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(~00 C«e. v.• book) GOMMONWEALTH OF PENNSYLVANIA
~ ~ DEPARTMENT OR HEALTH c(~
t.«urw~.. i~-ool VITAL 8TATISTIGS ~O ~~O V a7~
LOCAL REGISTRAR'S C~RTIFICAT~ON OF D8AT8
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201 Seaaa Dx~ive _~________Fort Pierce Florida
Address
~ Nw.e~r SM.w Cflr c..US ii~M
~E Lo~rer Merioa Mont ame
ne~th ~ Pkmsytvanis
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NQx~~.~e_l0_-___~~__.so«~ sK~~ty ivo. ..~bb-
~ Marital Status -•-•-.~~~ey!_.._._.__~__...w.__St~ ~.e._-----------.-----o~~ ~ s~cti..__ Febru~..~ L~~~z
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i If Vcteran, ahich War
--.._---__.____._.~_------k•..__.____.._.._.__.-••---..~_-•-••--.. Veteraa's SMaI Na ...._Y_
j ;NEDiCAL CER1'1FICATE Interval BetaPCCa
' Psct I. Dtat6 v?as cauxa by: Odsee aod Dead,
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~I I~mrd~ate Ca~ue (a!_ --C~'~1Qt.~C~? OID8Z111.GIIflgYIr~L~S_.._--- - -dgY-g
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Part l!_ 017iER SIGNIFICAM' CONDITIONS: cootributiog to dcath but oo! related to tbe immediate cause yiven In
Patt I (a)
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Accideat. Suic~de or Homicide _ --How did IniurY occur . -
I Name and Tidt of Person p~,~~~~
~Vho CcrtiEied Caux of Death (M.D., H6-Eete~ter) __-t.~w+,i.,+K--~~ ~AB~C _
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spital___...._-___ _--B~ Mawr_~Pen~Yas~lvanfa :
I This is to certify that tbe informatiou bere Qivea is comctly copsed jrom an origina~ cereficatt of deatb dulyr fikd ~vith me
as Local Registrar. "Ilu origina! certlfiutc wi11 be forwarded to State Vital Statistics. Harrisbury, Pennrylv.~nls (or permaoen~
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y_ Gladwyne, Pa. 1903 11~ 19~
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