HomeMy WebLinkAbout12-18-06
HI05.905MS REV. 6/06
This is to certify that this is a true copy of the record which is on file in the Pennsylvania Division of Vital Records In accordance
with Act 66, P.L. 304, approved by the General Assembly, June 29, 1953.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
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Calvin B. Johnson, M.D., M.P.H.
Secretary of Health
Date
Frank Yeropoli
State Registrar
0978134
NOV 30 2006
No.
'Hl05.143 REV. 0212006
TYP€ I PRINT IN
PERMANENT
BLACK I~K
1. Name of Decedent (Frs~ middle, last, s~J
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH . VITAL RECORDS
CERTIFICATE OF DEATH
7. Bi and state or
June 14, 1915
N. Middleton
Bel. FacIIilyNane(ltrotinsibJ
915 Alexander Spring Rd.
12. W. Decedent w<< In the
U.S. Am1ed Fon::es?
!;aV" DNo
"""""'"
lIcIualRssIdenc8 17a.StD
Top.
Dickinson
PA
t7c. R9 YIIS,DecedentUvedin
17d.D ~~J1'111llwil1in
11b. County
Cumberland
19; MoIler'I N8me (FIrst, middle, maden sumame)
Rosie Nellie Brown
2Ob. InforTM1fs Mair);) AddI'8Sl (Street. rJty I bwn. state, zip code)
915 Alexander S rin Rd.,
21c. PlaceofOlsposition(Nameofeemetery,cnmalayorolherplace)
Waggoners United Methodist
ClIy/-
8
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~
Part II: EnlerQ/ter~mnrllMn!itmnw;hllJlm Intlmlth
butnotl8l9u1lingln1he~Cld8ghoenIlPstI.
28. D1dTotlaxoUBBContrtbJ!ek:lOeulh?
Dv" Dp_
DNo Du",,-
29. If Female:
DNoIpregnlrllwithinpasf:year
D_""""ddoalh
o Natpregnant, but pregnll1l w1tt1n 42 days
of_
o rt>tpregna'd, bulpAlgn8llt43 days 10 1 yell'
ofd"'"
DU~lfpregnwrt\dhinttlepa&tyear
32c. PIaE d kljury: Home, FIml, SlrBet, Factcly,
OfIIceBulding,lIItc. (Spec/f',1
Carlisle, Pa 17013
Hoffman-Roth Funeral Home & Crematory Inc.
St. rlisle Pa 17013
23b. L.JcenseNlrnber
Zlo. Dole S~nod 1_. day, yea)
Jt/, v /9, ~G
MJ c;lc{"T ~ .3 2 L..
26. WesC.. ReferTed Iof.lediCall Examiner I Coroner for a Reason OIherth., Cremation orDon8tioo?
o v.. .(!j;Ilo
{
o
,
',qAM. '"
CAUSE OF DEATH (8M Instructiana and eump'-)
1Em'Zl. PART I: Enterthe~-__, njuries, aoomplicalkn-1haldirecllycauaed1hedealh. DO NOT enl&rtsrmlnal BWnIssudl a cardiac iIfT8&I.
respira10ry aIT8It, orventicularbillallonwilt1oLII:shlMIng1hee1lc*:lgy.l.isI.oriyoneCllUl8oneach !i'll.
IMMEDIATE CAUSE (F,o. ,..... Q" G"'-- J ~)~
condiOOnlMUltingl1'1dealh) -. ..1.- y/,
Ol.- to (or lIS a consequence ofl: .
Appn:ndrnaIei1lerval:
Onaetk)DeaIh
=~~=~i:e~.Y'
Enterfu8 UNDERLYING CAUSE
(dlseaseai~jurythati1itialedthe
svenls IeSlJIling In death ) LAST,
DIJlI to (or as a consequence 01'):
DUI!I to (or.. a consequeroce of'l:
$
308. Was an Autopsy
Performed?
3Gb. WereAutlpsyRndings
AvaiablePr1ortoCompletlor1
of CatJse of Death?
31. Manr'lllrofDea1h
~ DHom-
0- 0__
o ...- 0 CoW' Not be Defem>1"'"
'2.
Z
s;:
Dv" ~
Dv" $0
321:l. TIme d lr1ury
32g. Localionollnjwy(SIreet,city/klWn,state)
M.
33a Certifier (check only one)
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;::U:~:"::=.~'::!=:::~n=~a~:=:::~drnanner..'~___________ ______-D
~J:~J::~~:= ,ndJ or InveItIgation, In my opinion, dNth occurrtcllltthl tim., dew, end pllce, and eM tc the c:alM(s) and mlnl'llr a staIflt _...D
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H105.143 Rev. 2187
COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH' VITAL RECORDS
CERTIFICATE OF DEATH
STATE FILE NUMBER
1.
AGE (Last Birthday)
twp
SEX
2.Female
T
SOCIAL SECURITY NUMBER
3. 203 10
DATE OF DEATH (Month, Day, Year)
6 2004
BIRTHPLACE (City and
Stale or Foreign Country)
9,tate Line, PA
loti s
. 5.85 Y".
COUNTY OF DEATH
HOS IT AL:
InPldentD
...
FACILITY NAME (If not institution, give street and number)
Resldeneefa ~~~~fy) 0
RACE. American Indian, Black, W1i1e, el
(Specify)
10. Whi te
SURVIVING SPOUSE
(\fwlfe.Wvernllldenllame)
..;?72 Belvedere St.
AS DECEDENT EVER IN
U.S. ARMED FORCES?
YesO NoQll
'2.
MARITAL STATUS - Married,
Never Married, Wdowed,
Divorced (Specify)
,..Married
15.John E. Mini
PA
17c. 0 Yes, decedent lived In
17d.~ ~~h~e::~~I~~~of Carli~le
citylboro
Did
decedent
liveina
township?
17b. CounlV Cumberland
MOTHER'S NAME (First. Middle, Maiden Surname)
1.. Anna Catherine Bowers
INFORMANTS MAILING ADDRESS (Street. Cltyrrown. Slale. Zip Code)
20b. 372 Belvedere St., Carlisle, PA 17013
f:'LACE OF DISPOSITION. Neme ofCemelefy. Cremetory lOCATION -CityfTown. Slate, lip Code
.cOth.. Place Waggoners United
21c
Other signi1icant conditions contributing to death. but
nol resulting in Ihe undertying catJse given in PART I
Sequentially list conditions { b.
if any, leading to immediale
. cause. Enler UNDERLYING
CAUSE (Disease or injury C.
. that initiated events
resulting on death) LAST d.
WAS AN AUTOPSY WERE AUTOPSY FINDINGS
PERFORMED? AVAILABLE PRIOR TO
COMPLETION OF CAUSE
OF DEATH?
MANNER OF DEATH
DATE OF INJURY
(Monlh,Dlly.Yellf)
TIME Of INJURY
INJURY AT WORK? DESCRIBe HOW INJURY OCCURRED.
J2f
o
o
Homicide
o
o 30.. 30b. M.
o PLACE OF INJURY - At home. farm. street. factory. office
bIJlldlng. lite. (Spllclly)
3...
Natural
Accident
Ye.D NOO
30c.
Pending Investigation
Could not be determined
Ye. 0 No IZI
Ye.O
NoO
Suicide
28.. 28b.
CERTIFIER (Check only one)
~l~':h~F~tGJl;t~~~~~~s~~:a, ~~~~~tc:1 g,~~a~~(:r~~3~~~~a.r.h~I:l~~~.~~.t~.~~.~~?:~.i~~~.~~).....
2..
:~7~~/
.PRONOUNCING AND CERTlFvtNG PHYSICIAN (Physician both pronouncing death and certifying to cause of death)
To the best of my knowledge, death occurred at the time, date. and place, and due to the causes(s) and manner as stated.
'M~OlCAl EXAMlNERICORONER
On the basis of examination andlor Investigation. In my opinion. death occurred at the time, date, and place, and due to the causeS(s) and
manner as stated.. ......................................... ....................
31a.
REGISTRAR'S SIGNATURE AND NUMBER"'. .. ~ t\ J
33. ~ ~. ~~CJI\;
bJ \ I.;;U \It\1
34.