The URL can be used to link to this page

Home My WebLink About08-16-06 -2 I Ol...o "10'-0 '( 111\ j, III ccnifv that the information here given is correctly copied from an original certificate (.1' death duly filed with me as i .l)(;d Rq2i\trar Thl' miginal u:~rtificate \vill be forwarded to the State Vital Records Office for ['ermanent filing. WARNING: It is illegal to duplicate this copy by photostat or photograph. " ,11'1111///'"""" ,...."'("'\.\\\ OF P{f:----__ \\\~~1'J);--.. t~_:/ - - \~\ ~ ~ - -~~ - '-P'" ~~( .. - -, - \~~ ~ c.J1,_ _{~. ,!~~ ~*\-. ~." :"/*$ --..~ ". . /.'...~l "\.~~A~\\'\ --<---~lMEN1 \\'i: ~~'l'l "'"",.,//#",/lIJI'" ~ '. ~/;;~~ Fcc lor this certificate. (i;6.00 Local Regi,trar P 12411134 APR 2 7 2006 No. Date ..1 -l-l Aev.Ol106 ~INTIN ANENT 'KINK COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH STATE FILE NUMBER C0 1 Name 01 Decedenl (First. middle, Iasl) \' S" ,. Social Security Nurrber I' Dale 01 Death (Monlh, day, year) Harry E. Wolfe M 1.96 - 14 - 2161 April 21 , 2006 5 AiJe (LBsl birthday) 6 Under 1 vaal Under 1 dav 7 Date 01 Birth Month, day, year 8. Birth lace Citv-andslateorloreioncounlrvl I aa. Place 01 Death Check onlY one 85 I Months Days Hours I Minutes I 2/18/21 I I :;SPijal: I Other: Ves InMtienl D ERIOuI Iienl o DOA 0 Nurslnn Home a Residence D OIher.SDecifv: . Bb. County 01 Death Be. City, Boro, TWD. 01 Death ad. Facility Name (If not inst~ulion, give slreet and nurTtler) 9. Was Decedenl of Hispanc Ofigin? 10. Race: American Indian, Black. White. etc. e Dauphin Derry Twp. M.S. Hershey Medical Center M No 0 Yes (II yes, specify Cuban, (Sped'l1 " Mexican, Puerlo Rican, elc.) white ~ 'T 11 Decedenl's.UsuaIQcc lion Kind of worl(: done durin rroslolworkin Ule; do 001 slate retired 12. Was Decedent ever in the US 13. Decedent's Education {Seecitv onN hinhest nrade connleted 14. Marrtel Stalus: Married. Never merrie<!. 15 Surviving Spouse (If wile, give maiden name) Kind 01 Work I Kind 01 BUSin~sIlndU~ry Armed Forces? I ElementarylSecondary(Q..12) I College (1-4 or 5+) Widowed, Divorced (Specif;1 Clerk Enola Super res ]g Yes D No 12 2 M~H~~ M"~~~~'" . 16 Decedent's Mailing kldress (Street. cilyl1own. stale, zip codel Decedenl's PA Did Decedent 17CQi. Hampden 2436 Lambs Gap Rd. Actual Residence 17a. Slate Uveina Yes, Decedent Lived in Twp. Twp Township? . Enola, PA 17025 Cumberland 17d.O No, Decedent Lived wkhin 17b. County AclualLimilsol Cityfaoro 18. Falher's Name (First. middle, last) 19. Mother's Name (First, middle, maiden surname) Iverson Flickinger Cora Mae Wolfe 208. Informanl's Name (TypeJPrintl 2al. Informant's Marting Address (Street, cilyllown, slate, zip code) Raymond E. Wolf 163 Red TANK Rd. Boiling Springs, PA 17007 ! 21a. Method 01 Disposlion 21b. O':t~8ia~~~ay.Year) 2tc. Place of Disposrtion (Name of cemetery, crematory or other place) ~~d. Local"n (C,,'own. slala. z~ code) i o Burial ~ Cremalion o Rerroval Irom Stale o Donation Hollinger Crematory t. Holly Springs D Olher'Speci~: PA 17065 ~ 22a. Signeture of Funeral Service Licel'lS88 (or person acting as such) 122I>F~ens~ N]U; 7 4 _ L l22c. Name and Address 01 Fac~" i ~., 'f. j;;'.>&. ./J~?c.-r:--~.' Richardson Funeral lhne Inc. 29 S. Enola Dr. Enola, PA 17025 ! Con1Jlele hems 238< only WI'1en certifying 23a. To the bimv knowledge, death occurred al the lime, date and place staled. (Signature and t~le) 23b. LicensaNurrber 23c. Dale Signed (Mooth. day, year) ! physician is nol available at time of death 10 certily cause 01 death. Hems 24-26 must be cofl1)leted by person 2' Time 01 Death r ~el~pr7<.UJ~ 0: (;;'h day. year) ~ Was Case Relerred 10 a Medical Examioer/Coron8f? who pronounces dealh. 7; 30 PM '0 /'? <:; "" ....l;l"Ves D No CAUSE OF DEATH (See mtructlons and examp$es) Approximate inlerval: Pari II: Enter other sianificant conditions conlrilUlino 10 death, 28. Did Tobacco Use Conlr1>ule to Death? 1Iem 27. Part I: Enter the ~ - diseases, injuries. or convlications -that directly caused the death. DO NOT enter lerminal events soch as cardiac arrest, onset 10 death bul not resuhing in the underlying cause given in Pari I. o Ves q Probably respiralory arrest, or ventricular fibrillalion withoul showing Ihe etiology. 00 NOT abbfeviale. Enter only one cause on a line. D No ".. Unknown IMMEDIATE CAUSE (Final disease or 5€-j)'s; s vJ.1k S~ t, 'c- .:511 0 cl:.... 29. If Female: condrtion resuning in death) ~ 8. o Nol pregnanl within past year Sequentially lisl oond~ions, il any, b. Due 10 {of as fonsequence oij: . o Pregnanl at time 01 death f1:(V-' e. ~ PllLe-n; IA... o Not pregnant. bl1l pregnant within 42 days ;, leading 10 the cause lisled on Line a. ~ue 10 (or as a consequence on: ~ Enter the UNOERl YlNG CAUSE oldealh (disease or injury thaI in~ialed the c a Not pregnant, but pregnant 43 days 10 1 year ~ events resuhing in death) LAST. Due 10 (or as a consequence oQ beloredeath d o Unknown if pregnant w~hin Ihe past year 308. Was an Autopsy 3Ob. Were Autopsy Findings 31 Manner of Death 32a. Date 01 Injury (Monlh, day, year) 32b. Describe how Injury Occurred: 32c, Place of tnjury: Home, Farm. Street. Factory, OIliee Performed? Available Prior 10 Con-vletion o Natural o Homicide Building, etc. (Specilyj 01 Cause of Death? DYes D No DYes D No o h:cident o Pending Invesligalion 32d. Tima 01 Injury I '2,. Iniury 'I Work? 321. If Transportalion Injury (Specifyl 32g. localion (Slreet. cityllown, state) o Suicide o Could Not Be Determined DYes 0 No o DriverlOperalor o Passenger M o Pedeslrian o Other - Specify: 338. Certifier (check only one) 33b. Signature and TItle 01 Certifier Certttylng physlcqn (Physician certifying cause of deatl1.when another physician has pronounced dealh and COrTl'leted hem 23) G. GufN...r;' To the best of my knowledge, death OCCUlTed due to the cause(IJ and manner as stated ,,~.'" ....................,..........."'..,.,.......""..""............""'.."",,.., .. ..........'" ....".....0 Pronouncing and certifying physician (Physician both pronouncing death aM cer1ifying to cause of death) '%1?;Ut) 434 33<1. Dale Signed (Month. day, year) To the best of my knowledge, death occurred at the time, date, and place, and due 10 the cause(s) and manner as stated.....""" ,......... .."".. m'."" ..""...."""... ...0 O.!-j / f). I I 06 Medical examlnerkoroner On the basis of examination and/or investigation, In rrrj opinion, dealh occurred allhe time, date, and place, and due 10 the cause(s) and manner as stated .........0 34 Name and Address 01 Person Who CorTllleled CalISe 01 Death (Item 27) TypeIPrint ;:z:r's;;'~~ 13S;;Z;Z;;;~ 6;60'0 GVw- ~(i M.S. Hershey Medical etr. I~ I 1.,;l,,1/ II I Hershey, PA 17033 , " (See instructions and examples on reverse)