HomeMy WebLinkAbout11-02-10 (2)LOCAL REGISTRAR'S CERTIFICATION OF DEATIH
WARNING: It is illegal to duplicate this copy ~y photostat or photograph.
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This is to certifti~ th,(l the infrfrmation here given is
cl~rrectly copied fi-om ~u~ origi)~al Certificate of Death
dui_y filed with me as ~_.ocal Registrar. The original
certificate will be forwarded to the Sate Vital
Records Office for l~er~lr)anent filing.
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L~ity~ ~~~~+~~c~e-`c'~•-x_ D E 2 9 2009
L_,ocal Retistrar Date Issued
H105-143 REV 11121N)fi
TYPE /POINT IN
PERMANENT
BLACK INK
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
/see instructions and examples on reverse) ~T.r< <~, ~ .,, r..o~o
1. Name of Decedent (First, middle, last, suffix)
Donald Leon Brickner 2. Sex
Male 3. Social Security Number
165 - 26 - 5866 4. Date of Death (Month, day, year)
Dec. 26, 2009
Age (Last Birfiday)
5 Under 1 ar Under 1 M 6. Date of Birth Month, da , r 7. BI G end state or fo re) coon 8a. Place of Death CMdc on one
.
79
Yrs Months Daya ~m "'I^~B9 June i6, 1930 Carlisle, PA Hospital:
Inpatient ^ ER I Outpatient ^ DOA Other:
^ Nursing Florae ^ Residence ^ Other • Specify:
!!b. County of DeaM fk. Ciry, Boro, Twp. of l~alh 8d. Facillry Name (If not institlrtlon, give street and number) 9. Was Decedent of HLspanic Ork3ln? ~] No ^Yes 10. Race: American Indian, Blade, Whhe, etc.
~ (II yes, specify Cuban, (S~/~ W~ll. tf.'
Cumberland E. Pennsboro Twp. Holy Spirit Hospital Mexicen, Puerto Rlnan, etc.)
1 t. Decedents Usual lion Klnd of work d one du ' nest of woddn Xle. Do not state refired 12. Was Decedent ever in the 13. Decedents Education (Spedty any highest grade completed) 14. Marital Status: Married, Never Married, 15. Surviving Spouse (If wife, give maiden name)
Div
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ed (S
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Wid
d
Kind of Work Kind of Bu ' ss! Industry U.S. Armed Farces? Elementary / Seto ry (0-12)
~ College (1-4 or 5+) p
y
owe
,
o
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Nellie Lebo
Excavating Contra for Se Employe ^y~ ®~ arr
e
16. Decedents Maitlng Address (Street, city /town, stela, zip code) Decedent's Did Decedent Mi d d 1 e s e x
PA Uve in a 17c
Decedent Lived in TWP
®Yes
21 Hi ckor town Rd .
y ,
.
Achral Residence 17a. stale
Towruhip?
OecedantLivedwithin
17d.^No
Carlisle, PA 17015 ,
17b.county (,,,ymhArlgnd
Actual Limits of City / Boro
18. FatheYs Name (First, middle, lest, suffix)
Leroy Brickner 19. Mother's Name (Post, middle, maiden surname
live Ilgenfritz
20a. Informant's Name (Type /Print) 20b. Informants Mailing Address (Street, city /town, state, zip code)
Nellie Brickner 21 Hickorytown Rd., Carlisle, PA 17015
21 a. Medrod of Disposifion r ^ Cremation ^ Donation 21 b. Date of Dispe~sifion (Month, day, year) 21 c. Place of Disposition (Name of cemetery, crematory or other place) 21 d. Locetlon (Ciry I town, state, zip code)
• r
® Burial ^ RertavallromState r wascremehonexl3onationauthadzed
Dec. 30 2009
Letort Cemetery
Carlisle, PA 1701
^ DIMr - r by Medical Examiner/Coroner? ^Yes^ No ~
h)
. Signature of Funeral Service Licens (or acting s 22b. License Number 22c. Name and Address of Facility o man- o t unera Ome rematory , nC .
~
- ;
/
/
~ 013144E PA 17013
Carlisle
Hanover St.
219 N
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Complete itAms 2 c only when certifying 23a. To the best of my rrowledge, death oexured at the time, date and place stated. (Signature and title) 23b. License Number 23c. Date Signed (Month, day, year)
physician is not available at time of death to ~ ~
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ceniry cause of deem. ~
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Items 24-26 must be completed by person 24. Time of Death 25. Date Pronewnrxsd Dead (Month, day, year) 26. Was Case Referted to Medical Examiner i Coroner for a Reason Other than Cremation or Donation?
~
^
~ who pronounces death. a' i rJJ R. M, I ~ ,~ (~ '~ ~ ~`' ~ No
Yes
CAUSE OF DEATH (See Instructions and examples) r Approximate interval:
Item 27. Pert I: Enter tlne main of events - dseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, r Onset to Death Pad II: Enter other ~icnifxAnt conditions contrih~dlnq to death
but not resulting in the underlying cause given in Pad I. 28. Did Tobacco Use Contribute to Death?
^Yes ^ Probebry
respiratory arrest, or ventricular fibrillation witlrout showing the etiology. List only one cause on each line. ~ ^ No ^ Unknown
r
IMMEDIATE CAUSE (Final disease or ~/~/, I ~ S•~~• `~ Q ~~G y ,( ~ ~ ~ ~G~/ ~? ,
condition resulting in death) _~ a
~
~ / ~^ r
29. It Female:
^ Nal
rumt within past year
re
.
r
Due to (or as a consequence oq: r
, p
g
^ Pregnant rat time of death
uentl list conditions, g arty, b r
d
ag to cause listed on kne a r
Fster @ce UNDERLYING CAUSE Due to (or as a conseeryence oQ: i Not pregnant, but pregnant within 42
ays
of death
r
(disease or injury that irrifiated the c
s to 1
ear
nant 43 da
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.
events resultng m death) IAST. r
Due to (ex as a consequence of): i y
y
a
pregnan
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pr
g
before death
d
i ^ Unknown N pregnant within the past year
~
,
30a. Was en Autopsy 30b. Were Autopsy Findings 31. Manner of Death 32a. Date of Injury (Month, day, year) 32b. Describe How Injury Occurred 32c. Place of Injury': Home, Farm, Street, Factory,
Office Buildin!1, etc. (Speafy)
Pedorned? Available Prior to Completion
of Cause of Death) ~ store) ^ Hexnicide
~/
^
^
^ ^ Accident ^ Pending tnvestigetlon 32d. Time of Injury 32e. Injury at Work? 32f. If Transportation Injury (Specify) 32g. Location of injury (Street, dry /town, state)
Yes ILYNO Yes
No
^
^
^ Yea ^ No ^ Driver/ rotor ^ Pedestrian
~ ^ Passenger
Cald Not ba Detertnlned
Suidde M. pyrer • ~iy.
~. Certifier ( anry ~) 33b. Signature and Title of CedlNer /~~ , ~~ ~ - - "
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• Certllying physlckn (Phyeietien certHying cause of death wfbn arrofher physk:len has prarounexid death end completed Item 23)
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To tM bast oT my knowedge, death occurre
33e. Ucenae Number
33d. Date Signed (Month, day, Year)
• Pronouncing end eatMYM9 phyaiclan (Physician both prorauncing death and cedilying ro cause of death)
To tM best of my knowledge, deeM uccurrod at tM Nme, date, and plsce, and due to tM pose(s) end manner es stated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^
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On tM basis of examination and I or Inveatigatbn, in my opinion, death occurred at tM lime, date, and place, ant due to tM cause(s) end manner as atated_ ^ 34. Name and Address of Person Who Completed Cause of Death (item 27) Type 1 Print _
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