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~~oo c.n. qr soeU ~3 COMMONWEALTH OF PENNSYLVANIA
~.r Mh OEPARTMENT OF HEAI.TH
G"~~fO~' ~ VITAL STATI8TIC8 N~ 2 3 8 6 6~
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i LOCAL REGISTRAR'3 CERTIFICATION OF DEATH
~ _ R~~~c~na ivo.
FuU Name '
~ of Da~id S. ~ Takaa
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-1619 ~ornell A~e. McKeeaport_..______,_. Alle~. Penna. ;
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Place oE j,!C1CeQg Y•t Alle .
Oeath Penasylvania
tSb. MioYM w T~nalr~ C~b
~ Date of Death ..............!~k~12'_.6.5 _ Soeial Security No. ....-------......__....._..---..............._.....Race_.__. V~lite
Mar?cal stacus _.__.._MA1^1"1ed----..__...----.._._..._.._Se:_.._.Ma1e__-•--•--•-•-•........Date at s~n~-----__.....__June _-zZ-s---1~Z2..__._.._.
r:edical Doctor P Penna.
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~ IF Veteran. which War .---~•--------------..__....___.~....__.~..._.._____..___.-----•--•-••_-••-•-----.Veteran's Serial No_
MEDICAG CERTIPICATE Interval Between
Part I. Death a~as cau~ed by: Oaset and Death
laimediate Cause ~a~---_---------.._._.__~!~cute 1~S~Qeardial__Infarctign.____.__.__....___........ ....~.~i na _ ~
Due To (bi•--.._____......._.........~`e.~r13Y1~.~ ~l'.'.tG2'.3T.__nj.8-Ca.Se...._...~.. .._~.~-S...r-_
Due To {c).._-----------._._..._...__.__....»...._..._.__......__..__._..._._._..._.._.._...-----
Part 1[. 01'HER SIGNIFICANT CONDITIONS: contcibuting to death but not related to the imtnediate cause given in
Part 1 (a)
~ Atcident. Suicide or Homicide ...._._...----_---•---_...__..._---_--.„--.....__.How did injury ocau
Nacae and Tide oE Person
Who Certified Cause of Death (M.D., D.O.. Coroatr) .---_--•-_••--.~Z'...---~hjs'i~~_CT_..~.._.~'~1C~illXl~t--------•..._........_..___.____.._.. `
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This ls to certiEy that the informatioa here givm is correcdy copicd from an original certi(Icace oF death duly filed with me ;
as Local Registrar. Tbe origiaal certificate will be forararded to State Vital Statistics. Harrisburg, Prnasylvania for permanent
filing.
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, l«ol e.ot, of r~o~ s~ai;:ric. oi:niN No.
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1301~ Craig St. 1:cKeesport, Pa. ~
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FILED AND RECOROED `
gT, LUC1E COUNTY. fLM.
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