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This is to certify that this is a true copy of the record which is on file in the Pennsylvania Department of Health, in accordann w ti-
the Vital Statistics Law of 1953, as amended.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
6289860
No.
I
Marina O'R;evilly Ma-thew
Acting State Regisn-ar
JUL 19 X0,11
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H406-143 REV 112W6 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS -~ ~]~ -ry ~ ~ '-t_-~
TYPE 1 PRIM IN °~` .:~-~ = _•
PERMANENT CERTIFICATE OF DEATH ~-' ~ ~~~-`
BLACK INK -ZI ~ ~ f;-- f~
(See instructions and examples on reverse) STATE FILE NUMBER "Cj +f 4l~
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i. Name of Decedent (Rrs4 middle, last, sufBz)
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k s 2. Sez
n 3. Soda) Sealy Number q, Dak of a (Modh, day, year) ~.
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6. Age (last BiMday) Under 1 ar Under 1 de 6. Dak d &dh Madh, da , 7. Bi and state ale ' roan be. Pkce of DsaM Check onl one
I Montl¢ Oat's Hours Muvnea (~
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~ Hospikf: Other:
Yrs. !
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Q Inpatient ^ EA I Dulpagenl ^ DOA ^ Naming Home ^ Residence ^ Other - Spedy:
' 8b. County d Death Bc. City, Boro, Twp. of Death Bd. Fadiry Name (If not instiwtion, give street and numbaj 9. Was Decedent of Hispanic Odlpn? No ^ y~ 10. Race: American Indian, Bkck, While, ek.
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Mexican, Puerto Rican, etc.) (SAM e
• t1. Decededs Usual Oca Bce Kid d wok done du' most of woddn Ige. Do not skte reti 12. Was Decedent ever in the 13. Deceden s Education (Specity only higbest grade cempleled) 14. Martial Skws~. Marred, Never Maned, 16. Surviving Spouse pf w4e, give maiden name)
Kind of Work Kind d Busressl Indus
~' U.S. Am~ed Forces?
Elementary I Sewndary (o-(2)
College (1-0 or S+) Wdowed, Divated (Spedly)
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rG ' ~, Yes ^ ND
• 16. Decedent's Mailing (Street, city! town, state, zip code)
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-~ Rd Decedems (~ Did Decedent y~/~
Actual Residence 17a. State ~'r Uve in a t1c. ~ Yes, Decedent Lived m 1 f 1 DVl Y~~ ~ .Trop.
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P owns
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Y t1d. ^ No
Decedent LNed wNtin
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t1h. County
Actual Omits d Cityf Boo
16. Father's tikme (Fimt middle, last, suffoc) 19. Mothers Name (Flrst, middle, maiden surname)
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ZOa. Infom~anYs Name Rype / Pnd) _
20b. IdormanYS Maidng Address (Street dY 1 town, stale, zp code)
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21a Medved d DLSpos' ~ ^ Cremation
^ Donation 21b. Date of Dispositia~ (Modh, day, year) 21c. Plaza of Disposgim (Name of cemetery, aemakry a other place) 21d. Location (City , skk, zip code)
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~Btuial ^ Pemwalfrom5tak iWasCremalionorponatlanAulhorittd
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hyMedlcalExaminerlCoroneR ^Yes^No d / ~
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~ 22a. S' of Funeral SeMce Ucerrsee (a n ~ as such) 22h. Ucnnse Number 22c. Name end Addmss of Fadfdy
Complete gems 23a~c onty when cerlityirig 23a To ine best d ledge, death occuned at Me time, dale aril place staled. (Sgnature and tAk) 23b. License Numher 2;k Da S' ed (Mon ,day, year)
physidan le Tat avaiabk at time of death k
tif
d d m m ~ y 32~ 9~ o
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cer
y rouse
eath. ,
• Nems 2426 must be anpleled by person 24. Time of Death 26. Date Pmno Dead (Mo N, day, year) 2fi. Was Case fiefened to Medical Examiner 1 Coroner for a Reason Owe! hen Cmmation or Donation?
,• who pronounces d~th. ~ ~' : 3 ~ M. s~ yl v1 ~t ~ l
W ^Yes No
i Approzimale mtervaC
CAUSE OF DEATH (See instructions and a mples) Part IC Enkr other i in e t ;:B Did Tabacw Use Contnbura to Death?
hem 27. Pad k Eder the chain of events -diseases, injures, or complications - that tiredly roused the d~lh. DO NOT enkr lermi~al events such as roNiac arrest, ~ Onset to Death bd not resulting in the undedying rouse gNen in Pan I. ^Yes ^ Probably
re~imtary arms(, or ventricular fibtitlahoo without s g the elbbgy. Usl only ork cause on each line. i
No ~ Unloovm
IMMEDIATE CAUSE Final dsease or ~ ~ ~ ~ ~ ~ /~
mndtia resultin
in ~eath)
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f5 I Female:
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Due k (or as a censequer~ce oft, ~
~ pregna
w
n pss
year
^ Pmgnam at tine d deaN
erweYy ILd cenditiais, g arty,
le
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fi
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h' i ^
a k t
e rouse
ste
on
re a.
Duero (a as a
n Nol pregnant. but pregnant wiUtin 42 days
co
sequence oq:
Eda UNDERLYING CAUSE
of death
- (disease a iqury tlral initialed me i
c.
evenk resultin
in death) LAST ^
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Due to (or as a corrsegcence oq: , Not pregnant, but pmgnan143 days to 1 year
befom death
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Unlmown d
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nant wBhin the
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30a. Was an Autopsy 30b. Wem Autopsy Findings 31, Manner of Death 32a. Date d Inury (Month, day, year] 32b. Descnte How Injury Occurred ;2c. Place of Injury: dome, Farm, Street, Factory,
Pertained? Available Pear to Canpktion
~aMal ^ Honicide
I Office Buildng, etc. (SpeeilyJ
of Cause of Death? -Q
^ Yes ~No
^ Yas No / ^ Accident ^ Pending Imestigation 32d. Tine d Injury 32e. Injury at Work?
^
^ 32f. If Trampodatkn Injury (Spedry)
^ Driver/Operate ^ Passenger ^ Pedestrian 32g. Laotian of irryury (Sheet, city I town, stale)
/ ^ Suinde ^ Could Not be Dekrtmned M Yes
No
. ^ Other- Spealy
33a. Certifier (check arty one) 33h. Sigiawre and T of ttiker
• Certllynng physleien (Physickn ceditying rouse d death when arather physidan has pronounced deaN and completed Item 23)
To the beat of my knowledge, death attuned due to the rouse(s)end manner as staed_________________________________ ^ -
• Pronouncing and cedNying physkian (Physidan bdh praauncing death and certifying to rouse d death) ~1
Ta fhe best of my knowledge, deaM attuned et the time,date, and place, end due to the rouae(s)and manrer as saled__________________ pJ 33c. Lkarzse Number
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~ 33d. Dak Si (Magh, y, year)
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• MedlalEsamirorlCoroner // /~~
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On the basis of exemtrwtion and f or investigation, in my opinion, death attuned et the Ume, doh, and plece, and due to the rouse(s) end manner as akled_ ^ 34. ~ I A d of Person Wla Carmkted Caus~M~ eath (h~ ~ Type! aunt
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35. Registrar
s Signawm and D
Number
- ~T~ pFF(C~ I~ 7 I C~ 10 I 0 I 36. Dak Fled ( , y, year)p
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Disposdion Pemtil No. V 5 "I _! "! lQ 3
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