HomeMy WebLinkAbout07-08-09 I05.805 REV (01/07)
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 15433714
Certification Number
.Y
H105-143 REV tt/1008
TYPE/PRINT IN
INr
SLACK INK
1 ,
N •
.,~
U
~ •
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.
~x~x'
~~~ ~l~~ AP 1 3 2049
Local Registrar Date Issued
r••-.~
t~- .,~
..y l~./
• _
~Z y.
t
,
...4J ~
....~ n
f _,,
~i j ~~
{
y~
N vw• l
EJ
J S, ~-..-... r
.
•• r
~
~
..Q
~'
Q '~
i. "7 r"
~ r
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
(See instrUCtlona and examples on reverse) STATE FlLE NUMBER
1. Name d Dacedertl (FlrM, middle, teal, nANx) 2. Sex 3. SocW 3ec«My Number 4. Data d Death (Month, day, yar)
W Roush M. 168 -26 - 5497 A nil 9, 2009
s. Age (Coat tArtltdey) Llrwier t lktder 1 8. Dale d BkBt (Month. 7. ( and dace « ~ ) 8a Place d Desth Check one
r4onaw Oeve rldn serseee FloepW: OUer:
7 6 Yra. Oct . 7 , 19 3 2 Car 1 i s 1 e , P a . ®Ittpetlent ^ ER / ^ DOA ^ Nuraktg Nana ^ Rafdera ^odter • Spedly:
eb. CaaMy d Dart 8c. CNy, , Twp. Dadt pd Fadltly Name (N rat kel~fon. glue sheet end reenter) 9. Was Decedent d 1Meprdc Orlgin7 ~[] No ^ Yea 10. Race: Arteaart Inden, BIed4 White, sb.
Cumberland So. Middleton Carlisle Regional Med. Center Me>d~art,P9erbRban..b•) White
11. DeaderK'e tlerrl Kind d wok a cne moat d Ms. Do not state 12. was Dsadent ever in the 13. Delederd's EduaUan (SpecNy ortly ttigleet grade comp leted) 14. Mxital Stalw: Mertled, Never Herded. 15. Survivktg Spa ma (K wHa, glue meldert name)
IOria d Iona d &rktea I U.S. Arced Foroea? EbneMSry / Secadsry (0.12) College (1-4 «5+) Widowed, Divorced (Spedfyt
Sales/servic e ChemicalGo. ^va ®rb 12 yrs. Widowed
18. Daoedera's MMrtg Addrea (SMN, dH /town. ewes zip cods)
91 6 Pine Road DacadenYs Drd Deadxtl
Adwl Raektwwy na. sale P a _ uvs ~ a n~. ®Yes, Deadertl Lhba In Dickinson Twja . n
~~
T01N1~"p' nd ^ No Decedwd Lived wIINn
Carlisle, Pa. 17015 t~• Cumberland Adrrurr~Ned cly/Ooro
18. Fatlera Name (Fkp, nrldde, la4 edPoc) 19. Motlrer'a Name (Fret, n9ddk, rtralden aumame)
Beulah Hoover
20e. Irtfonrtanrs Name (Type / Print) 20b. Inbnnertrs McNktg Address (SMSL cky / bsm, etde, zip Dods)
85 Southside Drive Newville Pa. 17241
21a. Metlgd d DMpailbrr ^ Crenetlon Dautlat 21b. Date d Dbposr6on (Madh, day. year) 21c. Place d Dlepaskbn (Name d cemetery. aemetory a other place) 21d Locatlon ICY / ~. ~. aP ~)
~l3taW ^ Rerrtovdtromstete tryaCreeetlorrl3o A
il 15 2 Holly Springs Cemetery
Mt Mt.Holly Spgs.Pa.1706
^ ^Ya^No pr
009
r .
22a. F+aerel Servla ardr 22b. Uceree Number 22c. Name and Addrw d FedWy 5 01 N . B a 1 t i mo r e Ave .
~ G~rc~,~(~ FD-011932-L Hollinger FH/Crematory Inc. Mt Holl S rin s Pa. 17065
Noma 23ae sty wlen artllykq 23s. To the my knowbrlpe. daNll ooarred et d» tlme, date and plea tlated. (sigreae. and tNN) 23b. Uaree Number 23a IhM sign.a (MorHh. deY. Yad
le nd avelleble a tkre d earn b
aAly news d death.
Nerrr 2428 rteet M aarplNad by person 24. Time d Dsedr dry. year)
25. Dab Pronounced Deed (
M
at
h 28. Wa Cos Rshnsd b M,dPal Exeminer / C«aer for a 19awn qMr tlen Cmalbn a Donsdat?
/
ale pranorencee death. /~ ~ , fO /0 M. ~
~
y
~
Q f~~ ^ Ya ,l_7, ^o
CAUSE OF DEATH (See I atW atumplN) r Appradmate ktNrvel: Pert II: Fnbr otler 28. Dkl Tabaao Ues CaMbuN b DeaM7
INm 27. Pad 1: l'cnbr to mth.ia<t1~6 - deeeeea, frn(nales, a rnmpNaYae - YW 3ectly canned the deWn. DO NOT sder terminal event such a ardrec arta4 r poet b Death laA not reerlUrnp h the urndedykrp sues gMen h Part I. ^ We ^ Probady
raptsbry erreet, a vermkaly tlbrNMtlort wNhod alawkq to otology. Lbt only ae erne an each We. ~
r ^ ~ ^ ~
IAMIEDIATE CAU@E fRW)dasw a ~~ + ~ ~~ r
card8on rarltlng n deah _~ a. ~ r 29. N Fernde:
Nt~
d
^ ~
r
Due b (a a a axragwnoe r
~ w
Ri
n ~ 1~
^ Pr•
r1•Id d the d dalh
"
M
bt candtlon. N any, b. 1^QMl'/s U yy- A ~ 9
~
b CMee NYed On tke e. pw to a ae e r
n
ter
E
UNDERLYNa CAUSE ( '~"GB °t1~ r
Nd tool wltlnin 42
^ a•trW~. Pr•PWt ~Y•
d d
tl
~
~
!
~~~
» c. i ee
n
OYO1° 1001"'"'9 n
Dw b (a a e ooneeg9atce d): i ^ Nd pnprM, bd prglrwM 43 days b 1 yar
tetra death
d. r
lhtlotoevt N preprreM wNhin tlne D~ Y•er
30a. ~ 30b. 31. d Deem 32a Dale d Iryuy (Madh, dry, year) 32b. Deeabe How Irnjrsy Occrand Stree4 FertDry,
32c.
~ ~ ~c
'
/ v
d Caua d DatnT ~ ^ ~~e 01
)
l
^ ~ J
~~ NNOO ^ Y~ ^ ~ ^ Amt ^ p~yp t~ 32d. Trne d kt)trry 32s. Injrxy at WarlCt 32f. N Tranepodatlon kpsy (Spadly) 32g. Lacslbn d MMay (SnsN. dy /town, aleb)
^ Suk10e ^ Could Nd M Deterrrrlrned ^ Yes ^ No ^ Oniver / Opambr ^ Panrger ^n
M Otler • SPecilY
33e. Certlflx (deck OdY ohs) 3~. Sgretura and Title d CenNfer
r
• c«nlYwrg plryeldern (I'hyekkn awtlykng carpe d earn when anotler physkien has praeunced lath and conpleted hem 23)
TotlebatdmyknosiWlpe,dedhoaarraddwtolMCaee(e)andmweraWMd--------------------------------- ^ , ~j-,
~ 9 .•
'`-~
• Pranownekng rM artNyknp physklan (Phyaiden both prarorxnckrp death and arrwykng to awe d deetln) 33c. Licence Number 33d. Dale Signed (Modh, day, year)
Tote Met d my krrowledge, aa.th occurred r to time, sea, rod plea, .rna due to IM awe(s) «nd manner u .terse.. - - - - - - - - - - - - - - - - -
• R
nt
l F
N
/ c ~~ '73 ~ 33 i ~, 9 /v 9
e
a
.sem
er
«erer
On the bent d exanketlon end / a Mwsdge8on, In my opinion. death acerrrad et tM time. date. rM plea, sod due to tlns aros(e) and mercer es eterd_ ^
~. Nam
and
Addreae d Person Who C
om
~pleted Csua d Deatln (Nam 27) Type /Pmt
e^
Repleuar's : Dent FNsd (Mash
dry
Year) ,
,
~
/
Q
^
1
~
~~Y V ~
,
, ~
;
~ e
~ T' i 1Y~ p~~ 1~.5~C~ . t~'
Dlaposkion Pem9t No. , ~ (~' )."] ~~`T~'~ ~ / /o t ~