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HomeMy WebLinkAbout0171 ' ~ . . ~ ~ - • ~ _ . 1 , ~ ~ . - 1'~"~'Sfi~# ' ~ . ~ WAP.NTNG: It ia illegal t o diplicate this oopy by photostat or photo~raph ~ ~ , 3 ~ ~ . ~ - ~ ~ - (Q ' , ~ S ; i . ~ ~ ~ ~ , .No. . eA • ~ ~ . ~ . . , ~ ~ - ~ ~d „ ; ~C: ' ~ r~ ,r, ; . ~ r ; Thia ie to cer~i~~?, ~ha.t~ ~t,hi~s ~a a true copq oY the record which is on ~ ~ ' ~ in the Fem,~jriJvai[ia; D~ep~meiit of Health, in accordance rrith 4ct 66, P. 7° n n o ~ ' 3~4s aPP~'oQ~ .b~~ ~~e'Geil?er.a~.'. Assambly, June 29, 1953• c~ ~ ev f"'d n ~ i , ° - . io °i' ~p z .I } : ' . ~Q O~a ~ ~ ~ (Fee for this'cei•ti~'i`c= Le ` .G~C- ~ `f~ ~ ~ R' ~ ~ . - ~ . ~ Q ~ i - ~ . . _ - ' _ ,;=::1~-;~~ ' Ttlomas W. Georges, Jr., 1~. ~ a~ ~ ~ ~ ; , . _ ' : : :~:;j • . Secretary of Health ~ . . p ~ ; • ' ~ - ' . . ~ .~f - ' Harrisburg, Pennsylvania ~t ~ : r a I ~ ; ;d:.~=~.~:.- ~ • ~ ~L l. i ` % c~.r _~.~e.~:~-- ~a,~.,,..~ Nvs-zau R.~?. ».s9 ~ oow~oNw~?trn oF ?~NSnv~u? ~~i, . ~ou~ No ov~+~r af ~un~ ~ ~ ~~r{~ vrr~t nwrnrKS . rrtwuer . SQ C.ERTiHCATE OF DEATH ~ o~sr. Na _ - t. ~oav~~ ~ ~ t o~?~o,s U ~t,~.&t~. t~~ ~ ' ~ If d..d~ aa +wt «a,. t.~ clt~? b. ~Oa Ion~ .na ~i.» ~ or boroupiti nan~ of lawml~tp - . No ea~ ua 0. or fJwnb~rj Q~ r+~~• d R~ Nan~ ( 9~ VETERAN Yw Q No Q - of llo~piql or 6nti~wion f ho~pitat, steN1 Mq~id~ War_---~__._ b~ S~rtd No. I. l1AME ~OF (Fw~ b~ (MfddW a p~ '1 OJ1TE WlonNa (Dr~ (Y~ , ~o aeu~ ec~~o ~TM ~ ~ ~of a wr~ ao ~ ad a.~wa w. ~.~t oeCE/?sW ~ p ra. a.o.aaa ar.d iti______.._ ~own~l~t{?. . L~1?E~ ~ b~ Nor daas~Nd Il~d witl~in ~dud M~nib dw ' ar - ~ SEX RACE ~ 10. OF IR?N 11. AGE pn y~~ li wiel~r 1 If urda 21 fauts • JII1ARRi~ NEVER AAARRI~ Q l c~l~u~QA~.~..vmoow~ o oivo~ p~~f I 7 ~~e~w+» o.y. ~+o~n. ,wn. y-------- 1~. USWL OCCUrAT10N (rven ff ntk~ 13. SOCIAI NOi. 14. sIR (Sf~le ar fpripn opuntry) is. pTIZEN Of WiIAT CO(lNTRY't .~1 ~ R~ ~ 16~ RA1 ~ ~ 17. MOTt1ER'S ~ ~7'LLYG~ZtJ' ~ 1~ F11 ' ~~"C~` . • . IN /1IVD AODRESS l - • / . . . i1 ~t ~ ~ ~ . • .G M~c~ c~nHC~?~ c~~«~. m~ n~~. a? a~«~ `~e. ~a cAUSE oF oEl?,~ EM.. a,y? o~. ~w.. p.. a~.,ia. c•l tb1 a cd• o~aET AN~ oEl? PART 1. D~a~ wN sau~ed by~ ~ - • ~~,(~•r• UAMEOIA?E GUSE W ~ r_ C~n~Mon~ M «M. w?hlel~ ~ , ~ ?rN w aboy~ c~ ~ ~ ~1 - Q' i W ~t.liiq 1h. ~nd.rlytno c~iN brf. 0llt T~ k~ K ?ART IL OTf1ER SIGNlflCANT COMDITWNSn oon~Akg to dNth buf no1 rslaMd b th~ Y~al~ uus~ ¢v+n in /aA 1(~ --21. WAi AUTOPSY ~ ru Me !t a. A~6iT 22 b~ OESCRISE Fi0'W ACpDEM OOQJRl~ ~2. a TIME ibur MaMb Dw Y~w ~ Of w YM Q Ms Q~ AOp06~R E.S.L - ' ?t d AOpOd~IT OOQJRR~ ~ 2t a MAtE Of AC~CID9JT t~0+ ~M, ZZ f. CIT1f. ~OROIXi1; TOVY1i5~1~ GO!lNTY STIITE 1All~ M llo~ w1Yb 1~rn~, ~~y alt.) wplt M wotk . 2~ ,lw~ ~ ~M .boa. e~d d.~a..d .ad ,ha~ d..~ ooaRnd N,. .nd o~ ~M d.n ~t.hd .bor. ~t / E.f.T. M, a ~ • a a s~aa~.. w,..~+.a f 11?~(~ a MMttAt ZI. Y~ TE 31.,t Of C~METERIf OR CREMAT d. LOCATION .~ora. Twp.. i QN1~1 ReMOVAt ~ .ZG' ~y ~ ~ LK.t-Lt,s~Gf ~.1-t ~t} T-~ d.~ ~ .CtiL~.+~.,, fJ~ Or? 1~E 1 , ~ 711RE Alq OR L <c ar - .~.~ac.o t . * . . _ . . ~~177~ ~E 171 , _ . ~ - ~K ~ ' ~ - _ ~ . ~ ~..~~~~~~.~a-._,. -