HomeMy WebLinkAbout05-01-13 �:�. � �.�.�.,.,.�,..�.�,. -
H105.805 REV(9/ll) „'// �/� „ /)��/„
l�- 11 �l/
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00 R�e��j�j�'�t r+�.-` �1� � ,,,,,������� This is to certify that the information here given is
��,n��p��H OF pE�;y: conectly copied from an original Certificate of Death
R E G!v s �,t� (�p: �,j ;.` ''�1� _- _sL` d u l y f i l e d w i t h m e a s L o c a l R egis t rar. T he origina l
_�g_ =-, i; certificate will be forwarded to the State Vital
���� ���� 1 �j� 1���p � � a� Records Off'ice for permanent filing.
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P 19435784 c��,�x �:�;�� �=°�'�q ���a`��''�,
� �rMENTOE�`�`''' `�L�,u"�.'�."`l�.�r�ex- AP,�t 30�20i3
Certification Number ��P�Q��' �(,1�'p"�`�' "��������°""' Local Registrar Date Issued
���'+nc/Prtnt In C U M B E�3�,��.���F Py��VLVANIA�OEPANTMENT OF HEALTH�VffAL RECORDS
"e"` f'�=.lFICATE OF �EATH Sbt�Fi/eNUmber:
. -�-.i.<:r�enYs legai Name(Flrst,MiUdlc•,Last,Su�x) 2.Sex 3.SoUai Sc<urity N�mbe� 4.Date of D�ath(MO/Day/Vr)[Spell Mo)
� . 'PataiCia J_ To�c3 r' -�c3� q4 95 F��arY 20. 2Dl 3
Sa.Age-Last BlKhday(Yrs) Sb_VnCer 1 Vear Sc.Under 1 Da 6.Data of Birth(MO/Day/Year)(Spell Mo�fh) 7a.67rthplace(City and Staie or Foreign Country)
Mon[hs Days Hours Minute5 Jan •�7, �940 Sl�n �31a
��' �� 113=y 7b:BtrthP{aee�C tY�
Sa.R�sidence(Siate or Foreign Co�ntry) 'Sb.ftesldence(Streef and Number-Indude Apt NoJ 8c.Did Deced�nt Live in a Townshtp7
864 Carl Nlgnpr, O �Yes,dacadent livad in Nortlz Middleton c P-
aa.ne�ia�ce tco.,��.> �e B�P�-
G�snbErland Se.Residence(Zip Code) �'7p�3 O No,Oecedenc Itved.wrcem u,,,�ss ot c�ev/bo�o_
9.Ever in US Armed force57 10.Marltal Stat�s at Time of Death �MarNed 0 Widowed i1.5urviving Spouse's Nam¢(if wife,glve name pAOr to firs[marriage)
0 Yes 0.'NO Q Unknown 0 Dtwrc�d 0 Never Marrie[f 0 V nknow '�'.�$Y'a L'� 2'paa
12.FatA�r's Name(Firsl,Middle,last,Suffix) 13.MOtheYS Nam�Prio�to FirsS Marriage(First,Mitldle,Lnst) '
Janies P_ Jaoobi Adeline Borja Mendoza
14a.Inforrnant's Name 16b.Relationshlp ro Uecetlent 14c.In(ortnanCS MaiN�g Address(SV�eT and Numb�r,City,Stat�,Z1p Co�.fe{
o Edward C_ Todd Husband 864 Carlwynxie Manor, Apt. 8303, Carlisle,P
G .•-••------°....................•-•---••--°•------•---'- -°--•-•-•-.............-----•----- i a� on v o.,e
s.v -------------. a:..acc o......_.._.._°5.°-...--
zIf Death Occurred in a Hos ital: LJ In . '""'"" """""' w "'"'""..."""'"'"'................ . ...._.................... _....."""".......................
_ p patient �If Daath Ocarred Some here O[her Than a HospiWl. �' Nospice Facllity �DecedenYS Home
� Q Emerg�ney Room/Outpatien[ � Dead on Artivai Nuroi�g Nom�/long-Term Carc Facillty O[her(Spacify}
15b.Facility Name(If not insHt�tbt�,gNe street a�d number; i5c Cfiy or Town,State,and Zip Cotle SSd.Gounty of Death
� 864 Car1 e Manor, 8303 Carlisle� PA l70'13 C�annberland
16a.Methotl of OlspoziNOn � Burial � Cremation 16b.Date of OisposFtlon 16c.Place of Uisposition(Name of cemefary,crematory,or other place)
' p aemova�trom staoe p oonacion
� orne�tsP�<irY� 3/1 20'I 3 Evans Crer�tion Services
Z16d.Locatbn oT D�sposHion(GI[y or Town,Sta[e,arM Zip) 17a.Signaturc of F 5¢MCe Licensee n�1nLertnenT 17b.License Numfxr
� I�eo1a, PA FD 012633 L
�
o-17c.Namc arM Compbt<Address oi Funeral FacfY
F�ivin Brothers Funeral I�i-c�x�, 2nc. , 630 S_ Hariover St_ , Carlisle, l70't3
� 18.DaredenYs EducaHOn-Check She box that best describes the 19.Decedent af Hfspanic Origin-Check the 20.DecedenYS Race-Check ONE OR MORE rac�s to Indicate what
highest dagree or level of school completed at the Hme af tleach. box that best d�scribes whathar the decetlent the d�c�dent considered hlmself or h�rself to be.
� Sth grade or less is Spanish/H7spanf4LaC{no. Check tha"NO^ �Whita � Korean
� No Aiploma,9[h-12th grede bo ii daceden[is not Spanish/Hlzpanl4�tino. �Black or African Amenicen Q Viatnamese
� H�gh school graduate or GED compleied �NO,'wf Spantsh/H(spanic/LaHna �Ame(ican I�dian or Alaska NaHVe � Other Asfan
.0 Some mli�ge credi4 but no deQree �Ves,M�xican�Mcxican Amerlcan,Ch{cano 0 Aslan Indian � NaWe Nawailan
rJ�ASSOCiata degr�a(e.g.AA.AS) �Yas,Puerto Rican O Chtn�se 0 Gusma�ian or Uamort'o
� BacheloYS degree(e.g.BA,AB,BS) �Yes,Cuban Filipino � Samoan
Q Maste�'s tlegree(e.g.MA,M5,MEng,MEtl,MSW,MBA) �Yes,oihe�Spanish/Hispanic/Lafino �Japanese
� Docto�afe(e.g.PhU,EdD)or P�ofessional degree O �ther Paciflc Islander
(5pecify) �Othe�(SpeciTy)
.MD,ODS DVM LLB JO)
21.Decetleni's Singl�Race Seif-DCSignaCion-Check ONtY ONE fo tndMate what the deceAe�t constd�rcd himself or herself co b�. 22a.QecederK's Usvai Occ�paiion-Indicate typ�of work
0 VYh(te. �Japanese []Samoa� don�during most of working life. DO NOT USE RETIREO.
0 Black or African American �Korean �O[her Padfic Islander
_ �Amcrican Indian or Alaska Native 0 Vieinamese 0 Don't Know/NOf Sure C�-a3IZ1S AC��L1St�L'
�Asian Indian �Other Aslan Q Refvsed 22b.Kintl of Busfness/Industry '
.a 0 Chinesa �NatWe Hawailan �Other(Specify)
�'$Fillpino 0 Guamanian or Chamorro
� Hi rlc
ffEMS 23a-23d MUST BE COMPLETEU 23a.Oafe Vrono�nced Oead Mo Day r 236.Signatuta of Pcrson Pronouncing Death(Only whe�applicable) 73c License Nvmber
CERTF�tiS OFATH PRONOUNCES OR F.�rua 20 i 201 3
23d.Date SlgneC(MO/Day/Yr) 24.Time of Death
�Z"OX.- 3-�0 a_m. zs,we,Medical Examiner or Coroner Contacted7 � Yes Q No
CAUSE OF�EATH qpp'pxymate
26.Varf 1. Ent¢r the�hain of events-diseases,(njuries,or compltcaNOns-fhat direcciy caused She deafh. DO NOT enier ferminal events s�ch as cardiac arrest. Interval_
respiratory arrert,or ventric�aiar flbrillario^n without show(lq6`[he eriology. DO NOT AB6REVIATE. Enter only one<a�se on a Iine_Add additio�al Ilnes K necessary = Onzet to Death
IMMEDIATE CAUSE - > ` .�P//
(Final disease or condition oue to(or aa a conseq�ence ef):
resulting In tleath)
b.
5equent1a11y list contliitons, Dve to(or as a consequsnca o�: i
iF any,Ieading to the csuse
Nsted on Iine a. Enter the _
. VNDERLYING fAUSE Due to(or as a ConseQUence o�:
(disease or injvry that
Finitlated the evenss resulting d.
� in death)IFUT. Oue to(or as a co�sequenre o�:
� 26.Part 11. En[er other i 'fl i�t diti t ibuf{ t d [F but not resulH�g ln the untlerl�Nng o�ase gWan in PaK 1 27.Wa5 an autopry perfoyn�d 7
� O Yas �No
�
. . 2B_W�R�a�topsy TinAings avaflaMc
to comple2e the ouse of d�a[hT
� 0 Ycs No
4 29.If F$V�ale: 30.Oid Tobacco Use Contrib�ate to D�athi 3i.Mann�r of��ath
� 0 8 Not pregna��wlthin past year �Y�s � Probably
� Pregna�t at Hme o£d�ath . No �Nan'rd� 0 Momicidx
°� 0 Not pregnant,but pregnant within 42 days of death 0 .�Unknown Q Attide�t � Pending Inv�stigaHon
� S�icide �Gould not b�daYermined
�0 NoY prcgnant,but p�eg�ant 43 days to 1 yea�bcfore deatt 32.Date of Inj�ry(Mo/Day/Yr)(Spell Month)
� Unknown if prEgnant wRhin the past year 33.Time of Injury
34.Place of Injury(e.g.home;co�struccton siCe;farm;school) 35.Locatton of InJury(5[reet and Number,City,Siat¢,21p Code)
36.injury at Work 37.If Tra�sportaHOn injury,Specify_ 36_Describe How Inj�ry Occ�rred:
Q Ves �Drive�/Operafw 0 Pedes[rian
� No Q Passeng¢� Q Ofhe�(Speclfy)
39a. rttPer(Check only one):
Gertifying physida�-To thc best of my knowledg<,death occurred due to the cause(s)and manner staced
�Pronouncing 8�Certifying physician-To the best of my knowladge,tleaM occvrred at the Hma,date,and placa,and due to Me cxuse(s)and manner staYed
�Medical Examiner/COroner-On tha sis aminatlo and/or investigatlon,in my opiMOn,death occ�rred at the Hme,date,a�d place,and due fo tha ouse(s)a�d manner stetcd
5{gnateircofcertifier: V� ✓ e THeofcertitier:_/��U LlcenseNUmbe.J�+��es2_bblb-�
39b.Name,Addrcss and Zip Gode of Person Completi g Ca�se of�eaih(Item 26) 39c.Dafe Sign�d(MO/Oay/Yr)
� � � t 2-'Zz-�3
40.Regis[rar s DlsSrict mber 41.Registra�'s Slgnatu�e
� 42_Reg(s[rar File Dafe( O/Oay
� 43_Amendm�n - ���:�� �_ �� �� �O,�r
� �-'��.'c1��`-3
� S�bv� �• �� -�' � -3-
� . � . � DisposiHon Permit No. C�� ��\`� \ H305-143
REV 07/2011