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HomeMy WebLinkAbout06-29-11 O-At_ REGISTRAR'S ~ERTII~IATIGIV ~' ~DEA~~'I~ 1N~RNING: It is illegal to dupli~at~a tl~~is c:.o~ ~~ ~~ho~tr:-St~rt or ~at~otogr~,°~ni.p f'~•~ ft11-'Lf?~ti ~~)~t~t)l•~(t~. ~i(~~.4)6~i `,, ; , .,,,., ,, CN ~~~ ~ ~ ~ t ~~ I ~. . ts)I,;:-,n.rtiun f~e(~e r~l~Ln 7~ ~ ;t''~,~,p,~, ~~~~"_ ' ~ ~,~,. r ~1~ : cl ~ r i- _ ~ ~r,r_tl(~11 Ce)-trl ic~)~l° ref U~~Ith ~,~'`~.~,, ~. ~; _ o ~ ~i;t~il t~ ~( I a( ,ti I~t;t~i5O~al'. I'll(' (~ti«3~1~11 i,~~~.! = ~~~ ~ z 1~~_ s~~ ,~,(I ~~.. ~.,. (:(jc~l i(> tf)~~ St~ltc `~'itsrl ~, ~.~ P 1486864 ''l I. ` y ~et< F p 1(` • ~ ~ 111 y~J __ ~ Cl~ttllC~111i>fl ~+Ui'1]hl'S' - ..'='-~~~ ;3; ,::" ') ~ .,i~ ~ ~' ~,)~ltl~ (ti511C'(~ ~J C.,.. r"T'1 C"'~ ~~ '~aU~ -- - r i ~ = COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS ..~ ~ r ,J ~~ f.'.-.. f'T'7 nt05-tai NEV ,t•200b TYPE ~ PRtNT IN PERMANENT CERTIFICATE OF DEATH ~' ~._.,.~ `- ~' slACKINK (See instructions and examples on reverse) STATE FILE N UMBER ..-_ z c ui ~.~ z md01e, last, wtllk) 2. Sex J. Social Secwdy Number 4 Dale of Death (~~~ daY. Yeul __~~ I None d Oecet7ent (Frcst , Quentin Davidson Male 207 - 09 - 1892 April 19, 2011 5 Age (last B~nrday) Uttder t Year Under 1 des 6 Oate of &M (Monts, day, year) 7 &nttWaca ICIry and suk « I« couary) Bor. Puce a Oeatn (Check Day one) iarriM Gays hours iavtu4s HospWl. Other 92 yry Nov 29, 1918 Harrisburg, PA ^lnpatient ^ER7Outpatwnt ^DOA ®NurstngROme ^RestMnce ^Opwr.Soecdy 8D Counry of Death tk Cny, Boo. Twp of DeaN Bd. Faclgry Name 111 not utslituuon, give street and nu~,~er) 9 Was Decedent of Wspantc Ong,n? ®No ^ Yes 10 Race Amertraft Ytdari. Btacit. Whi4. eC. e~M S ~1 ~ • Cumberland Upper Allen Twp. G ~ U~~ W yes. spanry Cuban. I 1 CC ~ { \L~..~-1 ~~~ ~ ,t~ ~ ( Jkaextcan,PuenoRican,etc.) White 11. Deceilenfs Usual l3cc wort Knd a work du ne dw ntpst of w«k IJe Do not state rehredl 12. Was Decedent ever m the .Decedent's Education ISpeCdy ~ry n t grade compteted) , a. Mental Status. Marned, Never Mai ned t 5 Survnutg Spouse Ill wife, give nwden rumel Widowed On«ced Isp~rhl -0 of Work Teacher' Kux1 ul Business ~ Industry U.S. Armed Forces? Elementary / Sxandary (0-t 2) 12 College (1 4 or 5.) 5+ , Widowed and Counselor Public Schools ®vaa ^Nd 16. DeceMNs Maauy Address (Street, ary r town, state, zp cooel pecilMnt's Did Oec:edent 1 T gate PA lire in a t 7c. ® Yes, Decease lived n _yt~ P Y Q 11 e n Twp Actual ResidMCe , 7a 2 2 2 Messiah Circle , Room 4 2 9 . Townsrtip? 17d ^ ~ l~ederu Lived rntfurt Mechanicsburg, PA 17055 tTD.c«inty ('umberland AtlwlLrMSd GY~~ 1B. fapwr's Norma IFusl nvddW. ust, sotto) 19 Mruner's Name (Post, rtvddl6, maiden swnanwl C1 de S. Davidson Emil R. L ohs 20a trtbmtutt's Name (Type r PnM) 200 Informants Mabry Address (Street. city i town, state, zp coast Susan Martz 124 Woods Drive, Lot 4A, Mechanicsbur PA 17050 21 a. fsledto0 d Disposrwn ®Criurtuan ^ Donuiort 21D. Oaq d pisposibon (td«tm, day. you) 21c Place d Dtsposrtan (Name d cemetery. crematory «omw puce) ltd. Lowtttvt,Clry r town, state, tip coast • ^ &aw ^ Removal tram SUte ;Was Crematbn a DoneUdrt Authorized ®Y ^ ~ 4 - 2 2 - 2 01 1 Cremation Society o f P A Harrisburg , P A 1710 9 ? I C oroner es ^ Omar . ~M: 0Y MWlcal Eartwrr Name and AOdr.ss °' Facuuy Au e r Cremation Services o f P e n n s y van a , Inc . r z2° rD N 22D L . ,cense w e . ~ 22a uaa wterat serr lxensee I rsdn ac a5 sucnt, ~ / FD 138312 4100 Jonestown Road, Harrisbur , PA 17109 CompMe 2]a< arey 2 To ow Oast of my krowkdge. awn aurred at lM ttme. dau and puce stated ISgnatwe and taNl 290. license Number 23c. Oats Synod (MOrtm day. year) pfrysiurt a not arailaDre at Man to cMdy Huse d Man. • 24 Tvyw d DeaN 25. Data Prmartce d Dead (~~. daY. Yeu) 26. Was Casa Referred Medial Eaantrrwr .Coroner ty a Reason Opts than Crertuuon es 0onauort' dente 24_~ rtwnt «~ ~, ~~ • who prortoirtces rlpadt. `~ Z ~ ~` M. ~f I (~ 2, ©~' ^ Yes No CAUSE OF DEATH (See ineUueUone end examples) i Apprownate interval. Pan It. Enter Dater s~anmca^; c%>~tlms CestulDLi g io e~m. rvM rt Van r l M 28 Da ToOacco Use C«tlrdte w Own? ^ Yes ^ Prd0a01y Item 27. Pan t: Faux the tarn d events - dseasas. uyunas, « compt¢anons -put rlreetly tuned ttM DeaN. DO NOT order termrtal events such as cudac arrest, i Onset .o Death i yuy auia g r but nor resuttuy n the urtt i raspualory arrest. « venltiGJu ItDneau«t vwtMttA sttowvy tfte etiology. Lial dNy OrN faUae On each lets. ^ No llNUtorei i TE CAUSE IF ~ disease ot~.. /]/~ ~ /~~ ~ ~~~ _ t eWlay dw i 1 ~w' i ~r.~-Y 29. II Fentye. wr lan wRrt ^ Nd te atl _~ a ~ ( Due to for u a consequence d): i a.l. ~ C P Y D y ^ pregrlare a! tiro d dean 1 arcy p Ys1 iprtdtrorts Sepwtsall i ~ , , , y MaM~ b ate cause listed on ww a. Due td (« u a consequence of): ~ Eller Ete UNOERLYWG CAUSE Z fi Z /~rG , ~77 l Not tiu rrM 42 tYys ^ ask pq~ d dean lessees a inpiry mat irteuted the ' c ~ J 7 i wens restmy n dean) LAST uena oQ: to (« as a c«ue • D / ^ t4d a•grt W DU prgtr>< 4~ d1'a b 1 yer q t ua i ~ ~ _~ !~- txMae dean ^ llnkrioeei 1 pregrtue wOwt ere psM yer • d. 30a. Was an Adld(isy 300 Wad Autopsy Fvidvys 31 Mama d Dwn 32; Oete of Iryury (MOnm, day, Year) 32D DescnDa Flow uty,ry Occurred 32c Ptaa d MtpirY Fforrr, farm. Steel Fatditry, ~c• X14 ~ ISpedyl Porbrnted? AvaruOK Pees to C«rlpletion n? D ~Nawru ^ Rorrvcge " ea a cause d JTT~ ^ Accirkrx ^ PeMrtg 4rvetifigation 32d. Tarty a tryury 32e. u>Mry u W«k? 32t. a Transportation Iryiuy (Specrry) 32g. lixauon ul ugiuy (Sues. ctry r town, state) ^ Yes ~NO ^ Yes ^ No y ^ es ^ ~ ^ Omen Operates ^ Passenger ^Pedesuan r ^ Swcbe ^ Cot10 Nd Oe Dewrrwwd M Other Spec+N 33a Ceruher lawu wy onel ~ Cenrtwr • Cartitymy phyweiart ;Pnyarcun carufymg uusa a Beam when artaher pnysrnart rue Vr«tourited dwm and completed Item 271 vT - - - - - - - - - - - - - - - - - - - - ath xcwrM due to the uusa(a) arW muintr a• atated ~ ~ >--1 l d f k d T h b ` -~~ L L (~[~ ~'GJ C1 - - - - - - - - - J eat o now e ge, e o t e my • Pronouncing and urtilying physician IPnysrciart tkMh pr Oeam and carutyry to cause d deaml / .-' autad J d Jac LKense Number ~ ~ ~ ~S~ 73d. Data $gned rMunin, day /earl ~ ~ ~ % _ _ _ - _ - _ _ - _ - manner as ' -- - - To ute Desl of my knowlWge, deem occwrW al IM ume, plan, utd dw to tM cautte(s) an C~ ~ ~ G (,, ~ ~ / ~ / / • Ilsdical Eaaminer /Coroner snd dw to lM naiuaela) and manner u sated_ ^ date and puce Math attwred at tM tNie in op invea t d ! i yn I I:am 271 t ia , Pratt nget se d t1 d Ge A Wh C , , , , , an an a na On ttie eum p ~ ~ arW ~ u ddress o eryort yy g e n e LC tiff c.~. ,d ~/r 1 1 1/ r G J q ~ 35 R stru's a arW DWr ~ p Fdad t m, day. yaitSl~ ~ ~ / - - ~c a- [ ~, l(,. _ ~ G% ~, ` ~ . •"( r~~r; Viz ~~ ~ -l~ ss ~ ~ _ _ _ ., f GC~:c~~ / Orspoartron Pumu No. V l,V~ ~ `r 7 ~1~ '~ 1