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HomeMy WebLinkAbout08-11-10 ~ - ~ ~ ~-( lN~6~cNING: It is ~Ilegal tai duplicate this c~l~~ I~~y lahat~stet +~~ ~xhOt~ga ~;~~ti, t•c;.~ I-=.lf~ thf,, ~•,°rti(•i~~~(te. `tii~'~.tl+:) fl r J/ ~'. ~~ I` ~iY 4 4, ~_ ~.rLr~~ioe7.~r_ ~; . ~; u,, ~~f.- _ '"\" ^414. ~\~~,///^^ r/~r-~~ ~~r''",\t 1 fit. r'tt4:l I~ __.'~ It'll i` >' yy~)) S~ L~ry~2• `~~ /a•~ s '(.~ii w~ .. ,;-` ~ l;.t~ 1. 1 )(i~. !tt f'~ ~7cr1(jl ~ rn:.13 ~l'~rj 3~lP- ~,l 13it._"1114t~ 77 t I gig t~- ( ~ d %I I,(I :~. I~v MAY 2 4 2010 I 43 REV 1112006 _E /PRINT IN -RMANENT SLACK INK COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH (See instructions and examples on reverse) STATE FILE NUMBER ...., ) r~ r; ^,r - -,r~ ~ ~ :~ -- } ..~ ' ~r•-I t--'" r - - ~~.. ~,~ G""'7 t __ -.- i _ _ -. t..t . r t ...3r - _ _t ll 4 ~ ~ J : .. ~~ ~ i 1. Name of Decedent First, middle, last, suffix ( ) 2. Sex 3. Social Secud Number " ate of De ont l 1y~) ~~ a Charles L. Brand male' 322 _ 42 _0590 . Y 5. Age (Last Bidhday) Under 1 ear Under 1 da 6. Date of Birth Month, da , ear 7. Birth lace Ci and state or for ei count Ba. Place of Death Check onl one 6 3 Months Days Hours Minutes 1946 Sept 28 Illinoi DuQuoin HOSpital Other. Yrs. . , , Inatient p ^ ER I Outpatient ^ DOA ^ Nursing Home ®Residence ^ Other Speciy: 8b. County of Death 8c. City, Boro. Twp. of Death 8d Facility Name (If rwt institution, give street and number) 9. Was Decedent of Hispanic Origin? ~ No ^Yes 10 Race: American Indian, Black, White, etc Cumberland Pennsboro E 61 1 Fairway Dr . (If yes, specity Cuban, (SpeGly) . Mexican, Puerto Rican, etc.) White 11. Decedent's Usual Oau lion Kind of work d one d ud roost of worki tile. Do not state retired 12. Was Decedent ever in the 13. Decedent's Education (Specity only highest grade compl eted) 14. Marital Status: Manied, Never Married, 15 Surviving Spo use (If wife. give maiden name) Kind of Work Kind of Business/Industry U.S. Armed Forces? Ele~ Mary !Secondary (0.12) College (1.4 or 5+) Widowed, Divorced (Speciy) married Susan Orr Su ervisor Chr sler Corp. Lf3Yas ^ f4o 16. Decedents Mailing Address (Street, city! town, state, zip code) Decedent's p A Did Decedent II----~c~ bo r o Live in a 17 A t l Resid nce 17 St t N D~ ~ ~i~ ~h T 61 1 Fairway Dr • ua r c e a. a e c. L~ es, e t wp. Township? Cumber 1 and 17d ^ Nc, Decedent Lived wRhin Camp Hi 11, PA 1 7 01 1 17b. County Actual Limits of City /Boro 16. Father's Name (First, middle, last, suffix) 19. Mother's Name (First, middle, maiden surname) mar J. Brand Magdalen Sroka 20a. Informant's Name (Type I Print) 20b. Informant's Mailing Address (Street, city /town, state, zip code) 611 Fairwa Dr. Camp Hi11,PA 17011 21 a. Method of Dispasition r ^ Cremation ^ Donation 21b. Date of Disposition (Month, day, year) 21c. Place of DisposRion (Name of cemetery, crematory or other place) 21 d. location (City/town, state, zi code) [~ Budal ^ Removal from Stale r Was Cremation or Donation Authorized May 2 6 , 2 01 0 Slate H i 11 C e m . Camp H i 11,)~ A ^ Other • S ' al Examiner/Coroner'? ^Yes^ No 22a. Signaty~ol F eyp RI Service rson 'ng as h) 22b. License Number 22c. Name and Address of Facility ~ t 011248E Musselman FH&CS Inc.324 Hummel Ave. Lemoyne, PA Complete items 23a-c Doty when certifying 23a. To the bas w dge, death occurred at the time, date and place stated. (Signature end title) 23b. Li nse Number 23c. Date Signed (Month, day, year) physician is not avaiable at time of death to r ~ F ~ ~ ~7/ - ~ ` .' ~ ' certity cause of death. •~ / 7 ~ , ~ ~~/ Items 24.26 must be completed by person 24 Time of Death 25. Date Pronounced Dead (Month, day, year) 26. Was Case Referred to Medical Examiner !Coroner for a Reason Other than Cremation or Donation? who pronounces death. .J ~ ~ ~~ M. /^~ .~ a 3 ^ a U V ^Yes CAUSE OF DEATH (See Instructions end exemplea) t Approximate interval: Part II: Enter other significant conditions contdbu(j~q to death 28. Did Tobacco Use Contribute to Death? Item 27. Part I: Enter the chain of events - tliseases, injuries, or complications ~ that directly caused the death. DO NOT enter terminal events such as cardiac arrest, i Onset to Death but not resulting in the underlying cause given in Part I ^Yes ^ Probably respiratory anest, or ventricular fibrillation wflhout showing the etiology. List only one cause on each line. r r ^ No ^ Unknown IMMEDIATE CAUSE (Final disease or bl ,~ ~ ~ n ~ ~ V r condition resulting in ant) _~ a y 29. It Female ^ N dhi t t t Due to (or as a consequence of) r pregnan o w n pas year ^ Pregnant at time of death Sequentially list conditions, if any, b ~ ' ^ mgg to the cause listed on line a. t lead Enter Ble UNDERLYING CAUSE Due to (or as a consequence of): t Not pregnant, but pregnant within 42 days of death (disease or injurX that initiated the i d th LAST o' hi ^ events resu ng m ea ) . ~ Due to (or as a consequence oQ: , Not pregnant, but pregnant 43 days to 1 year before death tl ~ ^ Unknown it pre nant within the past ear g y 30a. Was an Autopsy 30b. Were Autopsy Findmgs 31. Manner of Death 32a. Date el Injury (Month, day, year) 32b. Describe How Injury Occurred 32c. Place of Injury: Home, Farm, Street, Factory, Pedormed? Available Prior to Completion ~ ^ OKce Building, arc. (Spectily) of Cause of Death? Natural Homicide ^ Y N ^ Y ^ N ^ Accident ^ Pending Investigation 32d. Time of Injury 32e. Injury at Work? 32f. If Transportation Injury (Specify) 32g. Location of injury (Street, city I town, state) es o es o ^ Suicide ^ Could Not be Determined ^Yes ^ No ^ Driver/Operator ^ Passenger ^ Pedestrian M' ^ Other • Specify 33a. Certifier (check Doty orte) 33b. Signature and Title of Certifier /h1 • CertNying physician (Physician certifying cause of death when another physician has pronounced death and completed Item 23) To tfre beat of my knowedge, death occurred dtx to the cause(s) and manner as stated _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ ~ i. - ~fLrl I V • Pronouncing 8rld certNying physician (Physician /loth pronouncing death and certifying to cause o1 death) To the beat of my knowledge, death occurrod et the time, date, and place, end drx to the cause(s) end manner ea stated _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ 33c. Dense Num~r ~ < (rVl) J5 tIJ 1. ~ 6 33d. Date Si d (Mon day, ar) `) ~ `( r • Medkal Examiner/Coroner ~ On the basis of exsminatbn and / or investlgatlon, in my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner ea etete~ ^ ype I P nt 34. Name and Address of Person Wtro Completed Cause of Death (I tem 27) T Registrar's Signatur District Numb ~ I I I I ~ / I /~ I 36.~(g.E' ~( th,~y~r) Y ` ` •~ `~ ~1 ~ ~y ~ ~~ S I n f ~' I h ~ ~ ` ~ , (~~ ~ /I ~/ ~ © Disposition Permit No. Q ~ / ~ / ~~ ~ Q n, C ~ ~ '~ p ~ ~~ ~ ~+ ~ ~ -