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HomeMy WebLinkAbout1922 1 . ~ , Wr~:~t~~t~~i~ir.Y.It i, ; . . l , - , . , i.~;~~,. . . ; . . I~a.c~.~: , , : '~ci. ~ . ~ T}iie is `t~o ccrtify th~it thi~ i:::~ i rt~~ ~ ci~aj c~a, .tli~ . r.i. c~rcf w.h~rl~ i~ cii~ tii~: ix, the Yer?~i~ylvaxi~~~..~c~artn~c.~i~f c~i ~ie;iltli, ~ii ;i~•tio~r~i.~.~i~c: tv~Cii ~~~t i}t>, L,~ '304, aPJ~ra~~;eci ~y~-t1i~,'G~:ric~'.al.~,~~.s5~•r~lk~l}~, JE~i~c.~`~; 1~~3. - ~ ~ y~ x,~~ ~4 ' `_(Fec far.this c~artifi~aic~, ~I.OU) ~ m - , G. I.~: ~W ~lb.d"r, ~1 r. , ~-•D . . . ~~c r~t~ ry oi He~alt~t ~ Vy . . . Ha_rri5l~ur~?, ~~'ci~~isylti~a.ni~ ~ • ' < wys aore~ wtv }~Jr+, ~ EOMMONrNf~?lxM,-~' PENNS1fl11I?NIA • . l~Al REG: NQ f ' .REPARiNl~lR dF NE~ITlt ~ t:'` ~ ' , . , ' V17AL'StA?i571C5, . _ . , oisr~~NO ~ ~ : ~CFRTiFlC~?Tf "OF f~EATH . ~ _ . - , ~ - ~ . _ - - - - . , . _ _ : ~ - - 1. DEATH , a: :Co~y b G~y ar "bo?ougA 2- [SEtE/~SED'S o- $ir~~t oddr~}~, q: D, er. ~K Number: . QCCUfRED . , ' : 1~A~ilING' . . . _ IN: ~~~,t e t~/t~ r . c. ~ r _ I~OD2ES5 , r U deatA d~el tiot occur u+ Citr : b. h+t .Oiii[*. Zen~,. a~d 51oti . o. bwdugM: ~iw now~ of edwesAip ~ni,` ~ ° . i ; tDo npt vse:Tt: D. ~ 60~ llun~ber} • . . ~ ~ . d. fvU Nowe . ,t"t~ r r- ; r, ~ ~ 3. YETE~AN 'Y~i„{] • NO ol Hospilai ' ~ ~ : i ' r ~ . j { -f - _ . ~ . _ , . _ w ins~i/~fi4n Cif no/ in h,osp4fcl: pive str«?:t' oddht~i : o.. MlKitl~ "WQr , b.5~ria~ . No... NA1NE 0? ' - e {Frr~ ~N~ddf~f . ~ c .ilast) : - : ~ S GI1TE (Mon/1~1 ^t~Yl lY~et) ~FCEASEp ' j~ . ~ ~r ~ pE~M +^.~n ~ , ~ . lType w prinlT'~ ~ - -y ~.Y .v.r.._~. . _ 6. WHERF G!D y c. Did dics4~ Gvr iri 'o towMhipi . ~ ~4 . OEtEASED a.. State . Y~s._ d~t~s~d iiwd ~e~ : : _ . lo~r.rshqi. ' ACTUALIY : ~ ~IVE~ ~bt.~COMnfY: ~ ~ M6 .~C~OS~~I11t~~ WINI/A' OR~40I It111~h~0I' ..T',s ~.0.2` - ~ titp.or~'foorouQi~ 7. ~EX 8 COIQR OR ~tACE' 4 AR/cRRtEO m MEkfR MARRlEO" Q 10. 'D/lTf Of, I~IRtH ' 11 AGf Iia y~on -if vat#N i p+w~: M u~dsr 24 iw~yn ~ 0 M~ Lc ' :V~r{ 1 Ti. w~~vvEO ~ " ~ qtYOtc~~ .O ~ ~:^sj ~ ~uMst6~~hdoy) : sloMks . poys Movn ~a ~ ~ } ~ ~ ~ ~ :s. iY USUAI OCCUPATION' C.+wnr r+t'q~dY 13 SOC ~ECURiTIr Rl0 tt , qtRTN?tACE: t~ats or lor+ cow~t?y) .13, ftli Et{,qF,~WNAi ~4ttNTRYT , ~et,. ~~'=e~?s~Q;~~r ~ I~. ~ ~ r~v~~~.~. , _ ~ '~'''~W's ~ , 67-rF j`}7.:MOTf~ER'S MA1tIDEN Nj~~'p'~~ ~i'~C`.~~~E~.l.3:t~~ ~i t -,K~~`r~ia~a ..,J ~ ~ ~ 1. . 1~~~ +'w ~~ji - ~ . . _ ,s. F t rr F ~ . f ~F.-,?~c~~,r~~,:._Ne?Me ~tRro~ss ~ r * ~ ~ ~ti'{~~ .e , _ ~ c~, w,. MEDICAL~~ERTfFiCaTE (ItenQS 2C M?ougA 27,uura~ 6e cowipl~?~d by pl~yaician oefy) . tNTER1Fkt EETY~fE1V' : ' 20. fAUSE OP OEA~N':~fiilt+l.•oety o~t caui~;W~ ~iM ~or (p).-(b! 6(il. ONSFF AND: DEATH : VART 1:'.Dwth *.as "ca~~ed 6y ' - i H.r( ~ 1 ' 1' ..f a~ 1 . . t j,,,•c : . . , . , . , ~ ' . . ; _ -.~FaurE cw~se. ta) • - ' . ` ~ _ co~d~~oa. .r ~y; - : , ~ ~ Y ~ qor~ ~is~ to obow m~s~ ` bUE '10 ~61 , : , - (oJ atatin9 !h~ ei+idertpee?g _ . _ - j cauu los~., . DtIE: T0 cl ` . ~ ' 1 _ . PART 11. OTHfR 51GN1f14AN1 CONp1i1~NS_ conhibvnng 10 :deoth but noi retared ro ri~e ~n+w~td.et~ mc» gir~n ~R Fort 1 tir; 21 VVAS'~UIOPSY ~~Y r'.~~?~J..~ I - - . 'r_ ~ i 'PERFORMED2. . _ . . - . i . . . - . . . ~ Y~1 ~_j No ~ 44 o ACCIOENT'~ 22. b OESCRIBf HOW A~CIDFNT OCCt3RRED ?2 c 71~ ~ Mow A~{onth ~poy . Yeor ~ , , OF rn Y~ ~ NO ~ ACCiOENt E S T. _ . _ . . . , . . _ _ _ , . _ _ . - - - - - - - 34. d: I1tCIQENT OC[UFRED 2? e PtAEE O~ ACt.-t6fNT e g hcme 1? ~ L_~TY SOROUGM, TOWf~:SMIC COUN(Y STAIE ~ While o! • Not. Mihile ' ~ farm. itree~. ~ef~~ ~ ~ - . . ~ ~ ~ - . ~ ~ . ' ~ ~ ; ~ . . ~ ro~k l j af work 23 1 F~ereb~ teAifY thot 1 obrndrd~tFe obo.r r.a7eA ~'!eceou> >r;~ •r~• ~~q'^ ,<c~rrec} f~9m tM coos~e and o~~tA~~date itot~d o6o.•.ot ~~m E~.7.~. . j . - . . . ' . . M p . ' . . ~ ~ - . - . . . ; , . . ~ ' o~~~~ 1 l y ` . . ~ . ~ . ` D'.{~' . A~,~.esi - ~ c ~ Date~ vg~ed - . Z1. a~.8UR1A~ ~ . . . b DAIt ~ . ?3 p' hF.N: eM:-eG• (',R 'RfMAirJRr .t . 1~~1T~QN ~,•T gero .~9 b'~O~..ne~ Sraffi CREMAFION " - . - _ , ~ ~ ~ ~ ~ - . ~ . RfMOVA! ~ - ' ` : , . - ~ . 25 Da1F'RF' D Br «EG REG! 'keR ~ SIGh4iL:F 5~~1<Ail,9E :.h~. o.a:RESS OP ~~in:E7A; ,^,:RE~TOR ~~,~r . '3~ . ~ ~ ' ' _ _ ' _ - . ' - - . ~ • ~ , ~ ~ . ~ ~ i / I ~ / l~' t , - - . ' _ _ . ~ . . , ' . ` . - . ~ . "~a~ ~ _ . . . - ~ ~ - . _ _ . _ ~ ~ .~r. _ _ ~:~~~~~s~.,r.'ssz~'~