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• WARNINCx tt is ille~al to duplicate this copy by photostet oc photo~eph. ls~~ J~
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This is to ~ert'tfY'tilet tbis •i~? ~~ue copy of the ~td which is on file in the Pennsytvenia
Depe~tmgnt bF Hea1tA, in scco~dertc~ witb Act 66~ P. L. 304, appcoved by the General Assembly,
June 29,-1953.~ ' ~ . - ; - ~ - .
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(Fee foc thia cectificate; .51.00)' T6oma~.W. Geory~es, 1r., #~1.D.
Secrefacy of Health
HaeriabucR~ Penaaylvaaia
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H1/~Z011~ Rw. 1139 q~Q CO~AMONWEAITM Or /Nit~KYlYAfI{A
IOCAI RKi. NO. ----M LJ u- ~ O~AtTMENT O/ NEAIiN
1IRAL tTATIfTICf
: ~~Y oo ~-3 CERTIHCATE OF DEATH
. ; oar. r,o. ------------------------6a___- ,
'j DEI?n+ countr b. an? o. eo~~oupA Z oECEASEV~s st...t .da..... R. o.. a w~ !l~~nt,..
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CURRED LehiEh ~19IItiOl~i11 ~DD'
RES~S l.~r'J S• ZOti~'1 aSti ~ ;
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~ a If de~th d'id hot ooa+r In Cily b. Past O(fla. Zar. ~nd St~N
~ a~«°~", a"' Al lent ovrn, Pa .
E (oo nor u.~ R. a a bx tiaeba)
d fuli Nanr VETERAN . YM Q No =I ~
_ ~ r~.qr.~ Allentrnm Hospital • ~
r a imtnu~ion (if not In lw~pltd. O~w sheM ~ddr+is) s. Whlch Wr------°--------- b. SNlal Na '
~ NAME Of (RMI b. (M~ddM) a ~t) S, OATE (Montla (~w) nf~ ' ~
Clvde Carney I o~n+ 11 28 ~.96T ~
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~ 6. WHERE DID PAYIYIa • ~ ~ M ~ ~ ! 3
DECEASE~ s. StN~ ? YM, d~aawd W~d In~_ 1owmMp~ i
ACTUALLY LAYl~ AZ1611tOWI1 +e • ~
~ tIVE4 b. C al N0. d~wad Nv~d wNhin ~chnl IkniM d--------- ----------dfp or ba'°upl? ,
7. SEX s. RACE 9 IIMRRIED ~j NEVER AAARRi~ ? 10. DATE OF 61RiH i l. AGf pn y~an H un~br 1 year H urd~? 21 haw~
M I W ~ v~noowEO p orvoRCEU pl 5/2/13 I 5~~rw''hd''') I µ0""" I°iy'I "O1"' I"a" `
1 Al OC4UPATION ( ff retke~ SOCIA SECUR NO. 11. SIRTHPUCE taM w oreipn aowNry) iS. C TI EN OF WF1AT COUNTRYi
~'l~la~ntainance~~an ( ~64-0~.-80~36 ( Nashvill~e. ~enn. U~~ _
e~ r :.ce . _ ~ _ ,
~ "~'"E °FF~°O~ieter Carney ~ ~~~n~iown"~~u~livan _ _ _ _ '
~ F~:~~ ~arney ~birs~~l
de~ar~ne Allentown, ys.t~
~ MEDICAL CERTIHCATE zo x+ ~ b. a«~v~.d a? p~r~ ~M1 INTERVAL 6ETWEEN i~
~o. uuSE oF cEl?ni~ E~.? a+h? a~ w+• al 0~ a W. oNSEr Awo oE/?n~ I;
~ART 1. M~th vvM a~w~d bri ~ i
~ uw~nu?~ u?us~ w ~~a~-
~kn~x~?}_Rsns~~b~ar_ ~nYQati,ga.t3,~m 4
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" ` Conditiorq, if ~ny, whith ~
~ p~ve rise to above c~use DUE TO ~ - ? i
~ slNirg rhe w+de~lyieg ~ ~
~ uuse I~st. Ol~ TO (d--- ' , .
PART 11. OTHER SIGNIflCANT CONDITIONS: aomtlbuMeO to d~~th b~? not rel~t~d to tM Imned~at~ tww piwn In Pvt 1(~) I ~I. WAS AUTOPSY t #
~ PERfORME~ ~ ;
Y«$ No Q _ , }
Z2. b. DESCRIdE HOW ACCIOEM OCCURRED 24. c TWIE Hour Mo~Mh Dhr Y~ ~ :
y, 24. /1CCIDENT I I pF ~w. ~
~ y~s ~ ~ ~ AC~CIDEM E.S.T. ' ~
f~ ~ 22. d AGCIDElR OORIRRE~ I Z'l. rIACE OF AOCIDENf (~.p.. honM~ 22. f. CITY. lOROUGH. TOWNSHIV COUNiY STATE ;
; WhIM N Not whiM f+~n1, ~trNt. Nc.) .
~ wak M work ~ }
~'-C " ~ 1 MnbY aNih thN 1 stNnd~d ~bw~ n~nrd d~a~d ~nd 1Mt dNth ooasr~d froen th~ eauw~ aid on fM d~N ~t~»d ~bow ~t in.. E.S.T. ~ ~
k `y,~~> ~ «o. AU,entown Hospit al 11:10 Yl~1 e
Al~ Penna. ~ c.~. .b~+.e 11-29-6? ~ °
; Sgnsrwe -f~{'C~J ~As4 !
t Z4. s. lURIAI ? b. DA1E 21. c NAME Of CfINEiE~Y OR CRdM/?TORV i lOUT10N (CMY, iaa. Twp~, f~ Ga~M„ R~Ma
~ ' a~unor~, [Y 12/1/67 Hennin~er ~rematoriu Readtng, Berks, Pa.
j REMOVAL - ~
~ 2ls. DATE REC'D sY REO. ~ 28. REti1STRAR"i iKiNAiU~E 37. TURE iHA~~~HJI~IE~AI OtRECTOR
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