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HomeMy WebLinkAbout1793 ^ ^ ~ j8o~41 _ _ tiVARIVING: It ie illegal to duplic ?tc tl~:~ copy by photoatat or photograph. N ~V 1 196~ ~ ' ' Date No. ~ ' ~ . Thie ie to certify` tha~ thia i~ a ti u~• .:c>py of the rccord.which ie on filc in the Pennsylvania Dep~?rtment of I[e~~ltt:, in accordance with Act 66~ P. L. 304. appr~p~ad~r~~the'General As ~etnbly~ Jur_e 29~ 1953. , - ~ ~ ~ _~~:;~~:t ~ 7`~ ~~~G~t C~ ` :~r . ` . , ~Fee ~sr;~~~ez.~cate. ~ 1. 00) ~ _ .,i ' , ,~t , C. L. Wilbar. Jr. ~il. D, ~ ~ , _-~-,.r , ~ _ , Secretary of Health ~ . _ ~ r'`- ~ Harrisburg, Penneylvania . ti-., . - - ~ - . ;,~r,,.,~ , ~ = : ~ - . ~ ...L _ _.~~~.T'_"'"- " ;t - t. . _ ..s.. ..i ~s : _ : ~ - a .i,:~:-.- 7~ - ` ~ - .c _ ' 3 ~ ~ t 4. NY5-2011Z Rw. 11~? ' ~ ° OOf~IiRdHWFAITN GF 1 rNKSY.VANIA ~ ICUI REG. NO~_. _..~..~.G_• OE~AR?MENt OF HEALTH - ' VITAt i1aTISTi~S ~ fasT~Nr . CERTIRCATE OF DEATH ' ' ' ~ ii ~ ~ o_ _ •.~:.~~;;;r- ~ ' t. DEATH CO ~ b. G1y O? rbOfOYaI . i =1 ~:G'S a. StrNt addttsl{~ R D. ot bo~x N~rmb~t i~, ~ OCCURRED t j!`:G - t: Q ~ i i ,Ni Phi]adelphia Phi]adelph3a n~:~~css 303 Countr.v Road • a If du~h did no/ oopN !n Clqr ~ c. : f oBic~e, Zone. and SqN ' ; ~;.i } o~ e o? o u o~. o h» n~.. t r.~++ r B e r h? y n~ P e m~ a• t:,, i c (Do not u,. R. D. or box N,N„ba, i , - d~ull~~ v~. S• N 8? A 1 H 0 8~ t 8 1 { 3. v~ :s~.tl Ya? fiC~j ~;1 ;t~i ~ ' . . a irntitution C~ no~ In ho~pit~l, pivr s?r~t ~ddna) ~ .:i,;ch Wa------ b. SMd No._~_--_-___~..__.. : j t a. NMAF OF (Rnl) b. W1iddM) e. (Vs ~ S. DATf (~NoeMla ~(DaYi (1~~a) t June SCUFtIAtB COOPI~Y. ~TM Ma~ 1„g; ~?.966 ~ . ~ ' C pid d~p~Nd rt :n e~cv.~rohip9 ~ ; 6.._lY?iF2c ~ . - , DECEASfO Sf Q Y~a, dte~ ~scd Gvrd 'e~^------------------ lowiMhy~. ~ . nCiUAllll , ~ ! lIVE4 b. C~ouelly _ ? Ho. det~ n. 6v a with~~ sttwl limits of-------------~-»---dt~ : r taroy~h. : ~ ~E 9 KJUlRIED~ NEVER AMRAIEI~ [ ~-•4~ BIRTH f 11. AGf fn y~an If u~dK 1 N u.~c~•r 41 iww~ , lasf {-thd~~ IIIIorMha C~» Houn i lNie. v w~oOwEU p DIVORCFD G; it; ,-,19p~~~ ~ • C~i31 Ci3UC '.2 USUAt ATION t~ren Ii r~tiredi 13 SOCIAI SfCtJRiiY NO. 1 i:;; -~it.CE t5tate o~..~o+r:gw+~wAtr) 1S. CITIZEN OF VM~t tOI~NTRY9 . L _ . . FULL OF S.~OUSE t: :'.~:~i_ ~IDEM NMAE F. ~o ~ ~ .~,.._3~~ f,J,~.?.~Q»~. ,a. F~niars i~~~r:; _ c~.u~s AND ADORESS ~a..,.a~.. c. ;~~+,P.~: - s ~rQ., ~-.'''~d~.l,,.. S z.,..~. MEDlCAL CERTIFICATE (iNma ~0 i1r'a~ph 23 nxwt b~ oompktad by hys.c~er. o„~,,~ - ~~RVA< <.Erv_~ ~ ~o. uusE of o~?TM: Em~. w» e.~.. p.. r~. e.~ m~ a td oNSEr A?:~ o~e~?TM ~ : m~ ~ ~ r~ or.r+, w.. ~,..a ~ ~ : 12 hrs ~ , Intra-~duodenal r:- ~t~ire e; atr~~~;~~ .a~.~. • ~ : ~ 111AMECII?TE Gl?SE N. - i ta+dc~iw,~, If ~r. whkl~ 8TiE1~!'a'QS - ~ 3 . lare ?iN M ~bowr s~tM DUE TO - ~ ~ ~ ~ ~ j. ' ~'•"^o ~h~"o Aorti c Atheros cle wai a : : ~ ~ . I ~,~~s i.a. ouE To td - vnl _ , . ~ ~ - - . :~A4i II.OTl~ SIGNIF{GNT CONDITIONSs ooMtibAinp to de~+h bvr not rcl. rcc: +o ~;rnnw~i~te uvae piwn M ~Mt 1(a ( Zl. WAS AIROoSY ~ FERfONMEDf + . ~ . 1 ! Kult~ple M.yelo~a - ~ mont~:: _ ^ v" ~K~ ' ; j : ; ~ ':2. ~CC~?~T I~. b. DESCRIdE HOW /1CCIOENT OOCWRE~ i sz. ~ u?~ Kou. ~on+b Q,r Yw I Y's ? 1'~° ? ( _ ~ ACCIDENT E.S.T. ' '~I. d. ACCIpENi OCCURRE~ 22 PIACE OF ACCIOENT (~.q. iwrey, 1' 22. i. C~ tY, 80ROUGH. TOWNSHIt OOUPIiY ~ S7AlE i' ; Whit~ ~f Not whil~ ~Mwy ~frMR M~~ ! 1 ~.k p ~ D ~ ~ i ~ ~ , I 33. I hereby arrihV ~i ~ qnded tM ~bow nsn~! deoe~d ~nd tMt d~ •h :cc c t~c-~, t1K• uua<~~ ~nd a+ the dar~ atN~d above n •.~q E.S.T, ~ i ' ' All D. ' J i s: ~,.ti,.. O.F. N3ELSP~1 ' Lz r: ~oo~•: e ~a...n, t~~~'~,Frila.,Pa. ~ o.e. ~o~,.a 5 19- 6 5 . ~ 24 it/~lAl {~O ~ ~I. b. QAT~ 21. ~ CE1111E; cRY OR .:~E W110RY 2~d. l TION K«Y. lwo.. TwP•. Cou^W) (S~~t~) • CD~IIATi0~1 ,A ' j REIU~OVAt 2 ,l Q~[t1' + Z5. DATE RECD Z~EV? t~ ~SlSI R~ ~ c rJAi y'RE AN~ AGait OF NERAI D~tECT I~ t F ~r.!- 1 ~i.,,?f~s i~•G" ` ~ ~ ~ n 9 /1 l~ ±Y ~ ~ ~ -r : - - - ~ ~ r - , " i FILED C.Nq RECOROEO ' S~, I.UCfE COUNTY, FL,.:. = " ~ . . = . . 18024'7 '~9 ~I!'!_ 3 PM 3: 0 ~ ~ . ~ ; ~ . s CL~'FK C~r~CUIT COURT 60CN ~ 1 v FAt?4 x ~ , . . _ _ - ~ ~n= ~ _r:~