HomeMy WebLinkAbout05-11-09 UiiBQ~ KLF IgUO'~
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, S6.O0
P 1524495
Certification Number
This is to ca-tifv that the inftn-mation here _*i~~en is
col7-ectly~ a~pierl lf~t>)rt tin original Certilicate of lleath
duly filed with me a, Local Recistr;-tr. the c~rirzinal
certificate roil'. he forwarded ~to the State Vital
Records Oft~ice for permanent filin~~.
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os-u3 REV itaoofi COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
TYPE ' PRfNi IN
PERMANENT CERTIFICATE OF DEATH /c, t`' /~
BucK INK (See instructions and examples on reverse) srnTE FILE NUMBER ~ ` Q "` 6t-~~ t )
. suPox~. 2 Sex 3- Social Security Numoer a. Dare o~ Daa6~ (Monln- day. year)
1. Neme of Decedem (First. mitldle. las
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G7e'cr•"- .G' C/. ~fr1Js?/'CL JYJA'~G' J/ L - Crl -S"J'L rfG/UR: /.~' c'.. C'C'
S Age (Last &nntlay) Under 1 year Under 1 day 6. Date of Binn (Month. day. year) 7. &nnplace ICM and state or foreign country) 6e. Place of Death (Check only one)
Mnmms Days ~wurs umuces Hospnal: Omer:
7
(~ ~~
7~ yrs /-.3CI '- /y/y .,,,/~iJ//S!C•Jr7 , r`7 ry lnpatrent ^ER; Outpatient ^DOA ^Nu•s~ng Home ^Residence ^Other~Speciry-.
6b. CW my of Death &. Qty, Bore. Trop. of Death 6d. Fa~lay Name III not mstauson, gNe street antl number) 9. Was Decedent of Hrspanrc Origin? ~'NO ^Yes 10. Race'. American InOan. Black. Wnne. ete.
L / .a~ /
~GI IY16(f /Q /1t~ Stay r/y h~r ~l//L'fG"/J ~W / ~ III yes, specity Guban, (SpeG~ly,
C_Q /~~$~G ~~f/Ci9CG~ /~f~"'!,e-~ Merxan. PUeno Rican. elc.1 ~„J ~I. yC
11. Decetlenfs Usual Occu tan (Kind o! work done dun most o~ wodu Nie. Do xf stale retved) 12. Was Decedent ever in the 13. Decedent s Etluwtwn (SpeoN only h~gnesl grade compleledl 14. Marital Status. Marred. Never Martied. 15. Survrvno Spouse (11 wife. prve maiden name)
WWOwed
Divorced ISpeciy~
Kind of Work Kind o! Business / Intluslry U.S. Armed Forces? Elementary / SecaMary (412) Gdlege (1-4 or 5.)
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SC ~~•jMQry ~3k /.: i7G Yes ^NO 3' Gx-trCl C(/PL
76. Decedent s Mailing AMlress IStree!, city town, stale. rip cotlej
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Q/ Decedents '~. Dd Recedent _
Aaual Resitlence 17a. Stale r!/./JJ y //R n . C~ Live in a 17c. ®Ves, Decedent lived m LG'"r f'~ ~/e ~/~' Twp
h ~7Vf
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Y /nisl Y T nsMp?
t 7d. ^ Nc. Deceaenl Lived wrtnir.
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770
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c has 1~L'. ~, ~ .
ounty
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Atluai um~ m cilY grim
18. Father's Name (First, coddle. last, suXixl 19. Monier s Name IFirsl. mkltlk, maiden sumamel
/ /a~F r C>,~ tk c
20a. mtormanf's Name MDe J Rrint) 2W. Inlorman(s Mailing Address (Street. cM !town state. zq code)
L9/4~ S ~rI f'~SOr1 S~ k,~~ZC~ !~!' L~~.-~i`s~C ~~ / 7C~/,~
21 a. Method of DlsposNOn ^ Cremation ^ Oonatpn 21b. Date of Disposition (MOnm, day. year) 21c. Place of Dispositgn (Name of cemetery. cmmatory or omer lxacej 21tl
LOCatron (tarty %tam. state. rip code)
Burial ^Removal lrom State ;Was CrematbnaDOnatbn AUMorized
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9 Cre'
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As
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s
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^ Other - Sixcr'N: i sY Meaicai Examirror/Coroner? ^Yes ~~an
mr
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22a. Signature of F rat, a Lzensee ( rson acting ass ) 22b. License Numder 22c. Name all Address d Facility / {~(•, f'/jq h ~/`/. A. e
• ~ .~ ('J - I3 8Z r tat ~~ itl/M n~u~.G. +c.t ~trae S f C`ii~~^.: fC! l~ , ~h of ti.w.. f'a1 i~^i c (.
CanDlete tten¢ 23ac oMy when certiFy rig To hest of my W~owledge, acurgetl at the time. date all place sWtetl. (Signature and tillel 236. License Number 23c. Date Slgned (Month. day. year)
physican Is not available at time of deem Io ~ ~ /~ y
~.~i / `,/^ ~
t r~ /~ ~ 'y (/ ~ ~- ~ `~
/
neNty cause W deem. `_
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Items 2426 must 6e completed by person 24. Time of Deam / ~ 7
~
~ 25. Date Pm/no'un)retl Dead (M2onm, day year)
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~ 26. Was Case Refered to Medical Examiner ~ Coroner for a Reason Other Nan Cremation or Donalron^
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who pnaxwrices Beam. l I
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/'=Y- Yes
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CAUSE OF DEATH (See Instructions antl examples) r Approximate imerval: Part II: Emer other ayn (rant c^ntliti^ns conmtnnine m death, 28. Oq To6a ro Use Contndne to Deam?
Item 27. Part t. Enter Ihm rha n of events -diseases. injuries. or complicatxans -mat direcMy roused dw deem. DD NOT enter lennmal events such as cartliac crest. ; Onset to Deam bN not resulting M the Ixdedying cause given In Pan I. ^ Ves ^ Propabty
resgmtory angst, or ventricular fibrilladon wittwut showing the etiology Usi only one cause on each lira.
~NO ^ Unhrwwn
IMMEDIATE CAUSE l1Fiiwl disease or ~,.,/
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t 29. 11 Female
>Crhu Ci L /.a
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corditwn resulting In aeathl
~ a /
C,
y
: ^
,
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Due to (or as a consequence oty:
Sequentlally list conditions. A any, b
~ J~" /~ Not pregnam wnh~n past year
^ Pregnant al eme a deem
.
leading 7o me cause 6sIN on lira a.
UNDERLYING CAUSE Due to (or as a consequence oQ:
t
h
E ^ Not pregnant. bN pregnant wAMn 42 days
n
er t
e
(disease or injury that InNaied the c. i of death
events rewning in death) LAST. 1
Due to (or as a cronsequerxe op: ^ Not pregnant out pregnant 43 days to t year
before Beam
tl ^ Unknown it pregnam wanin trig past year
.
30a. Was an Autopsy 30b. Were Autopsy FinMngs 31. Manner of Deam 32a. Date of Injury jMOntn. day, year) 320. Describe How injury Otturretl 32c. Plate of Injury: Flume, Farm. Street Fadory.
Office BuWing. etc. 1SpeMy1
Pedomfedp Available Prior to CornDlelion
of Cause of Deam? ~i1
10~ Mural ^ H°mic~e
^ Accident ^ PeMing Investigation 32tl. Time of Iryury 32e. Injury at Work? 32f- If Transponatlon inryry (Speatyl 32g. LocaUOn of Injury 151reet city :'town, stall)
^ Yes ~NO ^Yes ^ No
^ Suroioe ^ GWd Not be Determined
M
^Yes ^ No ^ Driver %Operator ^ Passenger ^Petlestnan
Ome so«~N
33a. Cedifier (cfleck Only oriel 336. Signature T41e o~CeMrer / r ,
dean Ing cause of death when another physician has pronounced Beam and completed Item 231
dy' g phy i i n certiN
oaumd due to the cause(s) and manner as stated_________________________________ ^
To the Dest of my know yledge ~ `/ ~ 1 ~' C ( J ~ j
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ng deem and cenAWng to cause oI deem)
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• 33c. License Number // / 33tl /D'al'e Signed IMOnm. day years
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manner as s
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y and prone, and due to the caasels) ari
cumed at the time. dak,
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On me basis of e:amination and! or investigation, in my opinion, death acurred at ill time. date. and place. and cue to the cause(s) and manner as stated. ^
34 Name and Atl ~ess of~Person YJ~~myKled Cease of DeaR,'Item 2"'~ Type Print
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35 36 to FAetl iMOnm-da>. year) 1 }~y^L
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