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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
(See instructions and examples on reverse) .._.__ _.. _ ......___
1. Name of Decedent (First, middle, last, suffix) Wandless Leston McBra er
Y 2~~xMale 3. social Number
_ 30_ 6820 4.DatedDeam(Mon ,da, a
~ar~u~°ar~y 7, 2011
5. Age (Last Birthday) Under 1 ar Under 1 da 6. Date d BiM Month, de , ar 7. Bi and state or for e' coon f ie. Place of Death Check a one
82 ""°""~ DayS "W~ '~"~ October 30, 1928 Gadsden, AL HospitaC Other. -
Yrs. ^ Inpatient ^ ER !Outpatient ^ DOA ~lursing Fbme ^ Residence ^ Omer - Spedly:
6b. County of Death
Cumberland 6c. Ciry, Boro Twp. d Death
Silver Spring 6d. Facility Name (If not ~ e street r)
r ages a~~ent Creek 9. Was Decederx d Hispanic Orgin? ^ No ^ Ye:
H
i
C 1 p. Face: American Indian, Blade, White, etc.
(
yes, spec
y
uban, (SP~M White
Mexian, Puerro Rican, ek.)
11. Decedent's Usual lion Kind of wok done ~ most d ~ life. Do not state refired 12. Wes Decedent ever in the 13. Decedent's Education (Spedry only highest grade comp leted) 14
Marital S(atUS: Married
Never Married 15
i
d
S
S h
il
Sales'P~senitive
'Mid49~rP~Ctl~ing
U.S. Armed Forces?
Elementary! Secondary (0-12)
College (12i or 5+) .
,
,
Widowed,
~/ .
~
ng
urv
pouse (
w
e, give maiden name)
Sally A. Yost
Yes ^ No
• 16. Dgp~aKaMatlintt~A/dttLSSlSkeet,r~1W lawttistate, zip code)
4 ~~uelYit~UrlLiarl-Vfb_ia Decedents Did Decedent
Mechanicsburg
PA 17050
ActualResidertce 17a.State y~{
Liveina 17c.,CalYes,DecedentLivedin Twp
Townsh~?
, ,7b County 170. ^No,DecedantLivedwrthin
Actual Lknits d Ciry / Bono
16. Fathefs Name (First, middle, lazt, t:umx) L. G. Mc B raye r 19. Homer's Name (FlrsL mkldle, maiden surname) Mary Dowdy
zoa.InfomranYsName(Type/Print) Sally A. McBrayer 20b.1"'°nnor'raMai'~gAdd'g~,(s'/>~~~)Vista Mechanicsburg, PA 17050
21 a. Method d Disposition r ^ Cremation ^ Donation
• ~ Burial ^ Removalrromstate ~ wascrematanaDonstbnAutlarQad 21b. Date of Disposition (Manor, day, year)
January 13, 2011 2tc. Place d Dispositon Name d cemete7, crematory or omen place)
~t. John s Cemetery 21 d. Location (Ciryltam, state, i coda)
(;
am
Hi~l
Pa
17011
^ Otlrer - S r by I Examiner/Coroner? ^ Yes^ No
• ,
p
,
.
228. d Funeral Se pe az such)
22b L' r
2662-L _
22c. Name and Address
9VI~'~s Funeral Home, Inc. 37 East Main Street Mechanicsburg
PA 17055
• ~ ,
ro items t only artifykrg
physician is not available atone of deem ro
artily cause d death.
• 23a. To the . deambcarred t date and place stated. (Signatu title)
n , 23b. ~ nse 23c. Date
!rte (Me
-h Y. Y~r)
~ ~
Hems 24.26 must be completed by person
• who pronounces tleam. 24. T'xne m 25. Date P pea m, day, year)
„ ~ ~ ~ M. ~ ~`~, U 26. Was Case Referred Medical Examiner / Cororxrr for a Reason Other than Cremation or Donation?
^ Yes No
CAUSE OF DEATH (See instructions and examples) , Approximate interval:
hem 27. Part I: Enter the d18kt d events -diseases, injuries, or corrplicatbns -that directly caused the death. DO NOT enter terrNnal events such az ardiac arrest, r Onset to Death
respiratory arrest, or ventricular frodllatbn widaut stowing the etiology
List only one cruse on each fine
~ Part IL Enter other signifxant candtiorts conmbutine Ln deaih.
twt not resul' n the n cause en n Part I.
bn9 ~ndeMr 9 9n' 28. Did Tobacco Use Contnbule to Death?
^
es~ P
Y-
.
.
IMMEDIATE CAUSE Final disease or
r r ~
~
tl~Nc~ ^ Unknown
cortdtion resuhkg in ~am) ~- a ~ • ~-lJt fh.-~~~r (L ~/ / r~~'
~ ~,yr~ l ~ ~ r~ ~ ~ ~ ~,~
~ ~ 112 111 C 1 ~
29. If Female:
^ Not
re
nant within
t
Due to (or az a consequence dl:
IIIIVv ksl andlticns, it any, b
Ieadrdre cause tisUd an Yne a. ,
~
I !; ~
~~~r ~r kl-~l..l./ p
g
pas
year
^ Pregnant at time d death
Enter Bra UNDERLYgM. CAUSE Duero (a az a conequence oQ: ~ ^ Not pregrwx, but pregnant within 42 days
(disease a irrjury That kitiated the
events rasultxg n death) LAST. c r
r d death
^
Due to (or az a coruequerxx of)'
r Not
pregnant, but pegnant 43 days to t year
• d.
r
~ ^ ~nknovmf pregnant within the past year
30e. Was an Auopsy
PeAomred7 31)b. Ware Autopsy Findings
Available Prior to Corrpletion 31 M of Death 32a. Oate d Injury (Month, day, Year) 32b. DascnLe How Injury Occurred 32c. Place of Iryury: Home, Farm, Street, Factory,
/
d Cause of Death?
Nature) ^ Flomidde Office Buiklig, etc. (Speci/yJ
t~-t~
^ Yes No
tl~ ^ Yes ^ No ^ Pe Inve oon
^ Accident rxkng stiga ~ mod. Time of Injury 32e. Inµuy at Work? 32f. M Transportation Inury (SP~~NI 32 Loatbn of i u Street, /town, state
9~ M ry ( ~Y )
^ Suicide ^ Coukf Nat be Deternwred
M ^ Yes ^ No ^ Dmrer/Operate ^ Passenger ^ Pedestrian
. Other • S
P~fY
~~ ~~ (~ onN oa) . S' nature a led enifiar -
-
~ ~~
-~
• Certhying physkbn (Physician certifying cause of death when aromer physkaan has proraunced death and completed Item 23) ,,MM
~~
~j / t
To the hest d my ktowledge, death occurred due to tfK cruaa(a) and manner as Wtad _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
---- ~ / r ~
~
• Pronounoing and certltyin 4n pronourckrg arofYing )
To the best of 9 Physic (Ptrysidan both deem and ro cruse of death
my knowledge, death occurred rt the time, dam, and plea, and due to the cruse(s) and manner ae stated_
•
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ 33c. License Number
33d. Dam Si ad (M m, day, year)
O \ `~ ~ r~ ~ ~ ~) ` ' ~ / , ~ ~) /
Cl
Medial Examktsr/Coroner
On tM heals of sxaminatfon and / or Investigatlon, in my opinion, death occurred at the tlma, date, and place, and due to t he cruse(s) and manner as stated_ ^ 4J (,./ l..- ~/-/
34, and Address d Person Wta Completed Cause`o (Item 27) Tie /Print
35. R ~ s Signature and District Number ~y~y1~ ~
-sue I ~ I
~ ~
36. Date Filed (Month, d
a
y, year) / I /~,L L.~../ J %~ (TVA ~ ~'
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