HomeMy WebLinkAbout2409 WARNiNC: It i~ Wepl to da~lkate Ws ap b~ ptietestat or ~6obt~ap~. ~~AA~c ~R
xvs-n°llx--a°~t-t-~e .~1 COMMONWSALTH OF YSNNSYLVANG
cta c«c. va boot)
~ N° 347'660
LOCAL BBGISTRAB'S CSSTIFICATION OF DEATH ~
~ 101
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Fnll Nune
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oc ~a ......................Llo~d..........----------~--...._.._.....................p~._...._.....................................-----.....Potter
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U~ ~.li.~b~...............2l..._._._...---------....._...._.......T.owanbe~....................._...............B~redtord.~.._................. Pa.
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xmbr StrMC Qb ar tai~ Co~sV - &aa
t - _ gtieehec~nin ~wt~..-- ( ~ornbaroot)............ Bradlard, p~,~a~;.
(.lh?. Boeo~[~ or TNeiip ~t~
n~?~ ~r n~w.._...$eptember...30.~1963........~ s~+,~c~ xo.....189r1E~b496..........x.~...----.White............
3[erried ltale ~ ~ September 1,1899
M~w s~s~ . . . ..........s~---.. . _
o~~n.. 8 i~n.. ~aintiar Berniae.Penn's•
..........strt~~................ . .
It vet~so, Which wu._ . ............vs~an~a setial xo...............................
11iEDICAL CERTIFICATE Intenal Betweea
Part I. Death was cau~ed by: Oneet and Desti~
Chronio Ltyovardit le 8•10 yr~•
Immediate csuse (a)~ .
Due To
. C~
Due To (c)... .._...............--•-~---n-••--••.
Part II. OTHEIi SIGNIFICANT CONDITIONS: oontrihuting to desth but not related to the int~@diate giv~ ~
Part I(a) X; m~ tq
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Aocident, 3uicide or Aomicide...--- . _........Ho~v did injury oocur..................._........n .._....~AO
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Name and 15t]e oi Pereon ~?A
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Who Certised Cause ot Deach (M.D.,1~7~~liij . G ~ C 11[l~ ~ ~ _ -q .p
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41? l[ain 9t., ~thsns~Pa vN v-n~
naar.es _ . . . . .o.... . . .
Thia ia w o~tity thst the iniormation here ~iven ia oorrectlY oopied fmm an oriQinal c+ertiHcste of desth duly filed with~me
ae Local R~egistrar. The original oerti6cste will be torwarded to Stste vtal Ststistica, Harrieburg, Penasylvanis tor pernoaneat
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