HomeMy WebLinkAbout07-26-05 (2)This is to certify that the information here given is correctly copied Prom an original certificate of death duly filed with me as
Local Registrar. The original certificate will he forwarded to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $2.00
`G-i! 7~N1Q F'1
Lori Registrar
JAN 1 02005 _
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF F~EALTH • VITAL RECORDS
CERTIFICATE OF DEATH
(Coroner)
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TYPE/PRINT
IN
PERMANENT X29-415
BLACK INK
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NAME OF DECEDEM (Fvp, Mi[Ide. LsaO SEX SDCIAL SECURITY NUMSER ~~ DATE OF DEATH (MOMh, Dey, lbar)
1• Harold E Benson x. Male 9. 177-32-8567 ,. January 7, 2005
AGE(Lap Birthday) UNDERIVEAR UNDERI DAY DAFE OF BIRTH BIRTHPUCE ICm'ara PLACE OF DEATH(Cl;u;k pNyoro-aee inatruclione mother rido)
MoMM Days lbun Mkadas (MmM, OeY. Yaar) Slab ar Forego Country) HOSPffiLL: OTHER:
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63 Yn. Jan4,1942 untington Co.,,,,~t,,,n^ ERrolAppbnt^ Dd,^HZm"'"0. ^ Rsaresnq,~J ,O1S,:~ily,^
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' COUNTY OF DEATH .CRY, 7W DEATH FACI entl nuntbar) NN$
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CEDENT OF HISPANIC ORIOINT RACE-Amxken Intllen, BIECk, Whne, arc.
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ryCUben, (SP•c!M
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• ~ Cumberland se Dickinson ~ 19 Half Mile Drive M aiun,PUMORIC.
White
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DECEDENT'S USUAL OCCUPRION KIND OF BUSINESSANDUSTRY VaAS DECEDENT EVER IN DECEDEM'S EDUCATION MMRAL STATUS-Mptlatl SURVIVING SPOUSE
(Gh'•I«adWO,k avwtlurlno mwt U.S.ARMED FORCE37 Nsvar Marrbtl, Wltlowao, (Il wile, give meiCen name)
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ro,~ (1J Or 511 MarrieQ Bonnie Nelson
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DECEDENT'S MAILING ADDRESS (Street, C~ .Slate, Zp Cone) DECED 'S
19 Half Mile RR, ResIGD~ENCe "'~~"" dd ,Te.~ybe,mpd.MNVedin Dickinson Tw}~ ,yp.
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Gardners PA17324 ~,°d ~°"' ""'"°
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FATHER'S NAME (First, Mitltlb, Lop) MOTHER'S NAME (fir&, Midtlle, Meitlen Surname)
+.. ,E- Mabel Bechtel
INFORMANTS NAME (TypdP"M) INFO MANT'9 MAILING ADDRESS (Sheol, CifyR , S1o19, Zip Code)
Bonnie R Benson f M'le Dr Gardners PA 17324
METHOD OF dSPOSRION
BwMI ^ Cremstion ~ Removal hom Stale ^
. DAFE OF DISPOSRION
(Month, DeY• ~e0 PLACE OF DISPOSRION-Named Cempary,Cmnetary
or OIMr Plan LOCATION-CayROwn, SIaN, Zlp Coda
D°""I°"^ O1""'~°""' ^ 1 /11 /2005 Hollinger Crematory t. Holly Springs
PA17065
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SqN OF FU ERAL RVICE LICENSEE OR PERSON ACTING AS SUCH
~ LICENSE NUMBER NAME AND ADDRESS OF FACILRY
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zx. ' szti ~lingerF.H.&CrematoryMt.HollySprings,PA
CompNte Mama 29aa waywMnc•MM
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~ nnmedtle.mlo To tla bap of my krrewle,lpa,tl•ath oaunsrt attM nms,dMeeM deco petetl. LICENSE NUMBER
Isipnalleeantlrroe> DATE SIGNED
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x3a, x9b. x9e
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~ x~~S~r ~Mby TIME OF DEATH prx DAFE PRONOUNCED DEAD(Mmth, Dey, Veer) VAIS CASE REFERRED TO MEDICAL EXAMINER/CORONER7
z.. 3:00 P M. xs. Januar 7, 2005 za
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xT.PART1: EMartMdbsatae,b^~orcomdkatiomlwhlchuueMthedMM.DOnoleraerN•modedtlyirlp,suchVeardhCOrrsadretoryarrM,shockwhaartlBiWro. ~Aplxoslmpe MRT11: doer IhanIWMMOnacontrbaln W0•adl,bul
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EM/EDUTE CAUSE (Fop ~ orreN entl deaN
~'•••a~^~n Gunshot to Head
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DUE TO (OR AS A CONSEQUENCE OF):
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8apranliaaylw oandXbrre e
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Earry.ISadklpb knmeBals DUE 10 (OR ASA CONSEWENCE OFg
due. EMarUNDERLYING
CAIIDE(Dissee ar inkxy e.
EW kitiYad aveMa DUE lb (di AS A CONSEQUENCE OF):
rwullinp In Oaatlt) LAST I
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WASM AUTOPSY
PERT-0RMED7 WERE AUTOPSYFlNDINGS
AWLABLE PRIOR TO MANNER OF DEATH D/(TE OFINJURY
(MmM, DaY. yap) TIME OFINJURV INJURY AT WtlRKT DESCRIBE HOW INJURY OCCURRED.
COMPLEFION OF CAUSE
of DEAFHT
Nalurp ^ Homicide ^
Aprx
~ ^ ~~ Self inflicted
gunshot-
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P•^dbplmeplpatbn ^ Jan 7, 2005
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3:00 P M.
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Sulclda ® Could rwl ba tlororminad ^ PUCE OF INJURY-AI home, hrm, greet, lacbry, oMOa
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(3P. LOCATON (Street. C~ wn, Stele)
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3q,Half Mi Dr, Gardners, PA
CERTIFp[R (Check aMy One)
'CERTIFYING PHYSICIAN (PhyskJen certHYinp Cauao d tleaM whm another phyacan hea prmouixetl death antl wrndeMtl Item 23) SIGNATURE ANOT E I
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T tn.b..eolrm'ana.l'nE•,apnaaapnwan.mE»ap..p).ram.nn.r..pma ..................................................... ^ Coroner
31b.
'PRONOUNdNO AND CERTIFYING PHY91C1AN(Phyadan potl, prmq.roinp oealnaM Certilyvq to uueedtlaeth) LICEN N B DATE SIGNED (Mmlh, Day, Nesrj
To1M bM Ot my krreMMdpa, daetlr oeeunatl ptM tkna,dab, end p4ea, prtltluta tlN•au•(s)era mmmrn pl•d .......................... ^ 31e, 31d. Januar 10 2005
NAME AND ADDRESS OF PERSON WMO COMPLETED CAUSE OF DEATH
'MEDICAL EAAMINER/CORONFA (Ilan 27) Typo or Prlm
Michael L. Norris, Coroner
OntMbWedeaeminedonand/orlnvMgallon,InmyrTpnlon,deamoewrrednthatlme,dm,raplace,anddwtotMesun(yand
m.nr»....tn.d 6375 Basehore Road
Suite ~1
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3z. Mechanicsburg, Pa. 17050
REGISTRM'3 SIGNATURE MDNU j^.~ (r~_• ..wLL ~~ ~ ~~~ ~ ~(~~ DATE FILED (Mmtlr, Gay, Near)