HomeMy WebLinkAbout09-03-10LOCAL REGISTRAR'S CERTIFICATION OF DEA1~~H
WARNING: It is illegal to duplicate this copy by photostat or photograph.
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
(See instructions and examples on reverse) STATE FII F NIIMRER
1. Name of Decedent (First, middle, last, suffix) 2. Sex 3. Social Security Number 4. Date o )each (Month, day. year) ti r
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Donald R. Brandt Male 208 - 24,-0094 ~r~/,L _,~
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5. Age (Last Binhday) 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 on one "
Months Days Hours Minutes Hospital: Other
8 5 Yrs. N o V 3~ 1 9 2 4 M i dd 1 e t o wn , P a ~~
^ Inpatient CSR /Outpatient ^ DOA ^ Nursing Home ^ Residence ^ Other -Specity
6b. County of Death fic. City, Boro, Twp. of Death 6d. Facility Name (11 not institution, give street and number) 9. Was Decedent of Hispanic Origin? ~ No ^Yes 10. Race: American Indian, Black, White, etc.
(It yes, Specity Cuban, (Speciyj
Dauphin Harrisburg Harrisburg Hospital Mexican,PUertoRican,etc.) White
11. Decedent's Usual Occu anon Kind of work done Burin most of workin lice. Do not state retired 12. Was Decedent ever in the 13. Decedent's Education (Specify only highest grade completed) 14. Marital Status: Married, Never Married, I5 Surviving Spcuse (If wife, give maiden name)
O u Krna LW
O a 1 Kind of Business I Industry U.S. Armed Forces? Elementary I Secondary (0-12) College (1.4 or 5+) Widowed, Divorced (Specity)
~ Pa State Hos }Yes ^ Nd nk Widower
16. Decedent's Mailing Address (Street, city /Town, state, zip code) Decedent's Did Decedent ~- r~~y
P e n n s y l V a n i a Live in a 17
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1014 Dogwood Lane .
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Actual Residence 17a. State
Township?
County Cumberl a n d 17d ^ No, Decedent Lived within
17b
E n o l a, P a 1 7 0 2 5 .
Actual Limits of Ci /Boro
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18. Father's Name (First, middle, last, suffix) 19. Mother's Name (First, middle, maiden surname)
Unk Unk
20a. Informant's Name (Type /Print) N a n e y L
S t e i nbe r ge r 20b. Informant's Mailing Address (Street, city /town, state, zip code)
. 1014 Dogwood Lane, Enola, Pa 17025
21 a. Method of Disposition ~ ^ Cremation ^ Donation 21 b. Date of Disposition (Month, day, year) 21c. Place of Disposition (Name of cemetery, crematory or other place) 21 d Location (City I town, state, zip code)
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Burial ^ Removal from State r Was Cremation w Donation Authorized
^ Other-S ~byMedicalExaminerlCoroner? ^Yes^No
4/30/10
St. Pauls Lutheran Church
em. Nook Pa
22a. Signature uneral ervice Licensee (or person acting as such) 22b. License Number 22c. Name and Address of Facility
Sullivan Funeral Home
LJ ,~,.LI.~tiL L FD011897-L
Complete kems~ 3a-c only when codifying 23a. To the best of my knowledge, death occurred at the time, date and place stated. (Signature and title) 23b. License Num er 23c. Date Signed (Month, day, year)
physician is not available at time of death to
certity cause of death.
Items 24-26 must be completed by person 24. Time of Deathj/ ~ ~
~~ 25. Date Pr unced Dead (Month, d/aty, yeah„ ~
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' 26. Was Case Referred to Medical Examiner i Coroner for a Reason Otner than Cremation or Donation?
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who pronounces death. !~
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Jl .J Yes
No
CAUSE OF DEATH (See Instructions an examples) ~ Approximate interval: Part II: Enter other gjgnilicant conditions contributing to dean, 26 Did Tobacco Use Contribute to Death?
Item 27. Part I: Enter the chain of events -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, ~ Onset to Death but not resulting in the underlying cause given in Part I ^Yes ^ Probably
respiratory arrest, or ventricular fibrillation without showing the etiology. List only one cause on each line. ,
~ ^ No ^ Unknown
IMMEDIATE CAUSE (Final disease or
condition resulting in death) ~ ~ F~ ~ ; `'7 r y> ~ ~
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- 29 If Female:
^ Not
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Due to (or as a~onse uence o(): r
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^ Pregnant at time of death
Se uentiall list conditions, if an , A, , - ^
leading to the cause listed on tine a. Due to (or as a consequence ol) i
Enter the UNDERLYING CAUSE Not pregnant, but pregnant within 42 days
of death
(disease or injury that initiated the i
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events resulting in death) LAST.
Due to (or as a consequence of): r ot pregnant, but pregnant 43 days to 1 year
before death
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, - ^ Unknown if pregnant within the past year
.
30a. Was an Autopsy 30b. Were Autopsy Findings 31. Manner of Death 32a. Dale of Injury (Month, Bey, year) 32b. Describe How Injury Occurred 32c. Place of Injury: Home, Farm, Street, Factory,
Pedormed? Available Prior to Completion
of Cause of Death? n ~
yJ^'ratural ^ Homicide Office Building, etc. (Sped/yJ
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^ ^ Accident ^ Pending Investigation 32d, Time of Injury 32e. Injury at Work? 321. If Transportation Injury (Specify) 32g. Location of injury (Street, city I sown. slate)
Yes l~No No
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^Yes ^ No
^ Driver/Operator ^ Passenger ^ Pedestrian
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33a. Cenifier (check only one)
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Ph 33b Signature and Title of Certifier ~ ,~? ~
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• Pronouncing and certifying physician (Physician both pronouncing death and codifying to cause of death)
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33c. icense Numbe
33d. Date igned (Month, day, year)
To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner as state
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
• Medical Examltter I Coroner / ,, /n ~
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On the basis of examination and / or investigation, fn my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner as stated_ ^ 34. e d A g[~ss Person C t o1 e~ em 27) Ty /Print ,.~,~-;
35. Re ' s Signature a~a~jlSMct~4rbl!~ ~ 36. Da Filed (Month, day, Year) i f
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This i~ tt) certify ih~_(t :he ii~f,)rlnati~rl) her~,~ ~~~j~~eu is
.OI-rectl~~ L.•OFi~'~ lrttlll ~)I uA)~~ina~ C~t~~i~icatr.~ uf~ Ueath
duly filed ~~~ith ~~~ :)~ l c)c~~.l F~e~r~~,tl_)i-. "~'he urirri)t~l)
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