
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Form RW-04 rev. 10.13.06