HomeMy WebLinkAbout04-18-12LOCAL REGISTRAR'S CERTIFICATION OF DEATH
,'~1(I11~G*!~-~~Nl~al to duplicate this copy by photosi.at or photagr>~ph.
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Fee for this certificate, `6.00 phis is to ~erti3e r ~-)) the ~r)fi)rni;(tiOn ht)e ;i~u( i~
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Certification Numbe)~
,a
Type/Print In
Permanent
- Black Ink
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Y
Lnc.(1 Re~'i>irar bate l~su(~d
COMMONWEALTH OF PENNSYLVANIA . DEPARTMENT OF HEALTH ~ VITAL RECORDS
1. Decedent's Legal Name (First, Middle, Last, Sufflz) v ~ v ~~ s a State File Number:
2. Sex 3. Social Security Number 4. Date of Oeath (MO/Day/Yr) (Spell Mo)
Richard L_ Kann
Male 210-26-5116 March 29, 2012
S
A
L
a.
ge-
ast Birthday (Vrs) 6b. Under 1 Year Sc. Under 1 Da 6. Date of Birth (MO/Day/Year) (Spell Month) 7a
Birthplace (Glt
d S
.
y an
tate or Foreign Country)
78 Mgnin: Days Hours Mingtes September 17, 2933 Walnut Bottom PA
7b. Birthplace (county)
8a. Residence (State or Foreign Country) 86. Residence (Street and Number - Include A t N Cumber 1 a n d
g
Dld
c.
Decedent Live lna Township?
Pennsylvania 1836 Walnut Bottom° 12d
Ves, decedent lived in p p y[ Tl twp
ad. CPU mr~i dog 4th n d
8e. Residence (Zip Code) 1 7 2 4 1 ~ No, decedent lived within Ilmits of
city/boro.
9. Ever in US Armed Forces? 10. Marital Status at Time of Death ~ Mauled ~ Widowed 11. Surviving Spouse's Name (If wife, given me prior to first marria
a
$] Yes Q No Q Unknown ~ Di
)
d
ge
vorce
~ Never Married ~ Unknown Kay F L e D a n e
'
12. Father
s Name (Firs[, Middle, Last, Suffix) 13. Mother's Name Prior to First ~ lage (FUs Middle, )
George Kann Sara s a ~a ~~1
o 1man
14a. Informant's Name 14b. Relationship [o Decedent 1 M ilin A dre (Sir d Nu Cit
Kay F. Kann wif
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If Death Occurred In a Hos ita l: P+~ _,_,;,,__,ce o ea ec, on y one
P
In
ati
t
~~~ ~
o
_ p
LJ
en
a HosPita 1. .......................... ................................ ...
~ ;If Death O red 5 h¢re O[h rTha
"' .us
Emer Hospice Facility LJ• Decedent's Home
~ gency Room/Outpatient 0 D
d
A
l
ea
on
rriva
N I g Ho /L ng T Care F Ility Other (Specify)
156. Facility Name (If not InstltuHon
l
t
•
~ , g
ye s
reet and number;
15c. City or Tqwn, State, d Zip Code i6d. County of Death
Green Ridge Village Newvill
PA 1724
e,
1 Cumberland
16a
M
Th
d
f
~, .
c
o
o
Disposition ~ Burial 0 Cremation 166. Date of Disposition 16c. Place of DIS osltlon (Name of cemetery, cr story ther place
p RemPYalfrPmstate p D°nati°" 4/2
Huntsc~al
Ch
f
he
~
~ e
/2012
urch o
t
Bre
hren
o[her(sPeafy)
Cemetery
i6d. Location of Disposition (City or Town State, and Zip) 17a. Si~e f Funeral Service Licensee or person In Charge of Interment 17b
License N
b
Carlisle PA 17015
.
um
er
~ FD 13895 L
17c. Name and Complete Address of Funeral Faclli
Egger Funeral H
ty
~ ome
lnc 15 Big Spring A e Newvilll=_r PA 17241
18. Decedent's Education -Check the boz that best describes the 19. Decedent of Hispanic Origin -Check the 20
pecedent's R
Ch
k
h
.
ace -
ec
ONE OR MORE ra es to indicate what
ighest degree or level of school com placed at the time of death. box that best describes whether the decedent th
d
d
e
ece
ent considered himself or herself to be.
Q 8th grade or lass is Spanish/Hispanic/Latino. Check the "NO" Whit¢ 0 Korean
No diploma, 9th - 12th grade
boz if decedent is not Spanish/Hispanic/Latino. Black or African American
High school graduate or GED com leted ~ Q Vietnamese
P ® No
not S
anish/Hi
i
,
p
span
c/Latino ~ American Indian or Alaska Native 0 Other Asian
Some colle
ge credit, but no degree ~ Ves
Mexican
Mexican A
i
h
,
,
mer
can, C
icano ~ Asian Indian 0 Native Hawaiian
~ Associate degree (e.g. AA, AS) ~ Ves
Puerto Rican
,
~ Bachelor's degree (e.g. BA, AB, BS) Q Yes
Cuban Q Chinese 0 Gua manlan or Chamorro
,
~ Master's degree (e.g. MA, M5, MEng, MEd, MSW, MBA) 0 Ves, other 5 ~ Fllipi"° ~ Samoan
panizh/Hispanic/Latino ~ Japanese
0
Other Pacific Islander
Doctorate (e.g. PhD, EdD) or Professional degree (Specify) 0 Other (Specify)
. MD DDS DVM LLB, JD
21. Decedent's Singie Race Self-Designation -Check ONLY ONE to Indicate what the decedent considered himself or h
lf
'
erse
io be. 22a. Decedent
s Usual Occupation -Indicate type of work
$] White 0 Japanese 0 Samoan
done Burin
Black or African American ~ Korean Q Other Pacific Islander g most of working life. DO NOT USE RETIRED.
~ American Indian or Alaska Native 0 Vietnamese ~ Don't Know/Not Sure Q u a l i t y E ng i n e e r
~ Asian Indian ~ Other ASlan ~ Refused
22b. Kind of Business/Industry
~ Chinese Q Native Hawaiian Q Other (Sped
fv)
p Fllipi^° O G°amanlangrchamgrrp
Technology
ITEMS 23a - 23d MVST BE COMPLETED 23a. Date Pronounced Dead (MO Day Yr) 236. Signature of Person
P
r
o
n
o
un in
g De
BY PERSON WNO PRONOUNCES OR
ath Only wh n a
licabl
pp
e) 23c. License Number
~~~ ~
CERTIFIES DEATH ""
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23d. Dlte Signed~Da / 24. Time of De t
~
1
Q
0
~
f• s M¢dica miner
xa
C
or
oroner Contacted? ~ Yes ryo
CAUSE OF DEATH
Approximate
Ye cq
26. Part 1. Enter the chain of a ^ts--diseases, InJu rtes, or mplicatlons--that directly caused the death
DO NOT
.
enter terminal events such as cardiac arrest Interval:
respiratory arrest, or ventricular fibrlllatlorl .,Ylthou[ sl~r..,ying The et
DD NOT ABBREVIATE. Enter only one cause on
Ii
~
a
n¢. Add additional lines If n¢cessary Ons¢t To Death
IMMEDIATE CAUSE --------------> a.
~~/L-~%[/j
~
_
(Final disease or condition
or as a con
Duuo I? sequence of):
resulting in death)
b.
Sequentially Ilst conditions, Due to (or as a conse
f
quence o
):
if any, leading to the cause
Ilsted on Ilne a. Enter the
UNDERLYING CAUSE
Due io (o as a co
nsequence of):
(disease or injury that
Initiated the events resulting d.
to death) LAST. Due [o (or as a consequence of):
s 26. Part 11. Enter other s~nifica nt di[I t ib ti t d th but not resulting in the underlying cause given In Part I
27. Was autopsy pertormed7
Yes ~ No
m 28. Were autopsy findings available
[o complete the cause of death?
29. If Female: 30. Did To ° Use Contribute to Death? ~ Ves Q No
~ Not pregnant within past year es 31. Ma of Death
0 Probably atu ral ~ Homicide
Q Pregnant at time of death
m No
~ Not pregnant, but pregnant within 42 days of death 0 ~ Unknown ~ gccident ~ Pending Investigation
Not Q Suicide ~ Could not be determined
Q pregnant, but pregnant 43 days to 1 year before death 32. Date of Injury (MO/Day/Yr) (Spell Month)
~ Unknown If pregnant within the past year
33. Time of Injury
34. Place of Injury (e.g. home; construction site; farm; school) 35. Loca[lon of Injury (Street and Number, City, State, Zip Code)
36. Injury at Work 37. If Transportation Injury, Specify: 38. Describe How Injury Occurred:
~ Yes Q Driver/Operator ~ Pedestrian
~ No 0 Passenger ~ Other (Specify)
39a. Cart (Check only one):
rtlfying physlclan - To [he best of my kno ledge, death occu red due to the cause(s) and m
t
t
d
r s
a
e
~ Pronou n<ing 8a Certifying physi -Tot bas f my k ge, death occurred at the time
dat
d
,
e, an
place, and due to the cause(s) and manner stated
Q Medical Examiner/Coroner - the ba of mina /or Investigation
in m
o
l ni
d
,
y
p
on,
eath occurred at the time, dale, and place, and due to [he
c
a
use
(
) a d
r stated
/'
/
J
~
.[
~
Signature of certifier: Title of certifier: License Number-
/ ~r //6~~ / 7Z.~
_
,
396`Name, Address and Zip C of P mpleting a of Death (Item 26)
39c. Date goad ( o/Day/Yr)
3 3= /
40. Registrar's District Numb r 41. Re str ture 42. g File Oate Mo Day r)
o
~~
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14~
~~
~
st aota..
'
43. Amendments
Disposition Permit No._ \ ) ") 3 0 YX(rf
H105-143
REV 07/2011