HomeMy WebLinkAbout03-10-11 (2) 105.805 REV (01/071
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00
P 17115528
Certification Number
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This is to certify that the information here given is
correctly copied from an original Certificate of Death
duly filed with me as Local Registrar. The original
certificate will he forwarded to the State Vital
Records Office for permanent filing.
FEB 2 8 011
cal Registrar/ Date Issued
v J / ' / Dbpawa, Pemll rb. O 51x'7 ~ 1Q 3