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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 15657582
Certification Number
_~-~~:_ =E! 11 :irio
1rP<_ ~atNr tN
uE,r,larlENT
°L~..K INK
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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 b forwarded to the State Vital
Record~i~e fp~ermanent filing.
Local Registrar
llate Issued
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS ~ : r
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CERTIFICATE OF DEATH •~ ~
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(See instructions and examples on reverse) STATF FIL F NIraAHFR ~..J ~ }~
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t Noma Ji Dr.,dent ;F~rsr •,:Jtlte lair. sutlul ~ Sax 3. Sonal Sacur;ry NumOer 1 of Daam 1Abnin, day. ar <., . !, .~ 1
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w c Male 188 -12 - 4465 July 29, 2
i Aya ~..L3el nau:tav~ User t czar Urdar 1 iav o. Date of Butft IMnnlh day, vest) % &rtnplace ICrrv and ;ta!a Jr tcr egn wuntryt t in. Place rl Dealh tChack xtw soar
0.4;neri Dar. IM1ais 4Mnutes HOSp1t31. lilndr.
88 ~' ~ Jan 5 1921 Dunearinon, PA ^ inDanent ^ ER Cwoaueni ^ DOA ~ Naslrg Home ^ Res,dence ^Cter - SDecrry
~b l Jar;-, 'r C ea:^. dc. Cary. Buo. iwp. Jrc Ceatn 8d. Fauuty Ndlne Ilf not ~niut:uwrt. g,ve strael and numozr; 9. Was Decedanl of Hupanu; Organ? ~ NO ^ Yes t0. Raue: .lnwncan utdlan. 6tack. WMte etc
111 yes speory Chan. rSpacrryt
ice Residence Mex;can. Puerto R;can ate, Cauc.
t t Cz_e~arc s ,:-„a' ti:_ca::cn K:rd Jf wOd 3l`ne d Unn' rM]sl pt m;:kc Ills Do na state ral~redt 12. Was Decedent dyer .n the t3 Decedanl s Educatwn ,Spanry Doty h;ynast grads comp leted) la htantat draws: Marred. Haver Haried. t5. Survrvtng Spo ols .tf .. de grvr ma;den nam41
K,r:o a .York KuM of Business; IrWustry U.S. Armed Forces' Elementary ' Seconuary 10-t2) Codeye t t ~a or S+f Wrdowad. Divorced tSpa;:ly9
UnknClwn UIl}CIlOWIl [~ves ^No 12 wldawed
16 Oa.:edem s ttadug Axress Sheet. cry town, state. ;W code) Decedent's Dtd Decedent
PennsylVanla
'] L, Actual Residence t; a. Stale
live in a t?c. ^ Yes. Decedent Lived in ~ ~ Twp,
20 N. 12th ST. Townsnp? r ,.,..,..Vi1
1'b. Counly ~..a.urrlJCi 1a1111 17d. [~ Noi
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!d Fanner ; Naana ,Fast Tw.:a past. luau) t9. Homers Narrw IFust. noddle. maldert wmamel
Unknown Unknown
'Oa. tntamarXS Name ~T.,Fa P~:r,11 20b. Intormani s Mading address r$treet. cry town. ibla, zb coda)
201 Po lar Hill Rd. Gardners PA 17324
21a 'dEln:wt .1 .:~sDCS~IKn ~.:iemauon ^ Dorgan
~ 21b Dale Ct DISp4id10n )Morin, >ay. ;rear) 21c. Place of OisDosuror,,Name of cemetery. crematory .r roar p,aoel 21d. lccatan IC~ry town:. state. no coos:
^ Bu:gar ^ Rem vai prom Stare ;Was Cremation or Donation Auth«ued
^ ~ roar ~_ a:.n ; 0y Medical Eaammer y c«dner? ~ Yes ^ rw
7/ 31 / 2009
Bitner Crematory, LLC
Harrisburg, ' PA '
.2a S:yrawre ,r = • _ ,caused person string di sucni 22b. License NtunOer :2c. Name an0.iddress of Facnrry Rena C.L. S[rilt FLnera ORYe r
- FD-014404-L 325 N. Hi h ST. t)uncannon PA 17020 -
Canptete Hems : t ;.ray .ran ceniryag 23a. To ma oast of my 'vno ga. deem uccurr 1 the tIRN. date ace stated..iSgnature arW btlei 230. L~censa 'rurrtDer 23c. Data Sgneo ;Hoorn. say, year)
prtySKldn 4 ral avdrlabla at :~me :f seam r0
~er>,ry cause ~ deem l.~
R ~ 3 ~ Sv 8 ~ ~-
o~ - X24 -02009
~ .rem, 2126 must rs comtwted by person 23 T:me ct Ceatn / /y~ 26. Date^Prortounced Dead ~ Mon/Nn~. dayy,.~vearl
_ 26. 'Has Casa Referred :o Medkatcxam;ner -Canter t« a Meason Otnar [ran Crernabon a Donation?
wn0 prbnpun[as Jeatn. 1 ^ ~ 1 M, r 1 ~ ~ M '
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(~ ` vc V ^ Yes NO
CAUSE OF DEATH (Sep inslruetlons arW Aaamplrrs~
r Aipraximate ~ntervti: Pan o enter Omer yyndKant cdnanorts contn0utv~tq'o death, 28. r7td Tobacco U Contrtune to DeaN?
~terrt 27 Pan I: Enter ;ne ;(,din cl evens - dlseases..ryurles. a complaauons -mat directly caused tlK oeam. DO NGt enter terrrurWl events such as cardlx arrest. r Cmset to Death out not r 95urying .n the urtdenytng cause gven in ?an L ^ Yes ~PrttOaory
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reipaatay finest. a venlncular tl0ntlatton aMCUt snowing the ebobgy. last oMy orw cause on each IoW. r
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Due to Icr as a conserJUence cf) v ~ Na pregtam a+tttn Dart Year
Sequenaaey ust cortatans. f any b, r
aa01Mj ;J ;f12 ;dose :iStad :n Ire d
I ^ Pregnant al tune d death
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Enter the UNOERLYY/G CAUSE Due to for as a Jonseguence oil: ~ ^ Not pregnant. 0u pragrtant wmwt 42 days
;msease a nlurv roar :rueatad :ne d I
dvar,ti resunir:g n deaml IAST. r of Beam
Due to nor is a ~nseQUence or1 . ^ Not pregnant, but Dregnanl a7 days to 1 yeti
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^ Unkrawn .f preguYd a;thin iM Gas) yeL
30a '.Yes an auteFsy s:o Nere ~ulopsy Flndutgs 3t. Mannar of Gaam 32a. Date tit Injury tAtonm, bay. ;;earl 320. Descrae Mow In;ury Occurred 32c. ?rata ct ~nlury' Nome. Farm. Street. Fanny.
Pertcrmad° avartaore Pray to Compleucr:
~Nalural ^ lianKWe CtIKe BuAa stc..S
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a Cause >f Ceam?
^ r=s ~ `+o ^ 'yes ^ No ^ au'~ ^ Penang mvesngaudn 32d 7TR ;t inrury 32e.:nl~; , ;t Mork' 32t. II Trarsponatwn ;rqury ;Scar: h•l 32g ~ocaucn cf Injury ~,Strest. coy town. stale)
^ Boards ^ Coua Not Oe Determined ^ Yes ^ No ^ Dover Operates ^ Passenger ^Pre<.r~an
M Cater ~ Speury.
3?a ,:drown c~:.:r :rny xe~
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Ta the best of my krwwNdge. death «currsd dud to tM cwsNs) and ;ttenrwr as stafetL _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1
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• Pronouncing and ceni}ymg physician ;PnysKtan darn .rcncuur,;rg dEa:n and cerurrmg ;o cause ul aeatr
To tM best of m
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^ 33c. LJerse : tumeer aid Dale S~gnad :r+onm day, ;earl
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ale. and prate, and due to the cwxysl and manner as stated_ _ _ _ _ „ _ ... _ . _ _ _ _ _ _
• Medical Eaamlrter, C«oner ~ f~ ~ h~ ? L -~ ~ ~ ~ / L J C
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On :he Dasrs of a matron and / « investgauon. m pinion, death occ«rad at tM time. desk. and Dlxe. and due to the causetsl and manner as sUtad_ ^ ,a ,raT . ~:.. ,, ~ ~ ~. _,
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