HomeMy WebLinkAbout08-22-12HIOS.N(li RF,~ 12'I I i
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LOC ~,(,~~ R'S CERTIFICATION OF DEATH
WA t~is`'u ~ I duplicate this copy by photostat or hoto r~ h.
Fee for this certificate, $6.00 `~~~ A(~~ z2
~~ ~~: ~7 This is ±v certia•. tij~(t the. 2t~f(nmatii.jl~ ,acrezi~:~en i carrectly ct>pieLl tri)In al{ 1>ri~inai i'ertific;jte of Death
duly filed witf; nse as Luc;.), Re~Iistra.~. "i'he original
certificate ~~ ilf he tin ~ arded ku tl:e State Vital
~~~~'~ ~ s>V(,{~i ~ Records Off icr '('r i7u tn<Inent *Illn;~.
P _18 61.4 5 3 ~u~~R~° CO., PA ~~~
JU 2 0 12
Certification Number
Type/Print In
Permanent
_ Local Registrar Date. Issued
GOM MONWEALTH OF PEN NSVLVANIA ~ DEPARTMENT OF HEALTH ~ VITAL REGOR DS
CERTIFICATE OF DEATH
2. Sex 3. Social Security Number~ta rile Number:
Joan B. Bitonti 4. Date of Death (Mo/Day/Yr) (Spell Mo)
58. Age-Last BlrthdaV (Yrs) Sb. Under 1 Year Sc. Vnder 1 Da 6. Date of Birth (MO/Da Fgmaspeu 005'3279 a rt5 lace (at 'June 1 C(' 2012
Months Days Hours Minutes P y and State or Foreign Country)
70 July 72, 7947 MOnan ahela, PA
' Ba. Residence (State or Foreign Country) Bb. Residence (Street and Number- 7b. Birthplace (County) ~/aShln ton
PA Include Apt No.) Bc. Did Decedent LiYe in a Township?
Bd. Realdenre (c^~nty) 4547 Dear Path Road ®Yes, decedent Iwed in Susquehanna
Dauphin Be. Residence (zIp coda) 7 77 70 t`~`rP.
9. Ever in US Armed Forces? 10. Marital Status at Time of Death ONO, tlecetlent lived within limits of
Q Yes ® No Q Unknow Q Divorced Q Married ® Widowed il. Surviving Spouse's Name (If wife, given city/bor
12. Father's Name (First, Middle, Last, Suffix) Q Never Married Q Unknow ame prior to first marriage)
John BBCk 13. Mother's Name Prlorto First Marriage (First, Middle, Last)
14a. Informant's Name Mary Celli
14b. Relationship to Decedent 14c. Informant's Mailing Address (Street and Number, City, State, Zip Code)
g Debbie Mirenzi Executrix
G _ _ _ _ 58 Lone Oak Drive, Marysville, PA 7 7053
s If Death Occurred In a Hospital: ~ ~ ~ - - - . - .. _ 15a. Place o eat ec n
o Emer ~ I^Patient ,If Deafh Occurred Somewhere OthelYTh n a Hospital ~ .a l~-~ _ _ _
gency Room/Outpatient Q Dead on Arrival Nursing Home/Long-Term Care Facility Othe L"5 Hospice Facility ~ ~ L_I pecedent s Home
15 b. Facility Name (If not institution, give street and number) ,lSC. Cit ( pacify) '
Hol Spirit Hospital Y or Town, state, and Zip Code
Cam Hill, PA 7 707 7 15d. County of Death
-- 16a. Method of Disposition Q Burial Q Cremation 16b. Date of Dis Cumbarla nd
$ Q Removal from State Q Donation Position 16c. Plate of Disposition (Name of cemetery, cremato
!E Other (Specfy) J11Z30 1 .5 5 2 ~ 1L MOn ~/all0y rY, or other place)
a~ 16d. L^~ation of DIS Memorial Park
2 position (City or Town, State, and Zip) 17a. Signature of u sal Ice Licensee or Person in Char
$ Donora, PA 75033 - Be of Interment 17b. License Number
a
E 17c. Name and Com late Atldress of Funeral Facility FS 07 2 849 L
3 Parthemore ~uneral Hom®& Cremation Services, Inc., P.O. Box
~' 18. Decedent's Education - Check the box that best describes the 19. Decedent ^f HIS 7 303 Bridge Street New Cumberland, PA 7 7070
~ highest degree or level of school completetl at She time of death. box that best describes iw Oether the decedent 20. Decedent's Race -Check ONE OR MORE races to Indicate what
Q 8th grade or less is Spa nlsh/His the decedent considered himself or herself <o be.
Q No diploma, 9th - 12th grade panic/Latino. Check the "NO"
Q High school box if decedent is not 5 / panic/Latino. ® White i~ Korean
grad Uate or GED completed ®No, not Spanish/His panish His Q Black or African American Q Vietnamese
Q Some college credit, but no degree Panic/Latino Q gmerican Indian or Alaska Native
Q Assocl8te degree (e. g, qq~ q,5) I~ Yes, Mexican, Mexican American, Chicano 0 gsian Indian ~ Other gsian
Q Bachelor's degreee(e. g. BA, Ag, BS) 0 Yes, Puerto Rican Q Chinese l~ Native Nawailan
Q Master's degree ( .g. MA, MS, MEng, MEtl, MS W, MBA) O Yes, other 5 Q p no Q Guamanian or Chamorro
Fili i
® Doctorate (e. g. PhD, EdD) or Professional de O panish/Hispanic/Latino Q Japanese I~ Samoan
gree (Specify) 0 Other Pacific Isla ntler
. MD DDS DVM LLB JD O Other (Specify)
21. Decedent's Single Race Self-Designation -Check ONLY ONE to Indicate what the decedent consideretl himself or herself to be. 22a. Decedent's Usual Occu
® White 0 Japanese Q Samoan
Q Black or African American Q Korean done tlurin gPation - Indicate type of work
Q American Indian or Alaska Native Q Vietnamese Q Other Pacific Islantl er B most of workin Ilfe. DO NOT USE RETIRED.
Q Asian Indian O Other Asian O Don't Know/Not Sure Clinical Psychologist
Q Chinese Q Native Nawailan Q Refused 22b. Kind of Busin ass/Industry
Q Filipino Q Guamanian or Chamorro Q Other (Specify)
ITEMS 23a - 23d MVST BE COMPLETED 23a. Date Pronounced Dead (MO Day/Yr) 236. 51 Mental Health
BY PERSON WHO PRONOUNCES OR gnature of Person Pronouncing Death (Only when a
CERTIFIES DEATH ~n~ pplicable) 23c. License Number
23d. Date Signed (MO/Day/Yr) 24. Time of Death
1 2 . ~-/ Q h"~ 2s. was Memcal Examiner or coroner contactedz
CAUSE OF DEATH O Yes m No
26. Psrt 1. Enter the chain f g ° ts__tliseeses, Injuries, or complicailons--that direct)
p ry arrest, or ventricular flbrlllatlOn without showing the etiolo APProximate
res irato y caused the death. DO NOT enter terminal eve nis such as ca rdlac arrest,
,
L- Fem. gy. DO NOT AggREVIATE. Enter only one cause on a line. Add addi<lonal lines if necessa r Interval:
_________> a, -~O
IMMEDIATE CAUSE -----_ ~e.J V~-.J -' 1t~-r~ t_ g~i. ~~J Q ~ ~~ `~~ ry. r Onset to Death
(Final disease or condition LLw.a-~,~ S ~
resulting In death) D t ( q f) ~ /S
sequentlany na conmtlons, b' /-~ ! ~ cy ~ pot c e"r 3 j
If any, leading to Lne r owe to (o as a consequence ot~: _ yr S
listed on line a. Enter thee
UNDERLYING CAUSE
.~ (disease or Injury Yhat Due to (or as a consequence of):
c Initiated the events resulting d.
In death) LAST.
Due to (o sequence of):
26. Part 11. Enter other s~fl~ t tllti t Ib <i d th but not res ultingsin the unde 1 In r
~ r Y g cause given in Part I. 27. Was t
m autoPSY Perf med7
Q Yes No
28. Were autopsy fin ings available
3' 29. If Female: to complete the ca s f death?
s ® Not pregnant within past year 30. Did Tobacco Use Contribute to Death? Q yes No
Q Pregnant at time of death Q Yes Q Probably 31. Manner of Death
Not Natural Q Homicide
es Q Not Pregnant, but pregnant wtthin 42 days of death No Pending Inyesti
~ Q pregnant, but pregnant 43 tlays to 1 year before death O /Unknown Q Su tide t Q Batton
Unknown if pregnant within the past year 32. Date of Injury (MO/Day/Yr) (Spell Month) Q Q Could not be determined
34. Place of In _ 33. Time of In)ury
)ury (e. g. home, construction site; farm; school)
35. Location of Injury (Street and Number, City, State, Zip Code)
36. Injury at Work 37. If Transportation Injury, Specify:
Yes 38. Describe How Injury Occu rretl:
Q Driver/Operator Q Pedestrian
_ Q No Q Passenger Q ether (Specify)
~ 3 ertHier (Check only ane): -
~Certifying physician - To the best of my knowledge, death occurred du
m ~Q Pronouncing 8, Certifying physician - To the b e <oot Ce cause(s) antl manner stated.
est of my knowledge, death retl at the time, tlate, and place, and du
m Q Medical Examiner/Coroner - On the basis of ex urination, antl/or investigations in a to the c e(s) and m
mV oPi nion, death o stated.
~ Signature of certifier: _ ' t~ccurred at She time, date, and place, and tluc to the c
Title of certifier: / 1, se(s) and r statetl.
~ 39rrb. Name, Address and Zlp Cotle of Person Completing Cause/'of Death (Item 26) License Number: ! /~ D7O ~~Le ~L
y--i !`Z ty L I f U ~- ~ S L-~~E•"t O N e ~~- f 7 O Y 3 39c Date Signetl Mo/Day/Yr)
40. Registrar's Distric< Number f / 2-
41. Registrar's Sig atur
~ / ~ ~ ~~ 42. Registrar File Date (MO/Day/Yr)
43. Amentlments -- ///'/
`J~y ~~--f'GI ,l f L E'c...V'y~vl P~ ~~ f7 o SGj r~ .
Disposition Permit NO. ~7 (~~~~Q ..___