HomeMy WebLinkAbout03-25-11 105.905 REV.(I/1Q
This is to certify that this is a true copy of the record which is on file in the Pennsylvania Department of Health, in accordance with
the Vital Statistics Law of 1953, as amended.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
6131840
No.
Marina O'Reilly Matthew
Acting State Registrar
MAR 2 2 2011
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N1os-1~ rev nlzoos COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS ~ O `n
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1~ CERTIFICATE OF DEATH ~ ~ _,,_ ~•-~
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1. Name d Dxedai (Pest, rddde, hst, sulk) 2. Sex 3. Sold Seamy Nulrha 4. Doh d Dedh
(Meal, day
Eva Maria Concepcion Female 056 - 56 - 5953 ~,Q, . Zoo~l
5. Age (tmt Silnlday) thda i yffir Uda 1 day 6. Dde d aAh ~A Y~ 7. (CXy and stale alaeign caxpY) 9e. Phce d DffiIh (Check aa)
7 0 r°a° Ikea lbra lial. Nosn9d: ama:
Yrs. May 17, 1936 Solingen Germany ^,,, ~,,,, ^~,, ^ype~~ ^I ^_,
• m. coiady d offia Bc. CNg Doro, Twp. d Deatn 9d. Fea9y Name m ret irsihtian, giro abed and nlmba) 9. ~ ~ °dpi'? No ^ Yes - 10. In6n 131edc ~m~na, dc.
Cumberland East Pennsboro ~ ~j ,,,~,,
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White
11. DecedalPe tlad ~ d wai acne ~ mod d Na Do rot elate 12 Wee scar h 13. Decedal's Educapm 1 ~P +9~ ) 14. Maid Steps: Monied, Nerer Maaed, ts. Smrroirp Sparse (r wh, pre mrdar nrre)
Knd d Work 1w d asilffia l idapy
Homem
k US. Armed Famffi? y seoolgay (o-12) Conege (1~4 a 5+) Nfidowed, Diwrced (Sped
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er Own Home ^Yffi ~No
12 Widowed
• 16. DeredeN's Maig Addeffi (S6ed, any I bm, sYla,:4 mde) Decedal'a PA Did Decedal
5251 Meadowbrook Drive TTa.®Ye4DeredalLiredil Hampden TaP.
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Mechanicsbur PA 17050 ?
1~.~n Cumberland nd.^No,Deaedallreaaa.l
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19. Fdha'a Nana (FYat, nodde, first suns) 19. Mans Name (Pest, noddle. mrden slanare)
Josef Skoru inski Erna M. Theiss
~"~R~Plrtd~iuela Melville 29b•Infamaa':MaigAadreffi(Sher,abyltoarl,ahh,apoode)
• 5251 Meadowbrook Drive Mechanicsburg PA 17050
21a Metlnd d Dhpreiat i ~'pal~pn' ^ Damon 21b. Dale d ! (• ~Y~ YeAr) 21c. Place d (Name d anelery• aarebry a aha Place) 21d Laadal (Qt'/bwn, afro, zip ~)
^ and ^ "°~""" w"0iai"'tlanaDantlonAi~''ffid
^ ptlla• br EmlieelCaaller? Yffi^No 2-12-2007 Conolite Creamator
y Schaefferstown PA
22a Finad ffi ach) 22h. Uceae Number 22c. Hare and Addlffia d Fait'
- FD-012662-L MYERS FUNERAL HOME E MAIN ST MECHANICSBURG PA 17055
aiywhen cap7yi9 ea bar gpwledge, aam oxared rule line, are and q~ shred I• aM 1Ne) 23b. lirense INeroer 23c. Doh Sigwrd (MaitlL deg leer)
Ili h e a d tine d detll h
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' Hare 2429 mar be mapkad by Pawn 24. Tone d Dffitll r p 25. DeM Pmianad Dead I ~g Yom) 26. Wffi Caee Ndared b Madcd Excreter I Caawfr la a Reason Otlrr tl~en Crerrenon a Ooration?
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CAUSE OF DEATH (Sea MatrueUone and examples) l Appmxinde ioenr:
ban 27. Pal l: End na -dseases, iMniffi, a mipicmaa-bd dexly eased h deatll. W NOT enter hntild adi ffi cadet arer, l pleat b Dalh
' Pea II; f~lhr otlrsr .
hat rel reefing n the aMeryilg case prat M Pal L 2& Did Td,axo Use Cadlbuh b DedA?
^ Yes ^ Pmbedy
respiataY creel a vaariaAa ~nlanm m
~W rmaig pre endogy. Ua soy ab ease an each fine.
YEDIAIECIIU9EfFnrdeffiaea c I ~ I
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mndim mallalg n ) ~ a. X P'1'i C. /) l/~~3 i.l~ i z9. n Famre~
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Dueb(affie aq: ~ PBR~~P%dYea
Seaualialvhtaand9ars,iay, b, ;
b ddltee sae had ao lie a ^ Preplalrnmeddedh
Enter ,yam CAIN Doe b (a ffi a caneeprsnce d): l
l ^ Na pmgar, ha pagralt sirl 42 dot's
(dffime aklPY pat hided tlw;
eral6naaYgndeetll)LAST. e. ~ adeil
Dar b (a ffi a mraequaice d): l ^ Nd preglal, hi pregM 43 days m i year
• d. ~ bdaedffiri
^ Uamoarltlplegreawiilnlepary~
39a Wffi re Aulopay 396. Wee Autopsy FYxigs 31. d offim 3za ~ d ~' Imo, ~g Y~1 326. Desaie lbw plpey Oaared 32c. Place
d
Mpy: Spar, Fechrg
Peaamadf
/ AvehhePdabCarpleim
d Cane d Dedh7 ~
Hamad ^ fbnldde B
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Dice
^,~ r-,/~ ^ Yffi ~ ^ paadea ^ peMeg pnai 32d Tone d Iryay 32e. 6~uy al Wads? 321. n Tranpapnm h~pey (Spedfyl 32g, L,acaiai d pquy (Strael, q'ry, I pxn, etas)
IIIAAA ~1 ^ Suidde ^ Cold Nd be Detar~ed ^ Yes ^ No ^ Dmar I Opeala ^ Passenger ^Pederda,
M Otlrsr - Spadl}^
33aCatlRa(dledcaiyale) - 33b.
' Cadnyingphydclari(Phleidenoer07yipaaaeadffiIhahnawnrrphyddanhespraxxrceddedhandtamplaedkem23) ~~~
To the mar d eR' IOgNIOdga, dedh OaaelM due h dR aNN(a) old nlffiIMIr ffi ahhd .. ......... ..... ...... ...........
tAal«,uaalg ~ I baN plalaesiq dedh end aaanyilg b cane d dffinq
To theb~rde%IomaMdga,dffitllamrndrbfetime,dre,oldphce,endduehtla
aaagm)and~nerffiahhd__________________^ 33c Ucame
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