HomeMy WebLinkAbout09-03-09 (2) IOiBU~ KI.A' I/D?
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 wiill be forwarded to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.0+~
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____ Local Registrar
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COMMONYYEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS 'Z; '"~ ~
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CERTIFICATE OF DEATH ,,..~ e„~~,,,,••• -
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NAME OF DECEDENT (Fist, MIdWe, Lass) SEX SOCIAL SECURITY NUMBER DATE OF DEATH (MOnU, Day, Vear)
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2. Male 3,186 30 - 5689 4. rCC ~/ /~ a2
AGE (Last Bkihdey) 1 Y 1 AY DATE OF BIRTH BIRTHPLACE (City and C I
Mandta Days Haas MMules (MOnM, Day, Yeer) Stale a Foreign CDUntryj
une20 r 1937 rlisle r PA
67 v HosprzAU OTHER:
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COUNTY OF DEATH CITY, BORO, TWP OF DEATH FACILITY NAME (It not Institution, gWe aDeet and number) WAS DECEDENT OF HISPANIC ORIGINS RACE - Amedcen Indian, Ble k, Whit, at .
_ No~ Yp~ It yea, dPdcgY Cuban, (S~cflY)
~Lll[Iberland ~E.Pennsboro TW~3. Ed L~ ~ C c. - Mewun, Pu Rican, ek. +g ~]hlte
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AS CED Ni EVER IN DECEDENTS EDUCATION MARITAL STATUS -Marred, SURVIVING SPOUSE
DECEDENTS USUAL OCCUPATION KIND OF BUSINESS I INDUSTRY
IONe Nna of wxk uorr a I U.S. ARMED FORCESS (aR•db p1A)' ~~ pl•d• ••marr.d) Never Monied, Witloweq Inwre. plw magen aam7
mwen<x,pln•,mppr •^l Construction & ~ Ebm.nr.rY/a•eopd.rY oedep. Dlvoreed(spedly)
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DECEDENTS MAILING DDR S (Street, Ciryffawn, Srate, Ztp Cale) DECEDENTS 17a. State PA Did t7c
decadent IWed'm twp.
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120 Garrison Lane ,
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ACTUAL dacedenf
RESIDENCE GveMa
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ter. Carlisle, Pa 17013 rved
(See insiructlons lownahtp7 17d. No, decetlant I
DnDtlreralee) nb. county Cumberland fl Ndd11r1aCIDaIWr11IaD1 Carlisle drym«o.
FATHER'S NAME (First, Middle, Last) MOTHER'S NAME (First Middle, Heiden Sumeme)
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INFORMA E (T [) INFORMANT'S MA1L1 G ADDRESS (Sheol, CirylTown, State, TJD Code)
2a. Batt ter zob. 120 Garrison Lane C rlisle Pa 17013
METHOD OF DISPOSI
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ON DATE OF DISPOSRION PLACE OF DISPO TYO - Na d t r,r tory LOCATION - Clry/Tarn, Stale, Zip Code
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• SIG OFFUNE SERV L 3EE P SON ACTING AS SUCH LICENSE NUMBER NAME ANDADORES3(1FFACILITY Hoffman-Roth Etilneral Home
22b. 014819 L 220. 219 N.
items 2 c only when ce ng To the bast of rtry knowledge, death at N gm dal lace stated. LICENSE NUMBER DATE SIGNED
Year)
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physidan N na evadable al tkne of death to
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mane d death (Signature and Title) .
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Ilema 24-28 must ba canpleted by TIME OF OFATH DATE PRONOUNCED DEAD , Dey, Year) WAS CASE REF ERRED TO A MEDICAL EXAMINER lCORONER7 f ~, L EQ
person wtw prarourtces death. ~
24. ~7'-/ M. 23, rQ/CC/) /~ a~D ~' 28. Yea No ^ ~ Jp7/
27. PART 1: Em« rM dw...., In1eHa a wmpnoNbm wmm~ quad+na sad,. Do nor enh. e.a mod. or °yuq, .van u grdlae o. neplratory ar..at, enxk or Mart adore, (Approxknate PART 11: Other signiflpnt eonditkns conulbuting to tlearh, but
uar Dory on. nuq en each un.. ,interval between not reaultlng In ma undem7ing cause given M PART I.
IMMEDUTE CAUSE (Final A ;onset end death
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CAUSE (Dlaease ain)ury
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teaUllilg on dent) LAST l
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WAS AN AUTOPSY WERE AUTOPSY FINDINGS MANNER OF DEATH DATE OF INJURY TIME OF INJURY INJURY AT WORKS DESCRIBE HOW INJURY OCCURRED.
PERFORMEDS AVAILABLE PRIOR TO
COMPLETION OF CAUSE ~ ^
NeWrel Homfdde (~r1°'• o•y vwd
OF DEATH?
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~..J//''''~~~ Suicide ^ Could not ba deremlinetl ^ PLACE OF INJURY - At home, term, street, lec[ory, ofrtce LOCATION (Sheol CIryITOwn, State)
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CERTIFIER (Check only one) SIGNATURE E OF E TIFIE
"CERTIFYING PNVgICIAN (Ph 'ten certgying cause d death when a oth8r physkian has pronounced death end completed item 23)
To the best d my knowlwth occurred duo to the cau°a°{sand manner n alated. ............................................................... ^ / /y1 ,Q
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• LICENSE,fJU
MBER E SIGNED Mon ,Day, Vear)
7RONOUNCING AND CERnF-YING PHVSICUIN Ph sldan bent
( y pronoundng death and certify,ng to ceuae d deagl)
To N° bast d my kmWadga, tlnih oeeurrae ai the time, daN, arM plow, and duo W tlra eawsap) end manner ss atabd ................... D
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31e. 31d. 3 /~ eZ-D ET3"
_ NAME AND ADDRESS OF PERSON WHO COMPL TED USE OF DEAT7,
`MEDICAL FJ(AMINER/CORONER (Item 27)Type or Print LJ ~C,~A~.~ ~AZZ~~a vyd
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On Ora lraNa o! sxaminatlon arMlw Invaatigatlon, I° my opinion, death occurred st the lima, dab, and plus, and dw to iha ceuwa(s) end
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REGISTRAR'S SIGNATURE AND NUA1~ ~
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~ DATE FILED (Month, Da .Veer)
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