HomeMy WebLinkAbout02-02-05
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Thi', i, ro certify that the information here given is correctly copied from an original certificate of death duly filed with me as
LO<'-11 Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing,
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $2.00
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RACE" AmBfican Indian. Black, \Mlite, at
(SpllCify}
10. Whi te
SURVIVING SPOUSE
(1l";!o.gN.maldonnltllt)
Eli zabeth Brown
11,
Pennsboro
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COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH' VITAL RECORDS
'"
CERTIFICATE OF DEATH
STATE FIt.eNUMIII;:R
SOCIAL SECURITY NUMBER
3,202 20 _ 4076
76 Yra
l::NT
,"
NAME OF DECEDENT (First. MIddI., LUl}
"
AGE (LastBirthdly)
Anthony B. Rishar
..
COUNTY OF OEA TH
..,
Cumberland
~. pennsboro
oeCEDEf'fl'S USUAL OCCUPATION
(ol="oIlh;"'noI=~
11..Crew Dispatcher 11b. Conrail R.R.
CEDENTS MAILING ,t,OORES (StrHl. itylTown. Slate. Zip Code) DECEDENTS
ACTUAl
RESIDENCE
(SMlnllruclionl
onOlherIkle)
KIND OF BUSINESS I INDUSTRY
MARITAL STATUS. Married.
eollgo Nev~=~s~~'
('.40.$+) 1'" Married
17c.J!gY8I,dec8danl~vedin East
106 Boyer St.
1.. P
FATHER'S NAME (First. Middle. 1lI11)
1.. Peter P. Rishar
INFORMANT NAME (TypeJPl1nl}
..., Elizabeth R. Vogel
METHQO OF DISPOSITION
'DonallonD 8ur!Ilmler.m.uon~emovaIlromstaleD
,21.1. Olher(Speeify) 0 21b. Ma
SIGNATURE OF FUNE~_ ENSE R PE TING AS SUCH
22.1. '"
CompIeteltemo23.1-<:onIy cao1iIyIng
phylicler1ilnolawilable lime ofdHlh to
certiIy ceun~dllath
Items2....211mullbecornpletedby
peI:sonwtlopronot.n:eldllath
11b.Countv
11d.D ~=i~~of
MOTHER'S NAME (Firl.. Middle. Maiden Surname)
1.. Mar Lekekas
INFORMANTS MAlLlJ'IG,~ESS (SIrellI. C~fTown"S"'al,jp Code)
2Ob. 105 Sh1rley Dr, M1C1cletown, Pa
PlACE OF DISPOSITION. Neme ofCemelery, Crematory LOCATION _ CitylTown. St.lle, Zip Code
or Olher Placa
,,,,Rollin Green Mern Pa JI... Carn Hill Pa
NAME AND ADDRESS OF FACILITY
,,sullivan FH 51 N.
LICENSE NUMBER
'" I-IMUJ'142
DA P
24. . M. H.
27. PART I: !n......d_.~...~Ion.....IdI...........d_.OOnot......"'._ofdylng
UoIOfIIr_.......on__.
3.
ucard"'...Nlplrlllooyonwst,sboekorhNrtl.lllu... 'Approxlm.lle
C"'"
...,-0-4 .IOddlllllh
OtIlersigr4lCa"11coodibon5contribulingtode8lh,but
noIresultngin lhe undElrtying cause given In PART I
~"y~ltcondilions
iI.IIly.lndingloirnmedialle
C8U1e Enter UNDEIl:L Y1NG
CAUSE(Di_ori~ury
...-.....
~ondealh}LAST
WAS AN AUTOPSY 'M:RE AUTOPSY FINDINGS
PERFORMED? AVAIlABLE PRIOR TO
COMPLETION OF CAUSE
OF TH?
E
01
"
TO(ORAS
"
MANNEROF' ~AT~
N.llural 19"" Homiclde
Accident 0
o
D.l.TE OF INJURY
(t.lantl,o.y.YNI)
o
o
o
TIME OF INJURY
INJURY AT 'AORK? DESCRIBE HOW INJURY OCCURRED
Pendingln""llig.\lIion
30b. M
.Athoma,larm.5Ireel,lactory.oIfice
",
".,
PlACE OF INJURY
buildng,ole{llpeQIt)
.,.,
YelO No
"",
LOCATION (5t"'et. CityITown. State)
YNO
NoD
s_
Couldnotblldel.rmtned
... ".,
CERTIFIER (Check only one)
~i:~~orn~=Jf:l~~~~~uS:t~&e:~h-==rrC~~~.~.~..~~.~~~.~.I.'~?~)....
"PRONOUNCING AND CERTIFYING PHYSICIAN (Physici.an both pronouncing delllh end certllylng 10 cause of death)
To the beet 01 my knowledg., delth occurred.lt the lima. date, and plllC&, .Ind due 10 th& G.lUIH(.} Ind m.nn..... .tIlled...
"MEDICAL EXAMlNERICORONER
On tile.... of uemln.lllon.nd/of Inv..tlg.ItIon, In my oplnlon, de.lth occurred.lt the lime, d.t',.nd plec&, and due to th. C.lu.-.(.) II'Id
IIWIInn.....etded...........................................
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