HomeMy WebLinkAbout09-30-09This is to certify that this is a true copy of the record which is al file in the Pennsylvania Division of Vital Records in accordance
with Act 66, P.L. 304, approved by the General Assembly, June 29, 1953.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
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Frank Yeropoli
State Registrar
Mritary
Stafius
1~~??Q~J
No.
;JAN 2 02009
Date
H, as-143 Rsv n/2ms COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
TYPE r PgINT IN
PewcK IINK' CERTIFICATE OF DEATH
reap incrn rrelnn~ e...4 o.e ...... -_..--
- t-Ilt NUMBEq
1. Name of Dacetlenl IFirsl tltle. IasL suRixl 2. Sex 3. Sxial Security Number 4. Date of Deam (Monts, day, year)
JoNN A2 • K~IVb JR• • _ _
5. Age (Last BiRhtlay) Untler 1 year Under 1 tlay 6. Dale of B~dh (Month, day, year) ]. Birthplace (City antl stale or foreign cwmryf 8a. Place o~eat'n (ChecklLOnej ~ ~~~ O ~ 0 s~ Z~
g rMnr~s pzvs H°ms Mi~ues HospiHt. Other
~ Yra December 30 1918 Ma sville, PA ^mpatient ^Egromparem ^DOA ~NuremgHOme ^Reaiaanp¢ ^omer-specity:
Bb. Coumy of Death Bc. Oiry, Boro. Twp of Death 8d. Facility Name (II rot insti:N.on, give street and number) 5. Was Decedent o! Hispanic Origin? ~1' No ^ Yes 10. Race: American Indian, BWck. While, etc.
(Ir yes, spedry aben, (spec/ry7
Cumberland Silver S rin Brid es at Bent Creek Mexican,PpedgRicamem.) 'bite
11 Oecetlenl's usual Occ aLM Klrte of work tlone tlurin most of works file. Do not stale refired 12. was Decetlenl ever in Ise 13. Decetlenl's Etlucanpn ($pecity only highest gtatle comple[¢d) 14. Marital Status: Marrieq Never Manietl, 15. Surviving Spouse III wile, give maiden name;
KinO of Work Kirtl of Buvness i Industry U S. Armed Forces? Elementary / Secontlary (0-12) College (1~4 or 5+) W'tlowetl. plvometl (SpecityJ
Su ervisor II. S. Na De of ^Y^e ^Ne 12 Married Jacqueline Ferray
ts. Decadence Maomg Andreas (sraet city /sown. agate np ¢¢aef De¢aeem's Ditl Deceeem
5214 Cobblestone Drive AdaalReaeen¢e lzaswle Pennsylvania weina t~q.~vea,Decedemrnadin_ Lower Allen
Townanip? Twp.
Mechanicsburg, PA 17055 nb conrnr Caa,raberland tad.^Np. Depeeem Dyed wknm
- Adaaf Limits of cdy / 13wp
18. Father's Name (First, middle, last, suMial
19. Mother s Name (First, mitl0le, maitlen surname)
John R
Rin Sr
.
. Lillian Nestor
'
2Ga. Informant
s Name (Type /Print) 20h. Informant's Mailing Atldress IStreet, city /town, stale. zip cotlel
Jac ueline Rin 5214 Cobblestone Drive, Mechanicsburg
PA 17055
2
,
1 a. Meldotl of Disposition ®Cremation ^ Donaliar 21 b. Date of Oisposi;pn (Month, tlay, year) 21c. Place of pisposiam (Name of cemetery, crematory or other place) 21 d. Location tCiy /town
state zi
code)
^ B
n
l ^
u
a
gamoval Irom State :Was Cremation or Donation Autlarlxed
^
w ,
p
Dlne•~Specify j byMetlicalExaminer/DOlpnel?
as^Np ocie of PA in
zza. s w m F reral ~¢e ^genaee (pr pera¢n a¢hr~ as aagm zzD
r¢¢na
N
b of Prussia PA 19406
.
e
um
er z2p. Nam¢ antl adtlreaa m Faddy Auer Cremation Serv ces o P ,
~ Inc.
FD 013376 - L 4100 Jonestown Road, Harrisbur PA 17109
Co Iems 23a-<mty w ceruTying 23a. To the bell pf my knowledge. death occurt at the lime, d antl pl ce slated. (Signature antl lillei
b
~
-
23
. License Number
Imyaidan is ntl available al a of eeam :o
`
~ _
cen.y cease of death -
5 ~ <' 23c. Date Signed iMOnm. day, year)
^'
_ ~, ~ _ _
Rams 24-26 must De compleletl by person 24. iim of Death n 26. Dale PronOUncetl Dane (Month, y earl 26. Was Case geferretl to Medical Examiner; Coroner for Reason Ot
m
C
who vrorwunces Ceam. er
an
rernaliqn d Donation?
C orUrom OF DEATH (see Instruetlons ntl eza gas) r Approxmate rnervaf. Pan Ir E m 5yg f I co tl Ions crotch t 1 d ntl.
hem 2 P d I. E.'ller Ise dla n of ev s d j plicalpns That dreclly causetl Ise tlealh W NOT
-t
t
m
l 28. Oid Tobacco Use CpntnDule to Death?
¢
er
er
sa
evens sues as cardiac arrest. Ousel Ic Death but not result n n the and I
respiratory acres., or venlr cola Ibdllal an without show ng the efology. Est only orre cause on each I'ne. 9 er ying cause quart in Pad I.
^ Yes ^ Probably
WMtlEDIATE~AU$E (Fmml disease or •~-~
con qn c
/ ~NO ^Unknowns
es 9 n ea _~ a , / ~ ~ _
. ~~ O n 1 W - - l_
LNG
_ • 29. II Female.
__
Du Ie (or as a
equance otl.
seweneaxy liar rgnditi¢ns
dany
~
~
- ^ Nol pregnant within past yea
,
, b ~-
y~
j CCp'r G~i~ dGYH~iY+~
ra
I atlinp to tM cause ksletl on Ise a ~y rprj
^ Pregnant al time of eeam
Enter Rte UNDERLYING CAUSE Die to (or as a consequence ol). -T
tli
^ Not
re
nant
nut
r
t
ilhi
I
sease or inNry that initiatetl the
vents res4lting in tleami EAST. p
g
.
p
egnan
w
r 42 days
of tlealh
D.te to log as a conseque ce oQ. ^ Nol pregnant but pregnant 43 days to t year
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-
30a. Was an Autopsy 30b. Were Autopsy findnys 3' Manner n' Death 32a pate of Injury IMOnIh
da
ear) 32b
D
nn
H before Deam
^ Unknown it pregnant wimin the past year
,
y, y
.
esc
e
ow Injury Occurred
Panorme0° Available Prior to Compiebon 32c. Place of Injury' Home, Farm, Street Facnory,
dcanaamDeam> ~r4aw'ai ^H¢mmide DRice 13ugWng. e:c. (Specity)
^ Ves ~JJO ^ Yes ®No ^ Accitlent ^ p¢ndng Inveshgahon 32d. Time of Injury 32e. Injury at Work? 32f. n Translaodalion Inju S acr
ry (p h) 32g. Location of Inlury (Street, airy' [own. stale)
^ Suwide ^ Coule No: rte Determined ^ yes ^ No ^ Dnver /Operator ^ Passenger ^P¢tleslrian
M. ^Otner-Specify.
33a-Ganinwr (chew any one) 33b. Sign and ie3e o Cenifi
• CMitying physician (Physician cenitying cease of tlealh when andher physiaan has pronounced tlealh and compleletl Ilam 231
To the hest of my knowledge tleefi otturretl due to the cause(s) antl manner ae statee_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
^
_ _ _ _ _
• Pronoundng and certlfytng phys' I. by both pronouni ng tlealh and ceetyng to cause of tlealh)
33c. License Num a 330. Date
o the best o} my knowledge de th tl t the time tlate end place. antl due to Ne cause(s) end tatetl_
^ r Sign¢J ,Mmth, tlay, year)
_
• Metllcal Examiner /Coroner M D - 0 ~ Z-Z_O (s - L 0 ~
On the hasis of ezamin
t
d I
'
' - O S' - 20 0 9
ron an
a
or
nvest gat on
n my oprnron death otturretl at the trine tlate, and place and due to the cause(s) antl anner as slatetl_ ^
34. Name antl Atldress of Per n Who Compieletl Cause of Death Illem 2]I Typa
P
~ ' °'int
episVar s g Jura and DistrfjQydflb~ L 36. Date Filetl Month, day, year) ~«~~ ~M
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