HomeMy WebLinkAbout03-15-10 his is to certify that this is a true copy of the record which is on file in the Pennsylvania Department of Health., in accordance with
the Vital Statistics Law of 1953, as amended.
WARNING: It is illegal to duplicate. this copy by photostat or photograph.
54_.32420
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Linda A. Caniglia
State Registrar
MAR 0 9 201,,
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No.
H105.113 REV 11/1006
TYPE / PRINT IN
PERMANENT
BUCK INK
CORRECTED (TENS: ~~~ 17 A- h COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS ..~ ~ G7 "^-~b '~~
per; r-~ DATE:3 -~- ~o o~ CERTIFICATE OF DEATH ~" Q~48~~
(See instructions and examples on reverse) STATE FILE NUMBER
1. Name d Decedent (First, midde, last, suffix) 2. Sex 3. Social Security Number 4. Date of Death (Month, day, year-
Ruth S. Van Brakle F
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e 185 - 28 - 1862 January 11, 2010
5. Age (Last BiMday) Under 1 year UMer 1 day 6. Date a Bill (March, day, year) 7. Birdplace (City and state a bregn candy) 6a. Place d Death (Check only are)
Ma~e~s Days Ha.s sknuks Hospital: Other:
8 7 Yrs. September 16 , 19 2 2 York, PA ^ Inpatient ^ ER /Outpatient ^ DOA ®Nursing Home ^ Residence ^other - Speaty:
' 6b. County d Death 8c. Ciry, Bao, Twp. d Death 6d. Faaliry Name Qf rat institution, give sleet and number) 9. Was Decedent d Hispanic Orgin? ~] No ^ Yes 10. Race: American Indarr, Blade, White, etc.
•
Cumberland
Upper Allen Twp.
I'~1~SS.~.' ~} }-~ ~/,~ l/C~H G'~ (K yes, sPe~Y ~~,
Mexican,PuerbRican
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) ISP~i1
11. Decedents Usual `tan Kind d work d
one most d fife. Do not spte reti
12. Was Decedent ever in the 13. Decedents Eduatiar (Specify only highest grade comp ,
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leted) 14
Marital Status: Marri
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i white
Kkd a Wok
Kirxl a Business 1 Industry
U.S. Amred Forces?
Elementary /Secondary (0.12)
Cdlege (1-0 a 5+) .
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wx, D ISPe~11 15. Surviving Spouse (K wile, give maiden name)
Dietician Food Service ^Y~s ®No 12 4 Widowed
16. Deoederd's Maikrg Address (Brest, dry / loam, slate, zip cwde)
I o v '~'1°T' A~lel~-- ~ R r Decedents Did Decedent
Aawl Reeidence 17a. stale Pennsvlvan
ia ~
170. ®vea
lkcedea Lived in ~
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16. Fallrer's Name (Pest, midde, last, srdfix) 19. Mother's Name (first, midde, maiden sananre)
George Edward Smith Mabel Amelia Goodling
20a. IMamera's Name (type / PIN) 20b. Inbrmant's Mat'ng Address (Street, cfly! tavn, shale, zip code)
Karen R. Worley 118 Plank Road, York Springs, PA 17372
~ 21a. Method d Disposition ~ ^ Cremation ^ Donation
® Buda) ^ RemovaltranState 21b. Date d Dispceitiorr (Month, day, y~ 21c. Place a Dispasitlar (Name d cemetery, crematory a other place) 21d Condor (City 1 bwm. state, rip code)
W»CrantlionaDartlonAuthorfaed
w ^ other - spaciry: ,try McrJial Er.ndrr / Coronn't ^ Yea ^ No Januar 19, 2010
~' Pros act Hill Cemeter
P y Manchester
~1 p , PA 17 404
' 22a Sigretae (a acting as such) 22b. Licare Number 22c. None and Address d Faddy
- FD 012 848 L Parthemore FH & CS, Inc., P.O. Box 431, New Cumberland, PA 11010
Campale dams cerAyrg
physidan ~ not available at drtr d death b 23a. To d,e best d my krrowladge, death accused at the tine, date and place stated (Signature and titre) 23b. License Number
23c. Date Signed (Mordh, ley, year)
axdly cause d death.
dams 24.26 must be completed by person
~ ~o a ~' 24. Time of Death ~ (~ ~
~ 26. Prorrorrrced Dead (Modh, day, yearn ~ ~ ' D 26. Was Case Referred b Medical Examiner I Coroner fa a Reason Odrr than Cremation a Dautiar?
M.
e ^ Yes ^ No
CAUSE DF DEATH (See and exarnPles) , Approxirtrte interval:
dam 27. Part t: Ereer the mein d event - domes, injrxies, a canrpNcadons - tlrat d~ctly ceased IM death. DO NOT enter dxmirral evens such as car6ac arrest, r Oreet b Death
res
irato
arrest
a verdriada
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h Part 9: Eller otlrer '
but nd resuEng m the r,rdarykrg c~sa given in PaA I 28. Did Tabaxo Use Cartnbule b Dean?
Yes
^ ^ Prabedy
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avkrg the etiology. List wry one an each frr. r
r . eQ~No ^ Unloawn
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-~ a. ,O>?7L'~tKJ1E' ul0 O~i.S ~ti/Cek ~iia-lihG-J ~.~"
Due (a ae a coneeprrra oft: ,
1st cardtiar, ti any, b, r
~2/Ylerl ~ E} d ~ ~ Q'Not cregrwe witlwr past year
^ Pre
rrM tl time d death
awe itled on 6ne a. r g
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Filer IINDERLYNyG CAUSE Due b (a as a cerrsegrrrrce oQ: r
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event re~d6ng
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Due b (a as a cauegrrrrce oft; i
d C, „ w ^ p but pregnan143 days b t year
. ~1, ^ Unlarown 1 preQwd within the past yer
30a was an Aubpey
Performed? 30b. were Autapay FinSnps
AvarlaYbb Pla b Canpledon 31. Maarr d Deatlr
,_,/ 32e. Dtle d dyray (Marty, day, year) 32b. Descn~e How Ooarred
~ ~• ~ a'uF. ~ Street, FetdorX
d Cause d Death? ^
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^ Yes [t~No ^ Yea ~No ^ AcAdenl ^ Parrdeg ~ ~' Tyne d ~ 32e. dqW tl WaKt 321. M Traropodadon tryay (Syec~Ty) 32g. Laotian d Ivry (Street, dh' /town, stale)
^ Suirdde ^ Could Nd be Debrtdrrd ^ Yw ^ ~ ^ Ddvx 1 Operebr ^ Passenger ^Pedestriarr
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33e. CertMx (wreck ady ar) 33D. 5predra and Tide a Cerh'Fer
' D~q p~ Ip ~g care d eeeer when ralrr phyeiden nee prarorrrced dean end oompleed INm 23)
ToYrbetlalmytaawNdpe,deelbaaonedduebtlupwe(afeMmenrraeYMd---------------------------------
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Prcirg dadr and certilyirg b awe d deelh)
To tlr bat of my deetlr oeaand tl tlr tlme, dell, end plane, utd due b the aua(e) end merrwr a staled_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ 33a License Number
33d. Dale Sprd (bbntlr, day, year)
• lMsrAetl Erenrtrrr / Ceraw
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~. Name Address d Person NAq
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bd Cause
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