HomeMy WebLinkAbout08-01-12 (2)H105.805 REV (01/07) ~.
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LOCAL ~' CERTIFICATION OF DEATH
WARNING: I~~~~ei~'dl to'~~ate this copy by photostat or photograph.
Fee for this certificate, $6.00 :,
P 18007788
Certification Number
This is to certify that the information here given
correctly copied from an original Certificate of Dea
duly filed with me as Local Registrar. The origin
certificate will be forwarded to the State Vit
Reco • , ice for pe _ ~ nent,filing.
LUl~tt-iteglstrar Date Issued
H1D5~143 REV t1kp08 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
TYPE /PRINT IN
PERMANENT CERTIFICATE OF DEATH
13LAac lMC (See instructions and examples on reverse)
CTaTF FII F NI INIRFR
t. Name d Dewdarll (FirN, midrib, lest, sunrc) 2. See 3. Sodd Sealriry Numbs 4. Date d Death (MOmh, day, year)
Violet I. Like Female 209- 12 - 5858 October 25, 2011
s. Aq (Last BMhdey) Under 1 Urabr 1 da 6. Dale d BM Modh, 7. and stele a Bs. Plow d Deem Check ore
MOne° Die NOUi """"~ Southampton Twp. Hapitel: Other:
94 vrs. Se tember 13, 1917 Franklin Count PA ^tryrpem ^ER /OdpNiea ^DOA n7 NaNnp Hans ^Reaidence ^Opwr-Spaciy:
m. caunly d Dean &. Cdy, Bao, Twp. d Deem ed. Fadlny Name (II not iahLAbn, give streN and amber) 9. was Decedent d HBPenb Origin? X
^ No ^ vas 1p. Raw: American IMien, Bbdc, Wlvle, etc.
In ra~ wecilY Ctd>an, ISp~i1
Cumberland Shi ensbur Tw Shi ensbur Health Care Center Meaban,PaaroRiwn.elc•) White
17. Deadem's IkIW a wak rbra nnN a we. Do not alma ran 12. Wss DeadeM aver in tlb 13. Decedent's EdA•aem (Spedly ony hiplxet grade ampeted) 1/. MadN SIBIee: Muried, Never Maned, 15. SurvNeg Spoke In wile. pNe meMen rams)
Kedd Wak I(iMd&ailma/I
act U.S. Amred Fawn? Witlowed, DNaced (Spedly/
Ela,renbry / sewrlaW to-lz) Cokge (1~4 «s.)
Floor Supervisor Clothing Manuf
urer ® No 8th Widowed
^ vas
18. DxNbm's Menag Adaass (S6at, mY/town, Nets, Np ads) Decedem's Did Dewdem
AcIUelResidence nastab Pennsylvania Lheina 17a~Ves
Decedatttiredin Shippensburg
121 Walnut Bottom Road ,
Trop
T°""eh"?
Shi
ensbur
PR 17257 1m, Cumberland
nd.^
~ived within
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CilylBaa
18. Femera Noma (firN, mMdb. bet, eutpa) 19. Momar's Nerve (FIIN, nwlde, mtiden eumare)
David Varner Lizzie B. Coy
20e. Irdamerd'e Name (TYpe /Prim) 2pb. Imamanl's MNilg Adtlrwa (Street dry / roan, Nate. zp code)
Pats M. Rhine 4865 Philadel hie Ave. Chambersbur PA 17201
2/a. Meppd d Dbpoaipon ^ O,m1egm ^ ~~ 21 h. Date of Dbpceipm (Morin, tley, ymr) 21c. Pbce d D'epcelllon (Name d omalery, menW W a dher place) 21 d. Laceeon (City/tovm, NNe, zq wtle)
® alnal ^ RemovNhanBbte ~ w°D'.mNlo"or°anu°"A,dhal~°
^ Diner. by Metllal Ezandna/tbrorer4 ^ ves^ No October 27, 2011 Parklawns Memorial Gardens Chambersbur PA 17201
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22a F as sucfi 22D. Liceree Number 22c. Name ant Address d Fenny
FD-014351-L Fogelsanger-Bricker F.H., 112 W. King St., Shippensburg PA 17257
dens 23ec any wMn ~ 23a. To me beN d my browledga, deem axarad et pro pine, tleb end pbce sbtaf. (Sipalure end Idle) 29b. liceree Heiner 23c. DNe Sgred (Main, daY, Year)
physcbn b rot evanabb N lone d deem to
caddy cause d deem.
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ec~.~/o 9o C/
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nano 2M%mwt oe wmpleted by person 24. tore d Deem a trine
r/rte
d/Deae day, rad 28. was case Rebned ro Marital Fxmnkwr / Cororer la a Reasm omen den Cremation a Oaaem?
vAro praaunwa death. /
/
OIJ 7 /•~ M. V p7,~ ^ Yes ~ No
CAUSE OF DEATH (Sea Inseructlona and exsmplea) I Approdmale btervN: Pad II: Emer oprer s~+ldcnm wldpmra cadr8cari!.~ to drew 2p. Di0 Tobacco Use Comrbub b Death?
item 27. Pan I: Error the fmHm,d.~- dweaess. trysts, a wngliwwnons ~ ~~Iaatt dredly cawed ple deem. DO NOT enter IennklBl evade such as cerdec aneN, i OnsN W Deem
' bd M resullig m the adenynp cause given b Pod I. ^ Vss ^ Probedy
mpraro7 arteN, a venhfcubr lmrpbtbn wbwd showing me ellobgy. L
el any ak: cause w eadr ins.
I
^ ~ ^ Unknown
Xi~qi1IEEDU1iE CAUSE /Peal disease or
N deem)
wndUon resulWl
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1 29. n Femeb:
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a.
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Due (a es e i
$ao~N ry (~~o ,{-
b. 1~?i/ : c c,'/n ~
In
b the aw~eYbd'odn li~w' a
peat year
~ Wg"a" w~"
^ Pragnem N time d dean,
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Ema rive UNDERLYING CAUSE Dw to (a es a carwequelme d): ^ Nd prepwrd, bA pregrem witlVn 42 days
(C160ase a m)Iny HIN trnpeted qa c i
event resupkg ro death) LAST. d deea
^
Due b (a ee a atwegwnce oQ: Nd Pregrwm, bld Ixe9aM 43 da Io 1
Ys year
U.. tetra death
^ UrAnown n pregwnl wphb the peN year
30a. Wes an Aldopsy 390. Were Adepsy FkaAngs 31. Death 32e. Date d Iryuy (Month day, Year) 32b. Describe How
mN7 ~"~
32c. Pbce d injury: lame, Fenn, Strad. Facbry,
Periormed? Avadeble Prim b Completion Nadaal ^ Homicide Orrice BuiMhg, eb. (3'perilyj
d Carte d Deatlt
^ Ves d'NO
^ Yet
k
^ AcddeM ^ Parsing Inveslipelion
~. Time d InjW
92e. Iryay et Work?
321. n TrawponNim IryW (Spedy)
32g. Esteem d kyW' (Sheet cdY /tam, state)
. ^ Suicide ^ CouW Nd be Delelmined ^ Vea ^ No ^ UNerloperNa ^ Passings ^ Pedestrian
M ^ Older ~ Spsdly:
33e. CemTim toted only ale) 33b. Sigalue end Tips d
• Celtnylrg phYekim (Physldal cerllryMg rouse d deem w4wn aroma physiuen has prorwureed death and aMrlpleled Ibm 23)
To UN beNd my bl•nbdB•, deeM ocevured due to the esuaelsj and nrrnerw Natad_________________________________
Pranounciq and rxrtllYNrg phyabM IPMsemn ham prawackg deem end wnnykg b wuce d deem) 33c. Licewe katmer 33d. Dde Signed ( Y. Y•etl
• TMedicNEmnirr/~~,daNh oecurwd Mtlte tlme,deM,aM pew, end due to me cauagq antl ntamler se NNed__________________ ^ ~~,' ~ ~ ~ `~ ~Zi ~~
On thehrbdesMdrWbn arallor mvaagstbn,mo,y opMlon, eeeRloamnd Mlhe tlme,MM, and place, and sue totM CSlwys)rd manrerss sWed_ ^ 3!. me sal AddrecedParean who
Carobted cau/se~a t>~ (item 27) type /Prim
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