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HomeMy WebLinkAbout12-15-10 105.805 REV (01/07) ~. I ` ~ ^ I / + ~-(~ 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 16085970 Certification Number 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 forw~d to the State Vital Records Offic~f~z permal~t filil~, ;~ vi-. 1 V 1 a1V ELECTRONIC MALFUNCTION WITH r ;O~ _ ~L ~U~ ~ 1IMECLOCK -THE CLOCK DATE ON ~ ~7 THIS DCX;UMENT IS 12 I IOUILS BEHIND -p'"~ THE ACTUAL TIME. :t> ~~(~~ji // l]~ ~ --REGISTER OF WILLS/CLERK OF ORPHANS' CRT ~"-~~~~~'~"--~~Q~~"~-I-~~``~ PT.F.ACF. N~l'TR• nI IF "rn a~T Ntos•t13ltEV tt2DOS COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VRAL RECORDS rPE / ~"~ al CERTIFICATE OF DEATH ~SLACKaN( (See instructions and examples on reverse) STATE FILE NUMBER ~I CJ1 =z~t~ Issued Cy:: ° 3 ~~ _ ,'~ G77 ~ Nrre d Ddaedwu (FNU, midde, W, rNlb) t 2. Err 9. Socel SewNy NMMer 4. Due d Drtlr nth rbX Y«n . D. Hazel Mellot Female 183 - 07 - 8396 December 5 2009 s. Ap (VU BiMdy') UMw t llntlw t 6. Due d Sitlr 7. ~ W stab a M. Pbc a D«tli Greta w one H«DNeI: OMer: Mwle Drys ttani arena 10-14-191 9 Pinola , PA ®lrlpmient ^ ER / Darombm ^ DOA ^ Nuaip Noma ^ Residence ^ Olnr ~ specny: 90 Yrs. S. Wr Decdem d wero~ ~^? ®No ^ V« 10. woe: Amarcen hMbn, Bledc, Whne, stc. - Br. Cardr d Dxn ec. CNy, Saro, Twp. d Deets m. Faciy Name M nd YreSUnon, ~ eart end mrrdw) In Y«. iD•dY Gben~ (SD+a~Yyt ~ ~^"^ rmn, ~) White Franklin Chambersburg Chambersburg Hospital 11. DecMm'a l1wW Kid d earls eons mau d w. Do nd ebb ~ 12. Wr Dectlenl ever b are 19. Decdrre Eduction (Seedy snits ~ wn4bbnl 11. Medal St«r: Merced, Nevin MrdM, 1s. Survharp Slreuce m rMe, p+a maiden nerre) ~OWb' Dhacetl (SPedyl Kid d Wark Kku d BrNwlbanay U.S. Armes Farce? Eb~ry I Sewtdery (P12) Cdbpe (N or 5r) widowed 12 Years homemaker ^ r« ®No 18. Decerrl's MuInA Atldnr (Sa••L Day/mwn. alb, zip ~) Dectlem's Did Decdeni oecedem urea b Ttro~ PA Live b a t7c ^ Y« 206 Roxbury Road , . AeaW R«leenc 17a. Sbm tin ~, Cumberland T°retmtnT na. 6a ~~ ~'+~' Shippensburg ~,/~ Shippenaburg, PA 17257 N M ' 18. Fmlrer'e Nrre (Fxe4 sidle, WL wawl en rrtremrel ddle, me s Nmna (Feu, n 19. Moan Aarvey B. Kauffman Lucinda Ellen Stale 20e NammriYi Nan IYYDe / ~) 2gb. Mamad'i MmNq Addrm , cY / torn, alb, z9 wee) VA 22181-3220 Vienna 2227 Abbotsford Drive Jane L. Carl , , 2ta. Metlred d DbpcYion r ^ pw,reypri ^ pwatgn 2tb. Due d D'mp«!iw (Mwdh, may, Y•+r) 27c. Plec d D'repnNbn (Name d ', aremmmY w direr Dbc•) 21tl. locNw (L11y/town, lime, zip wde) ® eodei ^ Rwnwalhantiele ~ wrCrwtmtlon«DwreebnAanalra 12-12-09 S rin Hii1 Cemeter Shi enebUZ PA 17257 T ^ Y«^ No P g Y P + lC oronr ^ Darer _ M rMlem EdwNrw ~ 22e. 31pWUe d Funwu pxeon eWrq r wrch) 22b. liirerir Nwtber 22a Name end Addrer d FaaNt' FD-012984-L Fo elsan er-Bricker Funeral Home Inc. Shi ensbur PA 17257 ~ ~ ~ rte aridaNe) 23b. tirire d(ay 7.lcc. Deb Slpred lM~,dY~Y•a0 artnaa+neduarearre, dab endpbw limed. tSiP+« DanPbb awn 23.s Wywhen cerllyin8 23a. Toare trek d [ y mt:ndarmb C7)r~,t.~. ~ 1. fit/ % ~~~~CT~~a~/ Q''`~ R1~513111-L DC~embP.~~S ioog bb a d M 25. Dab Prorremced Dead (Mats, aey, yam) 26. W« Case Reb Medkm Eurnerer / Cororrer br a Re«an Oawr wren Cremafian a Donaw? Tire d D« 21 . lams 2428 mrel be by Din ry wno Dremuc«erM. //1/ A M. D2L+e/lt be/~s t~Dy ^V« Na. . h7 i D ' ~ ade to rl 28. Did Tdrewo Use Cardr CAUSE OF DEATH (See Inetrseattons and aanmplss) 0.pproamrele Mervin: Pad 11: Enter Darer Ibm 2Y. Pan I: Erma are mro.dsYals - aeeara, Mme, a 10fe - aim lredh rnmd th arm. DO NOT w«r temiiiel events awn «carlec erreaL r Oreei to D«Ih bd not reeiYnrq n IM unded/inp ceuro given n Pan I. ^ V« ^ Probaby Q'Fb ^ lNNOiown reepbmory artew, a ramapAer IDribNon wntred ataaing th eaob8y. Lim day ore sane w rch Nre.. r ~~~ i 29. n Fameb: ©~ Nat pegmnl vMiii past yam m~ilnon recultln9 b deeNl a tC ~ ~ e _~ a. r oq. r ^ Prepmm u Nnre d arm pre m (a « a net wridliora, N wv/, p, ~ ^ Na pregrem, bd Dre9rem wNhnt /2 days b woes Nebo w kre e. Due b (a « e dG d deaN EUNDERLt'NG CAUSE r hul piegnBM 43 days r 1 year ~ ^ Nd WPbb d , are c (ebrr a injury aret iineb event r«rdMp n seats) LAST. Due m (a r a wreet~mo oq: r bebre arm ^ llNorown X prapreM wNNn the Deli yrr d. r 9Da. Wr r AaoWy 38b. Were Aubpay Fbinpa 31. 32a. Due d Nyury (Mwtl4 dey,Yerl 32D. DamrEe flow N9wY Ommee 32c. ~d& Rome, Fem.,/Street. FMOry, PwlomadT Avanede Prior b Cwgbtion whuu ^ Nomldde d caw a DemhT ^ Acddere ^ PenlnB lnvempetlon 32d. TNne d lnury Sze. bMt' u Wark7 32I. n TrdrepMatbn NMwY (Syearyl w ^ Peeerbn caer l ^ P ^ Din /O 328. Locmgn d inMY (Siren, cNY /town, state) ^ V« t1o ^ Y« ^ No ^ Suicide ^ Cadd Nd be Omerrrdrietl M. ^ V« ^ No pere or a g ar peer. Speafy; ~.(~~~) 33b. SprWUre end T' dCenSrer ' CeuWbS PhY•kbn IFM~bn ~NYI^S cues d death wlrrr eretlrer prysirbn Ms prareuaetl sash rrtl wn9bt•e hem 23) • ) ,, To Hre MUdmy b,oaWpe,arM acwred dnarthe wwepl•~~rrmW_________________________________ 3~ 1N~ 33d. Dale Slpred lMaah, ny, yam) • Prwrarering and arlAYYrp p~b^ (PhnMs^ ~ PO erne end cwMYbg b tree a arts) To tle Oeu d my brewbd0•• tlrlh rrecurree m the 1Mr, ear, asd pbc, arm sue b the erre(d) dM manner r etuea_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ . ,C' ~ ~ ^{ 2~ 1c \ ' "L t ,J ~ 'p- O ~U • tMlzu EadnYrwlgaarrr dw,~pbc,drW tlr to thecwaye)rdmwrerrsteted_ drtlr utne tbre o Mwt t &. Name end Addre«dPer~on Who Canplered faueed Damh (pain Type/PnM , p , iny On am lrbdeernbMion aMlw 35. Rapmrefs SpWUre and OMad I ~I ~ I ~ / I `) I 96. Due FNetl h, aey~ ~ U ( \ v`~ ~~ 'U I'c (~ /, r , J 'w. C ~ C. ~(I) l z7'~1~ \ J I 1 1 f'7 rl. , Y DbpoeNim Perndl No. y'1y ~'~ -J ~ 1 / •.