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H105-143 REV 11PL006
TYPE /PRINT IN
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
(See instructions and examples on reverse) crerc cu c w u~ncn
1. Name rn Decedent (Flrst, middle, last, suffix)
Dorothea Mae Gillespie 2. Sex
Female 3. Sgcip(Sscuriry Numper6 2 5 5 6
[4}`~LL}} l1 - 4. Da rn ath (Month, da ar)
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5. Age (Last Birthday) Under 1 year Under 1 day 6. Date rn BiM (Month, day, year) 7. Birthplace (City and state or fo reign aanfry) 8e. Place of DeaM (Check on one)
9 4Yre Atonlt~s Days twos Mhxxee
12 - 5 -1915
Kansas City , M o . Hospital:
^ Inpatient ^ ER / Outpatient ^ DOA Other:
ursing Home ^ Residence ^Other - Specify:
Bb. County of Death Bc. City, T f Death 8d. FatiGty Name (If rat instdution, give street and number) 9. Was Decedent of Hispanic Origin? No ^ Yes 10. Race: American Indian, Black, White, etc.
Cumberl a n d West P e n n s b o r o N ~ (Ii yea, specify Cuban, (specify)
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I ~ Mexican, Puerto Rican, etc.) L.y ~ •
11. Decedents Usual tlon Kind of work d one dud most rn Ida. Do rat state retired 12. Was Decedent ever in ttre 13. Decedents Educatan (Speaty any tdghest grade comp leted) 14. Marital Satus: Mended
Never Married
1!i
SurvMng Spo use (If wife
give maiden name)
Kind rn Work Kind rn Buaineu / I
ndushy U.S. Amred Forces?
Elementary /Secondary (0.12)
College (1-4 or 5+) ,
,
Wxlowed, Divorced (Specify) .
,
06der Fill Nuts & Chips C~]Yea ®hro 12 widowed
16. Decedents Madirp Address (Street, city /town, slate, zip aide) Decedents Did Decedent
173 Stoney Point Ave. Actual Residence 17a. Sate P a Live Ina 17c.
^Y~~D~^"~ad"'- Twp.
Shippensburg
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1m.ca~ty Cumberland t7d.^ ~
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18. Father's Name (Flrel rtddde, lest, suffix) 19. Mothers Name (FBI, middle, rrraiden sumarrre)
Claude M. Ha es Nellie Marie Harkness
20a. InfomienYa Name (Type / Prtnl) 20b. Inrortnants Marling Address (Street, city /town, stare, zip axle)
Nellice Gilles ie 173 Stone Point Ave Shi ensbur Pa 17257
21 a. Me rn ~ ^ Cremelbn ^ Donation 21b. Date rn Disposilgn (Month, day, year) 21c. Place of Dispositbn (Name of cemetery, aernatory a other place) 21d. Leafion (Cdy /town, state, zip axle)
Q a,dal I~ Removal from stela i Wes Cromstlon a Dorotlon AuMorized
^ Other - Specify: t by Medical Examiner / CorarterT ^ Yes ^ No 4 / 10 / 2 010 o h n s o n C o Memorial Gardens Overland Park K a
I'~ jct.`s
22a. skyla~ f Funeel Servke Licensee a person acting as such)
~! 22b. License NrmYter 22c. Name end Address of Faclllry g g e r u n e r a 1 O m e n C
- FD 13895 L 15 Big Spring Ave Newville PA 17241
Camplele dams 23ec only when certilyirg
physician Is not evaileble of time rn death o . To the best rn my death occured at the tirtle date and stated. (Signet I ~
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~ A , 23b. License Number 23c. Date Signed (Month, day, year)
rxMilycaueerndeath. ~
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dams 24-26 must be mmpletee by person 24. Time of Death p ,M~.'f~L
~- th
, day, yea
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25. Date p ~
" 26. Was Case Referted to Medial Examiner /Coroner for a Reason Other than Cremation or Donation?
who pnonaxaes death. ~'M M.
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~ 1 ~~ L 1 O~v ~ D ^ Yes ^ No
CAUSE OF DEATH (See IrratrucUons and examples) t Approximate interval:
Kem 27. Part I: Enter the 1~]giD9~fl1tlm1S - dseases, injurtes, or canlplicefions -that drectly reused Ste deaM. DO NOT enter terminal events such as prdec arrest, r
Onset ro Death Pad II: Enter other '
but rat resufiing In the undertying pose gNen in Part~l. 28. Did Tobacco Use Contribute to Death?
^ Yes ^ Probably
respiratory arteal, or ventricular fibdletlon witiraa slawirtg the etiology. List only one cause an each Ihe. r
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IMMEDIATE CAUSE (FNlel dseese or ^ No ^ Unknown
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cardition resrdtlng in death)
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29. If Female:
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D o (or as a consequerxxy of): - Not pregnant wttNn pest year
t~6y
~~adr~q to the soon Ia~ie e. b' ~ ^ Pregnant at time rn death
Enter the UNDERLYING CAUSE Due to (or as a consequerae oQ: ~ - ^ Not rd, bt,1
pregna pregnant wiMin 42 days
~d~a~sara~u ~l~s ~esT a c. r
r of death
Due to (or as a a>nsequerae o :
f) r -
^ Not Pregnant, but pregnant 43 days to 1 year
d. '
r !afore death
^ Unkrawn H pregnant whNn the pest year
30a. Was an Autopsy
Perbrtned? 30b. Were Autopsy Failings
Available Prior to Conpbtan 31. Manner rn Deattr 32a. Date rn Injury (Month, day, Year) 32b. Describe Flow Injury Occurted 32c. Place rn Injury: Fkrtte, Farm. Sraet Pettey,
rn Cause rn Death? Nalurel ^ ~~ Office Buildag, etc. (Specity)
^ Yes ~ ^ Yes ^ No ^ '"l ^ Perxing Imes8ga6on 32d. Time of Injury 32e. Injury at WorKl 32f. d Tmneportatbn Injury (SP~ih'1 32g. Location of Injury (Sreet, sty /town, state)
^ Su~ide ^ Could Nil be Determined ^ Yes ^ No ^ Driver /Operator gar ^ Pedestrian
M Other • Specify:
33a. Certifier (dledc Dory one) 33b. Signature T Ce fier
• CertHying physcian (Physician cerOfying pose rn death when another physician has pronounced death and axnpleted dam 23) /~
~~ •. C.,/ .
To the beet of my knowledge, deetlt occurred due to the pose(s) and merxler as stated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ " ~ ~
• Pronouncing and ubNlying physician (Physician both prorauraing death and certifying to cause of death)
To the best of my knowkrl
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death xcurred et the time
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^ 33c. Lice N 33d. Dsae Signed (Month, day, year)
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e pose(s) and manner as stated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
• Madkal Examiner /Coroner ~i _
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On the bash of examination and ! or investlgation, in my oplnlon, death occurred at the tlme, date, and place, and due to the pose(s) and manner as stated_ ^ 34 Name and Address of Person Who Completed Cause of Death (he m 27) Type ; Print
35. Registrar's 9md Di5}\1' per 36. Date Fllad (Monty, day, Year)
Dispositlon Permit No. _ ~ c~~-(~'1 I ~- ~ , C~-i..~~\ ~ "~w k~ ~ t,/ ~