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Home My WebLink About04-09-10~K ~~'`i . Rt.,! REGISTRAR'S CERTIFICATION OF DEATH I..OCAL hotostat or photograp h WARNING: It is illegal to duplicate this copy y p ~ ~ ~ Lt' 1 ~t Ill loll It i, 1 ~'}~), i~ l(l ~L i h ;.:'I A,al (`; l1 C ' )~ u ~ ~ 11i) ;.'' Q,~~H ~Q~Pfjj,'\ e i'tlr lri~, rertlt.~~l~. ~ j, rr~n >rtl~ .t F~) ~ tlt,+ t~ ~ 1 i~! C - ( c~~1 < . ~ _ ~tl Ij I rr~1~1,;1 < ,_ ,Pf..~ ;~~~~ • ~ ~_>~_ a ~. du1~ f ii,rd ti~ (tll n:~ i ,,. ~~ ~ : ~ ~ l~ i~ ~,~~~ ~tl t ,. ail; ~ ,)~t.: , cerh~icatc dill , ~ _ ~C~cT1"[~~~ Olih C )r. i l.li ~ ° ~,=~r ~ ' ' ~G~rY~2. ~ "~ f MAC 3 1 010 ~ ,; ~= `~~~~ ~~ P ~ 6 ~ 7 6 315 OF ~ rM _ _ ____ ----- __ - , _ _ -- - _ EN ,s -- _ -- ~,,,,,~~,,,~: L1,~a1 tze~~ltil1~:~~ rv _ -- (L(Uii~ lug, ; ~~ tither ~ ~:' O ~' _ Z F~, ,' `(~ ~~ i~ ~ ~ ~ f .., _ ` , t_-.; :a ~;~0 err -(". 1 - ~ ~~ ~~T ~ JG ` f l ri ~4 ~ ~ ~ t COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS 3REV 1112006 CERTIFICATE OF DEATH / PRINT IN 1MANENT (See instructions and examples on reverse STATE FILE NUMBER ACK INK 4. Date of Deam (Month, day, year) 2. Sex 3. Sodal Security Number 2 ~ 1 1. Namedpecedea (Flrst, miMee, last sulkx) Male 003 - 12"- 0632 March 27, Char 1 e 6 N . Trask 7.8inhplace (City and state or forekp~ counhy) ee. Place of Deem (Check any one) Under 1 year Under 1 day 6. Date of Binh (Monm, day, Year) Hospital; Omer: 5. Age (Last BinndaYl Hours Mininm ^Other ~ Spedry. klatla daY• Keene , NH ^ Inpadent ^ ER / Oapedenl ^ DOA ®Nureing Home ^ Residence 85 Vre September 22, 1924 10.Race: Amenran lnaan, Black, Whtte, etc. e street and number) 9. Was Decedent of Hispenk Origin? ®No ^ Yes ISP~d1A &. City, Born, Twp. of Death fid. Faakry Name (If trot inslNWOn, gtv (If yes, spedry Cuban, , - 8b. county of Deam Mexican, Puano Rican, etc.) Whlt e Ttrp, Golden Living, Camp Hill ve maiden name) Cumberland E. Pennsboro _ 1q Marital $Iatus: Married, Never Named, 15. Surviving Spouse Uf wife, gi cl on h' hest reds completed) W~ow,~, Divorced (Specify) 11. Decedents usual Occ eon Kind cl work done dune most d work) Ina. Do not sMte reared 12. W S De~Od Foy! ~n ma 1Elemerdary / seca,dary(1a 2N N eDa~ l1 ~ or 5.) Pear 1 Pamela Jeffery ICind a work Kind d easiness / Industry 12 2 Mar t i e d Master Sergeant US Armed Forces ®Yes ^"° DidDe°edent Newberry Twp. Decedents pennsylvania LNe ins 17c.®Yes, Decedent lived in 16. Decedent's Maifug Address (~. city I town, state. z1P ~) Actual Residerxxa t7a. State Township? 17d. ^ No, peceeent Wed within 1070 Sevens Road 17b.pa,pry York AdaaltaniMa ~''' B°'° York Haven , PA 17 37 0 tg. Maher, Name (Brat, midge, maiden sumeme) 18. Femers Name (Flrs4 rtkdtlle, last, suRa) Vina Soucise Norman Owen Trask zob. mrorrnanra ldeikng Address (sbeeL dN /roan. pare, ~ ~) 2oa. mrom,enre Name (typal Pnm) 1070 stevens Road, York Haven, PA 17370 Pearl P. Trask 21d. La~tion (Ctlyltown, state, zip code) i Crernetlan ^ ~~ 21h. Data d DisPOSitlon (Monm, say, year) 21c. Place a Disposiean (Name a cemetery, cremetary a oma place) 2ta. Mellwdd Diaposidon ^ April 2, 2010 Indiantown Gap National Cemetery Hanover Twp. , PA 17003 ® Burial ^ Removal from Slate j Med~pl Examiner~~Ca~one~ ^ Yes ^ No • ^ Otller ~ SPecdy~ (a 'ng as such) ?2b. License Number 22c. Name end Address a Failmy 2za.signa FD 013 340 L Parthemore FH & CS, Inc., P.O. Box 431, New Cumberland, PA 17070 _ , 23b. Ucense Number 23c. Dale Signetl (MOnm, day, year) Complete Mans 23ec onN when cenitying Tome best d my giow1edge, deem occurted at me Mite, date and Plats mated. (SignaNre and title) physiaan N not avatlade at tlnle of deem to ceretY reuse d deflm. 26. Was Case Refarted to Medical Examiner I Coroner for a Reasm Other than Cremetlon or Donatbn. 24. Time of Death 25. Date Pronounced DeedL(.~~~ah, day, yeal ^Ves I•r-~~.^.°/ Items 2426 mast be cartidm~ b' DBf80^ i 2 • 3p q M. Mar I l 2'1 20 I v wits pmrwrxMbs deem. I r Appmxunete interval: Ped IL Enter Omer - "~-"-~'""`'""" mb-mao to deem. 28. Did Tobacco Use ContdhNe to Deam? Yes Praba6N CAUSE OF DEATH (See Inetruelions snd exempbe) r Onset to Deam Mrs not resulting in ere undenying cause given in Pan I. ^ ^ in ties, a canpkcaeons -met dlreaN causal the deem. W NOT ante temenal events such as cardiac artesl, r ^ No ©~n mown hem 27. Pan I: Enter the rha:n d events -diseases, N the etldogy. List Bay one cause cn each line. r respiratory artest, a wfntdcdar fihdllafion whoa showing r 29. If Female. / ~ ~ / ~ r //"~ ^ Nd pregnant within pest year IMMEDIATE CAUSE IRnal disease or ~ V ~ ( Kse- r contlitlon resulting indeem) -~ a. 1 r ^ Pregnant at Mme of tleath Due to (a as a wnsequatce d): ~ `Y r~ \ ~ ^ Not pregnant. but pregnant within 42 days SequenealN kst conONOns, ii any, b. ~` G ~~ ~ ) r of death MM r ~aaynp to a reuse listed on kite a Due to (or as a consequence oQ: r ^ Not pregnant, but pregnant 43 days to 1 year Enter {he UNDERLYING CAUSE ' helore deeM (disease or injury mat initlmed me c. r events resdbng m loam) USL Due to (or as a consequence ofj: ^ Unknown if pregnant wehm the past year d r 32c. Place d Injury: Home, Fartn, Street Faaory, 32a. Dale d Injury (~nm, day. Year) ~~ DescnDe How Inlury Occurred Office Builtlirg, etc. (Speciry) 30a Was an Auopsy 30b. Were Autopsy Findings 31. Manner of Deam Penamed? Available Pdor to Completion latural ^ Ftomicida 329. Location of Inlury (Shell, aN I town, state) d Cause a Deam? 32d. Time d Injury 32e. Injury at WodC! 321. N Trenspatetlon Injury (Spedty) ^ Accident ^ Pending Invesegaeon ^ DrNer I Operator ^ Passenger ^Petlestden ~ ~,/ ^Ves ^ No ^ Yes ^ Yes L_y^~• ^ Suicide ^ Cald Nd he Determi~d M. Dtha' SpeaN: • 336. Signature arts TNe of CerMier cif 33a. Catlfia (check only one) ~ ~_ ' ` ~ Cer111ylrq phyakhn (PnYSiden certifying cause of deem when anomer physkian has pronounced death end canplaed Item 23) 33tl. Date Signed (Month, OaY~ Year) To tlta best d my Ipq,lledge, death occurred due to Me cause(s) end manner m aletetl _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ . Lcense Number ~~ ... ~ l,O akien (Ph ' n hdh prawurwing deem end certmying to cause d deem) O ~ ~~ ~ C7 rl /•r ,~~ 3 Pronolaicdng snd cenKYin9 DhY Y _ _ _ _ _ _ _ `T To the beet of my lorowkdg& tlealll occurred at me 6me, data aal Apra, and due to me puea(a) and manner ae _ _ _ _ _ _ _ _ _ _ Nedkel Examine / Cacaer 34. Name antl Address of PersarWiOEOalde ti~"~itVf~l~l"f'111~R;'tD.l]• pit the basis of axeminetlon and I a invea6gatron, in mY oPinbn, deem oceurted at Ure Urrre, date, and Place, a~ due m tlro reuse(s) and manner es atMed_ ^ 11.77rr11CC`1177 ~t n /~f ~r (~ ~~ ~ / /f 36. Del Flled ( ohm, day, Y~r) /'~ G L°I/ CCU / 35. Regishar~a ~~tyre aid Des ~ IO7 ~ l I d I ~ ~ ' I ~ •~ pr(> ~d D7Cl ~ r,,...,,...~n Permit Nn. C~5 ~ 51 a .