HomeMy WebLinkAbout12-29-05
!--1!115:-;o) kL\
Thi" is to certify 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.
P 1'33?~7'J
~. t:- ...; I oJ
No.
1,,/1/1111"""""""'"
',"""~~\.\\\ OF PE:;,----___
,l~y~4'JX""-
!l~_V - .~ .... \~\
/,_: ..... I."'"
f:~~1 .>> !;;e.~
~ B 1, ,;~ :,i i;: ~
... \, .' , ,~
..* ~ . ~.. ,!*~
\<::2~-'~~-o- //~/
"""-~. /..$$"
"'". .:sr.?../.....\;~. I,ll
~--- I MEN1 \"Iii: """'
~~;~/"""N//H//lJIJJI"
li-~~~~~~
Fee for this certificate. $6.00
JUN 2 9 2005
Date
-C,.)
)
1"-",~"1
',~D
---:-:J
[',.)
f\.,:,
H105.143 Rev. 2/87
COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH' VITAL RECORDS
TYPE/PRINT
IN
PERMANENT
BLACK INK
CERTIFICATE OF DEATH
STATE FILE NUMBER
SOCIAL SECURITY NUMBER
3.5)7 -7~ -1 (f 5"(,
DATE OF DEATH (Month, Day, Year)
4. June 25, 2005
c..Y\ .
C7'J::1\' 8b. Be.
AS DECEDENT EVER IN
u.s. ARMED FORCES?
Va,O NolKI
12.
17a. State PA
k n n i tnJ
NAME OF DECEDENT (First Middle, lest)
:l:J....r.7,rtt-'(;3E rt!
SEX
2. F
BIRTHPLACE (City and PLACE OF DEA
State or Foreign Country) HOSPITAL:
fewistown ,FA ~;'Itient ~
FACILITY NAME (tf not institution, gi....e street and number)
M.S. Hershey Medical Center
MARITAL STATUS - Married,
Never Married, Widowed.
Di....orced (Specify)
14. Married
Residence 0 ~~~) 0
RACE. American Indian, Black, White. et
(Specify)
10. White
SURVIVING SPOUSE
(lfwife, give maiden namlj
O'Connell
17b. Countv
Cumberland
Did
decedent
li....e in a
township?
17c. Ii] Yes, decedent lived in
twp.
809 Mandy Lane
Hill PA 17011
17d. 0 ~~~e~:~~7~~~ of
citylboro.
~
=>
'"
<{
:0
<{
MOTHER'S NAME (First, Middle, M.iden Surname)
19. Bessie - Wayman
INFORMANTS MAlllNG ADDRESS (Street, CltyfTown, State, Zip Code)
20b.2 North Main St. A t. P406 Beacon Falls CT 06403
PLACE OF DISPOSITION. Name of Cemetery, Crematory lOCATION. CityfTown. Slate, Zip Code
or Other Place
1, 2005
LJCENSE NUMBER
22b.FD 012633 L
21d.
Newville, PA
Home, Inc., Carlisle, PA
DATE SIGNED
(Month, Day, Year)
LICENSE NUMBER
23b. 23c.
WAS CASE REFERRED TO A MEDICAL EXAMINER !CORONER?
26. Ve, 0 No ~
: Approximate PART II: Other signifICant conditions contributing to death, but
.lntelVal between not resulting in the underlying cause given in PART I.
: onset and death
Sequentially list conditions { be..
if any, leading to immediate
. cause. Enter UNDERLYING
CAUSE (Disease Of injury
that initiated events
resulting on death) LAST d.
WAS AN AUTOPSY WERE AUTOPSY FINDINGS
PERFORMED? AVAILABLE PRJOR TO
COMPLETION OF CAUSE
OF DEATH?
DUE TO (OR AS A CONSEQUENCE OF):
MANNER OF DEATH
Natural
(g
o
o
DATE OF INJURY
(Montl1,Day, Year)
TIME OF INJURY
INJURY AT WORK? DESCRIBE HOW INJURY OCCURRED
Va, 0 No 00
Va,O
NoD
Suicide
Homicide
Pending In....estigation
Could not be detennined
o
o
D ~~CE OF INJURY. At home. ~o~, street, factory, office
building, etc. (specify)
30e.
Ve, 0 No 0
Accident
~. ~b.l...~~-t.;.J
SIGNATU
28a, 28b.
CERTIFIER (Check only one)
.t~~~~~IGor~~~~~.w;r.sj=~:rhcg~i~~UJ: I~ ::~.'C'~~(:r~~cT~~X~j~a~. h:t~~~~~~ .~~~~~..~~~ .~.~~~~:.~.i~~.~~).. . .......... .... 0
29.
I-
Z
W
Cl
w
'-'
w
Cl
u.
o
w
::0
<t
Z
.PRONOUNCING AND CERTIFYING PHYSICIAN (Physician both pronouncing death and certifying to cause of death)
To the beat of my knowledge. death occurred at the time, date, and place, and due to the causes(s) and manner as stated........
-MEDICAL EXAMINERJCORONER
~~~~:rb::I:::e:~~I.~~~I~~ .~~.~~~~.I~~~~~~~~~~~: .I,~ .~~ .~~.~~~~: .~,~~.~ .~~~~~~~~, ~,t. ~~. ~~~~:, ~~~~:. ~~~.~~~,~~'. ~~~ .~.~~. ~~ .t.~~ ~~~~.~~.(.~~ .~~~., 0
31a.
REGISTRAR'S SIGNATURE AND NUMBER
t7033
Id.t \ IdH 101
34.