Loading...
HomeMy WebLinkAbout2470 t :s i~... _1 r,. ~ . F .is c- • . . ~,~;.t~~ , r ,•r:~ t,,. rf:~~;~:. - _ ~ _ ~ . ~ . . V - :>t~~~~.~~~ . . ~;a. . .,.,r t.~ • . < - This i's: tca ~~t .~y .t:'=L't~his i~ x.i:rU~. .~r ~t.c~ ~-F r~ wi;.. c,i: i~;rti f,•ie.'• in the: Pe~h~iay~:T~.~nf~: ~~~~~,~r~~nt .fiP ~:.t:l.~ Zn z~ .~r+~ .r:c~e wzt.h ;ct c~ i.. • )~%l/ f a~~?_I'OtI~. ~JV ~'?~:E' r4°'f":TI'=l~: ~ SSF'7';f)LJ 'e'' 1' E' % 1 , ~ , , . . ~ ~ . ~i/~/ ~ ' . (Fee: for:"tl~is, cer`~z:'~.c~te, ;:I:.tx.,. ~ ~ , ~~4,~as ~eor~es, Jir., J. . ~.~cz•eLarv, ~f~ Feal:t~.h - _ _ . . ~ F:arri.~~ut eni~s;~~vania:. . IIVf-m/M ItEV. {'~0.~ . . G04M6NINEkLTai•Oi R~NNSVIYAt~k1A ' . ~ . . . . LGSALREG.~MO . . k1E0AAT.MENT O~ MEFl7H.. - a . . ..t;' . . ~ ~ ~ . . . . . . ~ . VITA1. 57ATISNCS " . . , . .f..~„ .1,3,~ ef= ,~3 i( ~ - ~ ; , , : 0~~ j 3~ ~ ~~2 ~ - CORGNER'i CER71f1C~ATE gF~ DEA?.H - 1. ~)EATM -s. Cb~rhtr . Ca1} p;4frat;. ; 2' LYECEASFD'S....' •~.5~ere1 iddtera. R.D.,~ee ot Naw6tr '~UR1tEC ~ . ~ . _ Ot~ f ..,y. . ~ . v ti:.J~l.i: . .f~~]Y' e. Yt ~tet~ i~ Pn~t OI~Ke: rl+rr:.~od' S~fte . : ~ ~e ~r smnr~ _ ~ w re R.O. ~ b~t'Ni~Lee1' . ~ 'i ~![,,,i - ~ Z ~ - ~ `t ~-^w . . . ~p , 3 VETENAN ' ?ts ~iu ~ _ : . ~~l~i~i„t~:y.4~.4.~ y? . . 't'r . . . . . . f IriW~i~1 l~ ~M 1~ i~iq~i. ~ive ~tees ~A ~a) ~ . fbtck far SerW No; _ • ~ MN! CF (lintl. Ip. (16i1~e) - ' t- ~R~Y~1 _ GA7C , fMnisch3 (I?~}~i , lYewr) ' ~ D[Ct/1~ > . e. _ . ~ ~ ~~T~ ~ ~ H ~ ti.3: : _ . J~ : - ~ ~ ; ° < Did decesaed I~~t w • a~p? . ` ~ ACTIMLLI/. . ' Sdef . ~ ~ ?.Yei, decnaid l~ted ~w .te~+ah~p:' J ~ I.IVET y- ~I~ . L- ~Q'.lf~ decrastd 1's~ed w~'an~rl lppt~ af ~ , exf nt ~e~ti. ~7~ OR:NACE ~ MAqttlEti NEYE#t ~ ~ EO AO OA. Of ~6iRYM t ~sE~~TI ~ . !f ~ :I )ea . !f wder 2{ 40~~ ` ~ fllYfJICtCEO ,D . ~j ! ~ ` . i6w, a I~INL 14TIOk (e~a? iftloi~a~,`.~ 4~- 59C1A43~CtIHIT1M MD ~ 1l' 6 GE I~~e pt in i . ` - , ~ . . - , - ~t4 ~~+1} ' - S C1.TIx~!! QF wlNtT CbWlTt~Xt ~ ' ~ ~ Zf~~- 3 f[ l1AME QF fr01lSE .j~ tT Mit3TMER'S MA~OEtt W1rtE ~ - • - . ~ ~ _ • , . ~ . ~ ' y~s+~...r . . . _ , . 1~I~AT1~Mfl1A~. .~~'yR~`~~ ' " t~i INFd2NANT.S.ti~UfE FI~IQ _ DR£ _ . ' A ~ ~ ~!~H ~ ~ . -.~t ' • . . YEbICAI. GERt1FICATION irrrer?v~iC eErwE~?+' ~ ~ G1JlE OF DEATN: F,ata pl~+ PM t~ per lid Is (~I /t (cT ONSET. ANO ~EATk . _ PART 1. dr? ~as c~~.yt ; / . . ~ . _ 1 . 4~DIAjE GIEE W _--_3~~~f`~'" f , .~3- , . l._, ~'~j - C~ife1~. it ~ic~ ' ' OUE TO (?l . t~ ~ `~'-~~f'...isrS~_~`~ ~ _ ~ . ~ p~e d~s r ~e carse > _ . . . , wreLt ~e ~edta~' • ` - e~t I~e , - Dt1E ~o (d _ : . - ~ . . . ' , ~ _ . . . • ~ . ~ . ' . _ . . r - . C _'4 . . . . . . ~ . ..l .PIl~T Q. p'I'H~R S_~'rNIFT(~AjtT,COlQq~~'l(N1S, aa~pib~ui ~o dead hw aot ~el~ted~co i6r ~cr~ui d~sease Rireo'~n Pan t-:+t~ ~2~1 NAS AUTOP'SV ~ . . - . . ~ ~ . ~ . . . " . ~ PERFOq~E D1 ~ -Yery~ . No p a? AOpOENT 22., b. DESCRBE HO~ INJURY OCEURREOT~ - ----`T„ v ~ c ~iuE (iw~ 4oeth Eh~ . le~r S111C10E.. n ~,p . . - ~ . . . ~ ~ . C ~ i; ~ i MOIiC10E l..~C~C~. t i-v.-~~ ~ 2 . L... C. c ~ ~ ~ . . . - i ti ~ UP ~ .^T_ E ~ ~ ~7 - . / . . ~ .v _ , t2. 1?NJ1~iY OCCURAED - - 22 e. PLACE~-OF ttlJURY fe.s .?o.r. Iar~. ~ 21 1.~itv 86ROVGH. TCwN~~it~ ~ ~OUKTv - T ST~ATg 1 Kile ~t Q lit Aile . ~ , ~ fLcwrt avee~. eic 1 ~ . . . . . . ~ . . ~ E ~ L j r r ~oek . .~y-~--~.._._. ~ ~ - t - ~ t. ' f<1 ~G • 1 i(~ 3r[ i~~tu~~uw~ d~dm de~A d t?e ~o~e uKJ Jec~ase.f «anl~c,i m ahe ImdmE> hrre a~~~e:. ah . enat ~ume.,f .!e ` .r4 rwmaud ~a ' . ~ a~E.S.T.' [be dateF3~ted ~!?•e. _ . . t. . ~ ~ ~ . . . . . . _ ' } C Si/rl~t d tat 6~j t= I fL~ r_ b 1ldress - ' ~ J ' Ft~,e ~ nvl- • ~ , L~ ~~a 0{~tlAL D 21 b. DAT ~ 21 .c NAYE QF CEwETERv pp ~o.E~A~pR~ 2a _s r.ti jeF ~{ro.._7~~~ . S: urn~ 1 St~tei 1 . ~ q ~ .~~za/L Z._ ~ ~ 7~~ ~'~,f, fll- ; ~ ~ ~~--~lL„vr'~-- 1' _ _ _ _ l % OATEREC'OBV EG 26 R bTRAR'SSIGHATURE 'ZT 5r~/~lA'.•_•FC ?~.~-~-_~-c~_ ^c c~_.,cc~~ ~.-qc-. p~-~' 1 .3 ~ '~i_ ~ - ~ - :~...~,~~~~,.,~,:t.l~ , ~4-- ; _ - - - ~ ~ - ~ ~ ~ f 1 :1 ~ r 1 -