HomeMy WebLinkAbout08-08-05 (2)
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This is to cenify that the information here given is correctly copied from an original certificate of death duly filed with me as
Local 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.
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Fee for this certificate. SIi.OO
Local Registrar
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COMMONWEALTH OF PENNSYLVANIA' OEPARTMENT OF HEALTH' VITAL RECOROS
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CERTIFICATE OF DEATH
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PERMANENT
BLACK INK
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not resulling in the underl~ing cause gi..en in PART I
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DATE Of INJURY
(t.lonlh.Day.l'ur)
TIME Of INJlJRY
INJURY AT WORK? DESCRIBE HOW INJURY OCCURRED
WERE AUTOPSY FINDINGS MANNER OF DEATH
AVAILABLE PRIOR TO
COMPLETION OF CAUSE N<llul<l1
OF DEATH?
Homil;ide
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o ~~CE OF INJURY AI home. :a~~, ~lfeel. fllc;lofy, offl!;"
tlu"d,ng, _Ie (Sp-.:~~)
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P<lnding tnve~ligalion
C()ul~noll.>eLil;llurmined
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CERTIfiER (Check only 00&)
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.PRONOUNCING AND CERTIFYING PHVSICIAN (PhY5i<.:ran tJOUlllH)Oounwng dualh and certifying 10 C;",ll~l:l of OtIalh)
To Chi belt 01 mlf knowlldgl. d.ath occurrld at thlllml, dati, and plae., and dUIIO It'll cau"'(I) Ind manner alllalld,...
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