HomeMy WebLinkAbout04-25-11 105-905 REV.(1/I]) ,I
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.
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Marina O'Reilly Matthew
Acting State Registrar
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Date
ISM 3 ~ COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS 116196
H,05~149REYf1 ~"' 4 7 ltd
IYPEIPRINT; F7T~"' DIRE: ~ ~ y CERTIFICATE OF DEATH
PERMANENT
BLACK INK (See instructions and examples on reverse) STATE FILE NUMBER
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2 Sez 3. Sodd Sauily Number 4. Dale d DeaN Intent, day, year)
'~"~dD~dent~'~'inid~'~''~`) Female 202 - 20 - 2775 December 19, 2010
Nellie Daw art
6. qge ~ Bkdiday) Under 1 Under 1 6. Dam d Beth , da ~ a 7. Bi 'end dale a fie Place d D~Ih Check am Odrer:
MoMw Days Hues MaAes Hospital:
January 25,1918 Hickory Ridge, PA ^ ~~ ^ ~ f ~~ ^ ~, ~ y fkxne ^ Resdence ^ otimr ~ speedy:
92 Yrs. 19. Hate: American Indan, Black, WNm, eta
9. Was Decedent d fi'spank Orign7 No ^ Yes
Bo. Camry d Death Bc. CAy, Bore, Twp. d Dedh Bd. Fedtity Nane ~ cef ewtiMUn, gwe atrcet and mwrba)
White
Cumberland East Pennsboro Golden Living & Rehabilitation Center ~,,,, Pae~ ~, em) 1
11. DaedaV's usual d wakdore du' mcetd Me. Do ndsmm i2 Wes Decadent eww N the 13. IkYs Educetim IsP~h utiY hghest !~ ~ 1/. (,) Merced, 16. Sunrvirg Spouse IR wife, gne rceklen rnme)
Krd d BusemssllMuatly US. Amend Faces? Ek~enmry / SermrMery (a12) Cdege (i~ a 6+)
2 Widowed
Ked d Wok
Case Worker
State Goverrtment
^ Yes 9~1 ~
~
,,,
East Pennsboro
• 16. Decedent's Meiing A~ress 1 dtyl mwn, state rip code) Dm's
Actual Residence 17e. Smm pA LNe n a 17c.~1 Yes, Decedent Lived b Twp.
TownshW?
911 Acri Rd
1n ~„~, Cum 17d. ^ No, Decedent Lived wilhn
berland acamlumimof Ciy~Bom
Mechanicsburg, PA 17050
18.FadmrsNamelFasl,mddm,led,sdya) ,g fAdlmraNanafRrs4midde mddensurtmme)
Mary Wasylyk
Alex Barak
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Address (shed
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20a. Inlamant's Name (Type I Print) ,
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20b. In
PA 17050
911 Acri Rd Mechanicsburg,
Anne Marie Franc hak
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odtionlNamedcememry
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21a. Metlad d
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Crema
~ was crenrdbn a Dorotlon Atdhoraed 2010
December 23 All Saints Catholic Cemetery Elysburg, PA 17824
^ Otirer ~ ' . ~ b/ MedkM EzmdnmlCaoneY! ^ Yes^ No ,
~
• d Funerel Service lisv~s~as such) 22b. liceme NuMa 22c. Name and Address d FedRy
Gilbert L. Dailey Funeral Home 650 South 28th St. Hamsburg, PA 17103
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dh
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and dtle)
dea0 scarred d tlce time, dde and place slated. sigrmkae
To tlw bed d my kravAedge
23a
23b. Licaae Number
23c. Date Signed (Abnlh, day, year)
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Carpmm tiena 23as aYy when ca
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s rot eve6able d fire d deem b
physkian
certify ease d death.
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26. Was Case Referred m Medical Exaivier I Caoce
r la a R~san OMar tlmn Cremation a lion?
~ 24~ d ~ ~ P~ 24. Ttun~a d Deatli
l : ~ 7 !I M' ~ ~ y
25. Date Prarounce
~ ~~ ~ a
o..., ^ Yes ^ No
n. r:.,~.,,,b. ~ M rrMSlaw mnlrimden to deem. 28. Did Tabeao Use Cadntum m Deam?
CAUSE OF DEATH (See IrssUUCUons and exempba) ~ r ~^""""°~° °'"" ~-
Itan 27.Pad I: timer the ghMa.9~-~ hM~, a ~ - Mat caused Ne death. DU NDT er~mr mmtind events such as cerdiac enest, ~ Oceet m DeaN
r
respiretay erres4 a ~nhiadar ~ch Fns.
PorRetim widmd showing tlm etiobgy. L'sl onty aw cause on
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eeaa
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Due m (a as a aruequabe d): ~ ~ I~ r
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' m cause Fend on kre a
Eder IRmERLYING CAUSE Due m (a as a ~ off: ~
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(deease a'ry' ry tl~at eMreled tM c.
evads resuPong m deaM) LAST. Due b fa as a amsequerce d): r
d ~-
but riot resulting m tlm undedye,g cause gven in Part I.
~. Was an Auopsy fib. Wee Autopsy Endings 31. Maurer d DeaM 32a. Dam d Injury (I,mntli, day, year) 32h. Descuihe flow mpry Oauned
Padamal? AvaFehm Pda m Cmipmtion r(~~ ^
d Cause d Dcelh? J"
^ AaFdent ^ ~~ I6a 32d. Tmm d Injuy 32e. b1uY d wok? 321. K Trecepamtiom Ir~ury (sP•~?rl
^ Yes~No ^ Yea ^ No ^ Yes ^ No ^ DdsrlOperemr ^ Passenga ^ Pedestrian
^ Sddde ^ Could Nd bB Demmvmd M. qha - Sywxdy:
33a. CeNFa (dmdc ady me) '. Sgmbne~AedTdm rti6er ~
d d~lh when arrotlier physidan has praouced death erd compmmd Imm 23)
^ Yes ^ PrabaNY
^ No ~ Unknown
29. If
Nd pregmrd wilf~ pad year
^ Pregumt at lens d death
^ Nd pegnad, hat pregnant witien 42 days
d deaN
^ Nd pregnant, but pregnant 43 days m 1 year
bekre d~M
^ Urdmwwri 6 Pregnant wtihn tlm P~ Y•ar
32c. Pence d kquy: fiane, Farm, SVed, Facmry,
OKce Buidng, ek: (SpedfyJ
3~. Location d bPN' (Skeet, dN 1 mvm, dam)
~.' C•rtlMng PhWelen (Plrysnen ~Yng ~•
'~`TTL TethehestdmymawMd94dMhoauredduemlhawse(efmdnmmmrasmmd--------------------------------- 33c.UcaweNartita
• Pmburbing ud emlXykrg phykien h0m end eeNtying m case d dean)
r~ TaUrelsatdmyknowmdge,dsmoarereddtlmmrm,d+m~andplaa,andduemtAeauaels)andmm~nerammd------------------^ /ylv~ t~2~ ~~'3,
o Medal EnmkimlCorormr end duem the eau a rid manner es ^ 34. Name arrd Address Person Who Case c
w Ontlmbeamdezamiretmnandlamveatlgetion,mmyoplnbedeaUroccuneddthetlme~'de]m,erdpma, xl) ~ g~G~~
~ t '] ~l ~ 36~De~ F1md (Madh~ dq'~ Y~l ~~i/ / IiC,
m ~. img~trafs mid o~ p~ l .1 ~ _ ~ /%/
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z D'spceMm Pemd No. ~~ ~ I ~ ~ ~
d Dale Symd (Mach, day, year)
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