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This is to certify that this is a~~u~:ca~iy,'~;of`t~~~record wluch is on file~ in .
the Pennsylvania Department of ~H'ealt~..°iri ~accprdance with Act 66, IS. L.
304, approved by the Genera~ g„ese~aa~~y;~; ; e~9,•S~ 1953. . . _ {
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(Fee for this certificate $ l.~ Q6~_~ ~ ' " ~ ~ . ~ . ~
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i - ~ C..~~L;~ Wilbar, Jr. 1M• 1~~ c ~r"m
Se~~etary of Health ~ R'~o
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3M-12~3 wvaso~aa wcv. ~~/ss / ' _ COiA~1MONWEAITH OF ?ENNSYlVAN1A C t!~ . s
lOC/1L RE0. NO.--•»-.... '
. ....f~~ ~ DD/1RTMEM Of NEALTH ~ v ~O ~ i
VITAL STATISTICS s ~0 •
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a.. ~~ti.~Q. CER7IFICATE OF DEATH ~ ~ ~ t° •
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i7 1. DEAM ii~' r ~ k Cd~r ~r boewow 2. DECE/1SE~'S a SN~ oddn~„ R. D., x ~ac Nu~ .
~J / OCCURRED • MAIUNG ~
/ il~k ADDRESS
~ If d~oM ~d ~~oow i~ Cihr b. ?oq O(fia. ZoM, a~d Sra~ '
or bereYql~. oiw w~~ af ~ewa~p i~
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o~ iwstiWliew i» ~h~Nr~e~) a WAicl~ Wer. b. S~riol No.
; I. NAME Of a (Finf) b. Widdb) c (laW) ~ ; S. ~ATE (Mo~~•` = - - (Dap) (Y~or) :
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arw « v~) o~?ni _ ~ • ~ ;
6. WHEtE DfO ~ c Did d~c~a~d ~w o T r.
DECEASED S1ae~------- - ~ Ya. Gv~d iw-• ....................................bMrnsl~ip. ~
ACNALLY ~ ~ :
' lIVE7 b. Covwy-- eie~'---- ? No, d~aas~d 1'iwd vi~iw actYOl 1'i~i1s of.~C.~~-~-~.--- ciM a borouyA. !
7. SEX L COLOR OR RACE 9. 1MARAIE~ NEVER MARRIED 10. DATE Of lIRTM 11. AGE ('n ~s If ~wd~r 1
ywr If rnd~r 24 hwrrs
~jM"t~!'~. f~~~'f~1~f.~(.CJ I 1NIOOYIIED Q ~IVORC~ ~ I3•t~ l o l N d'm' biAW°''Y ""°"tb I°°r' "°v" "`i~. `
2. USUAL OCCUM710ti (~ww ~ rNirrd) (13. SOCIAL SFCt1R1iY NO. I11. ~I CE (51at~ or for~ip~ oowlry)I 1S. CITIZEl1 Of WF1AT COUNTRYt ~
a..]rii .ei • ~Q / , I
ia w r~ srouse I». s c~ . ~
1R FATHERY NAME I 1 AM ADDRESS ~ ~
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MEDICAL CERTIFICATE t ~ ~ ~ ~ ~ ~pM~~d r/ PI?riiw~ ~wf/) INTERVAt {EiY/EEN ;
sa e/~usE oF oEwrns dr....y a.~.. w• o.. W. (b) a td• oMSfr n!w oewTH
MRT 1. Dw1~ wa o~w~d b~n ~ • ? ~ ~ .
{A4A4EDIATE CAUSE -~~~.~CLf . . .........~L..I~~!~.~~!~iRrY._..........----
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`q"aiN°"' ~ '.13d' ouE To a~ .~~~!~fil. ' :
~or~ ~„i» obew ooa~ . _
(e) ~tip tM wd~rl~ri~p
oew~ lad. DUE TO W
~ART 11. OTHE~ SiCiNIfICAlR CONORIONts aewi~ip t~ Aw~.brt ~w nla~~d b tM.iww~dioN oow~ piww i~ Port.l (a) Zl. WAS AUTOISY /
?EffORMEO? • .
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a ACCIDENT 24. b. DESCRItE HOW ACCIDENi OCCNRRED I2~. o TIME 11oor MowtM Dop Y~at
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ACCIDENT E.S.T. ~
2t d ACCIDENT OCCU~tED 22. rtACE Of AKIDEtiT (a9„ ~o~. 42. f. CITY. ~ORWlGH. TOWNSHI/ COUNTY STATE ~
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a wotw~ 0.4. b. Addreis paq • ~ ~ - '
. Z4. a WRIAL • 21. b. DATE 24. s. NAME Of CEMIETERY OR 21. d LOCATIOIi (Cw1?. Mt~., T~P. ~ Ceuetp) (SMt) i• {
CREMAiION Q ~ : , • . • i
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G DA RES'D REG. ?4. i`~.'~ 27 SKiNATURE fUNERAI DlRECTOR _
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