The URL can be used to link to this page

Home My WebLink About08-16-12 (2) LOCACI~F'!O~~~R'S C~RTiFiCATION OF D~ATI-~ WARI~1~:~~~~,iS'j~#e`'t`~ Lien duplicate this copy by photostat or photogral3, E~ee &x this certificate. ~h.O0 to ; Ill's ~`~ (f V F ~~~~~ ORFFiAt~`5 ~;vU~t PA (o, n~ Z,' ~° `. _ P 1621_0662 Certification Number Type/Print In Permanent Black Ink c a 4 C 5 Th1s is to ~rvrt)r~„ ;(.)! 14~( () ,;r(j~ .°,+ correctly c«~1~d ``Ir ~~ an u i )),,j ~ t-) +_iule filed with )~~( J, i_a (Cc~~J~;~:~ certificate will hl j'Orti; )) ~ (i ReC.04CIS l7r~lce f('i )kCilltlZ .t'( i'i , _ ,~ `` F ,` ~ ~ i' r ~~9j~1'ENTa`~`~Z,~,`P~, l..~~lGl~vL-.,~ •~~ /`'`_~~L_ FFBf` 15 ;~~ ~~ ,,,,,,°, Local iZegjstrar ~ / ~ ~P,,~. ~, ~.~. COMMONWEALTH OF PEN NSV LVANIA ~ DEPARTMENT OF HEALTH ~ VITAL RECORDS CERTIFICATE OF DEATH 1. Decedent's Legal Name (First, Middle, Last, Suffix) 2. sex 3. Social Security Number 4. ate of Death (MO/Day/Yr) (Spell Mo) Emma E. Demarest F. '137-24-7'195 Sa. Age-Last Birthday (Yrs) Sb. Under 1 Year Sc. Under 1 Da 6. Dale of Birth (MO/D ay/Vear) (Spell Month) 7a. irthpla Fe~(City rritpp State or Fei r~,C ntry) ~ ~ ~ ~ Months Oays Hours Minutes 1a1n 1 , NJ OULI] 1 t 95 yrs. Sept_ 28,1916 76. Birthplace(COUnty) Mi esex Sa. Residence (State or Foreign Country) 86. s d (Street d Nu ber -Include Apt No.) ~ ~e ~ Yvo ~' Sc. Did Decedent Live In a Township? ~ iddl t p p, Wa n s or g Y ' So _ M e on ~ Ves, decedent lived in I twd gd. Residence (County) I 7 0 1 5 Car l i s l e PA Cumber 1 and 8e. Residence (Zip Code) 1 7 ~ 1 5 Q No, decedent lived within limits of city/boro. Armed Forces? 10. Marital Status at Time of Death Q Mauled Widowed 11. SurviYing Spo s Name (If wife, give name prior to first marriage) 9. Ever in US UC Q Yes pfj No QVnknown Q Divorced Q Never Married QUnknow Deceased 12. Father's Nam¢ (First, Middle, Lasi, Suffix) 13. Mother's Name Prior to First Marriag¢ (First, Middle, Last) Harve M. Houston Emma Norwa 14a. Informant's Name 14b. Relationship to Decedent 14c. Informant's Mailing Address (Street and Number, City, state, ZIp Code) 0 Janet F . Catarino Dau titer ~ 2 ~ ~ Kuhn Road Boiling Springs , PA G _ isa. P ace o Deat c ec pn y, one ... ......... ........ ... ... .. ......... ..... ...... ....... ..... ...... ... .. .... ... ... ... ... .. ... wwrr If Death Occurred in a Hospital: LJ Inpatient . If Death Occurred Somewhere Other Than a Hospital: Hospice Facf lity Decedent's Home ~ Q Emergency Room/OUtpatienC Q Dead on Arrival Nursing Home/Long-Term Care Facility Other (Specify) ad 156. Facility Name (If not institution, give street and number; lSC. Ci Town, State, and Zip Code lSd- County of Death Cumberland Crossings Carlisle PA "170"15 Cumberland 16a. Method of Disposition Q Burial Cremation 166. Date of Disposition 16c. Place of Disposition (Name of cemetery, crematory, or other place) pRemgyalfromstate pDOnation Other (specify) 2/'15/20"12 Hollinger FH/Crematory Snc_ 16d. Location of Disposition (CITY or Town, slate, and 21p) 17a. nature of Funeral Service Licensee in Cha of n[erment 17b. License Number 0 ~ Mt_Ho11y Springs, PA '17065 FD-0'1'1932-L E 17c. Name and Com plet¢ Address of Funeral Facility .9 Ho11in er FH Cremator nc 1 N B 1 im n 16. Decedent's Education -Check the box That best describes the 19. Decedent of Hispanic Origin -Check the 20. Decedent's Race -Check ONE OR MORE ra s fo indicate what f- highest degree or level of school completed at the time of death. box that best describes whether the decedent ~ decedent considered himself or herself to be. Q 8th grade or less is Spanish/Hispanic/Latino. Check th¢ "NO" White ~ Korean No diploma, 9th - 12Th grade bQj~ if decedent is not Spanish/Hispanic/Latino. Q Black or African American Q Vietnamese /Latino Q American Indian or Alaska Native Q Other Asian i t S i h/Hi ~ span NO, no pan s c High school graduate or GED completed ) 0 Some college credit, but no degree Q Yes, Mexican, Mexican American, Chicano Q Asian Indian Q Native Hawaiian - Q Associate degree (e.g. AA, AS) Q Yes, Puerto Rican Q Chinese Q Guamanian or Chamorro Q Bachelor's degree (e.g. BA, AB, BS) Q Yes, Cuban Q Filipino Q Samoan Q Master's degree (e.g. MA, MS, MEng, MEd, MSW, MBA) Q Ves, other Spanish/Hispanic/Latino Q Japanese Q Other Pacific Islander Q Do Borate (e.g. PhD, EdD) or Professional degree (Specify) Q Other (Specify) . MD, DDS, DVM LLB l0 21. cedent's Single Race Self-Designation -Check ONLY ONE to indicate what the decedent considered himself or herself io be. 22a. Decedent's Usual Occupation -Indicate type of work [~} Wh(Te Q Japanese Q Samoan done during most of working life. DO NOT USE RETIRED. Q Black or African American Q Korean Q Other Pacific Islander Hour EW 1 f 2 ' t Know/NOL Sure Q American Indian or Alaska Native Q Vietnamese Q Don Q Asian Indian Q Other Asian Q Refused 226. Kind of Business/Industry Q Chinese Q Native Hawaiian ~ Other (Specify) Q Filipino ~ Guamanian or Chamorro Dome s t i c ITEMS 23a - 23d MVST BE COMPLETED 23a. Dale Pronounced Dead (MO Day r) 23 b. Person Pronou ncin Deat On y when applicable 23c. License Num er BY PERSON WHO PRONOUNCES OR CERTIFIES DEATH - /t ~ Z 23d. Date Signed (MO/Day/Yr) 24. Time of Deat 2 .Was Medical Examiner o ntacted? Q Ves No CAUSE OF DEATH Approximate 26. Part 1. Enter the chain of a ents--diseases, inJu rtes, o mplications--that dfrecSly c sed the death. DO NOT enter terminal a ents such a ardiac arrest Interval: respiratory arrest, or ventricular fibri llatlon lthout showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a 1(ne. Add additional Tines If necessary Onset to Death w ' L //' /~ IMMEDIATE CAUSE ~~l T {~~Pr3 ~t'~/TAAU~4• j y Y rf (Final disease o ndition Due to (o as a consequence of): " resulting in death) b. Sequentially Its[ conditions, Due to (or as a consequence af): If any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE Due to (or as a consequence of): _ (disease or injury that initiated the events resulting d. as a con In death) LAST. Due to (or sequence of): ibutina to death but not resulting in the underlying cause given In Part 1 27. Was an autopsy performed? r er other i "Fl t d"f t 26. Part 11. Eni o Q ~ / ~ ^ ` t/~~/72GC/'~ CI/~Iyr vt~~~Cll~ 2g Were auto s flndin s~vallable , p y g to complete the cause of death? m ~ Ves Q No d 29. If Fej~ale: 30. Did Tobacco Use Contribute to D<ath? Q Probabl Q 31. Manner of Death ®~Natu ral ~ Homicide E [j NoT pregnant within past year h y ~ [~ No Q Unknown Q Accident Q Pending Investigation u Q Pregna of at time of tleat but pregnant within 42 days of death Q Not pregnant Q Suicide Q Could not be determined m , but pregnant 43 days Co 1 year before death Q Not pregnant 32. Date of Injury (MO/Day/Yr) (Spell Month) ~ , Q Unknown if pregnant within the past year 33. Time of Injury 34. Place of Injury (e.g. home; construction site; farm; school) 35. Location of Injury (Street and Number, City, State, Zip Code) 36. Injury ai Work 37. If Transportation Injury, Specify: 38. Describe How Injury Occurred: Q Yes Q Driver/Operator 0 Pedestrian Q No Q Passenger Q Other (Specify) rtifier (Check only one): 39a. ~'je death occurred due to the c use(s) and manner stated wl d e f k b e g , my no e est o C rtifying physician - To the Q Prqnou ncing 23< Certifying physician - To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated in Cion, an inv¢stigation, in my opinion, de/a~th~ ~ red at the time, date, and plac¢, and due to t~h/e cya/use(s) and manner stated f ~ Medical Examiner/CO the basis~ J~ s ~O ~3 ~ 3 ~ £ r ~ // q ~ ( ~ License Numbe~F: --'~ - Title of ce rtifi¢r: / ~"-~ Signature of certifier: ~ ~-"- ~ ~ - 39b. Name, Addr s a d 21p Code of Person Cymplefing Cause of Death (Item 26) L j ~Gf ~ l~ /f'vc ~lcn-c f-r•~ t Yu 4 . ~ 3 LY 39c. Da~te3igned /Day/Vr) G(~ l~ tstrar's District Number 40. R¢g 41. Re s signature t 42. Registrar File Date (MO Day/Vr) ry oc ~ -oZ -/'~. I~AC~ 43. Amendments ~ //~~ H1O5-143 Disposition Permit No. V ~~ ~ ~ REV 07/2011