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t2s t«~. o.• eook) COMMONWEALTH OF PENNSYLVANIA
~ ~ DEPARTMEN7 Ol~ HE/1LTH
c«~~nnN, s~.oo~ YITAL STwTI8T1C8 N~ 3 9 8 3 71
, LOCAL RSGISTRAIt'S CERTIFICATION OF DEATA
I eqi:cerii a .._.......re~ ~
~ 1'ul1 Name ~ ~
of Deteased _ _.~n..-i---_~__.__. . - ~ -
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II Address - - ....'.3...__.~~---~?---..
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Death - - ..._.1..._..._.._. _ ! Pcnnsylvanls
n. se.ew? « T....W te..b ~
!'Jate of Dtath . j~Social Security No~~_~~~~~~~.Ract
II l~iarital Statut!'~~~~ . _ ~ ....Se:. _ .._._Date of Birth_... ....~...~....L.~Q.
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Occupateon •.•~~I~~~. . _.~.-.~..__.Birthplace_. _ _ •
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j IE Veteran. which War -----•---•-------•-•--•--...•--------------------__._~---•-------------------__.Vcteran's Seriat Na
!i MEDICAL CERTIFICATE - Interval Betareea
Pact I. Death was cauxd b• Oaaet and Death
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Immediate Catase (a)•--°-_. . . - - -
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Due To (b)•-•• - - - ~
Due To (c)_._.__._.__.--------__~.__~.._..__..~_...__~-•-•-•--•-•-----•--------•------•---
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Pazt ll. OTHER SIGNIFICAIVT CONDITIONS: coavibuting to death but not related oo tht immediute cause givea in
{ Part I (a)
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____w____________
1 ~ Accident. Suic[de or Hoauade . _ How did in]nry occur • V
Name and Ti oE Person
Who Certifie use of Death (M.D., ~.0.. Coroner) _--t----- t`~~~~~.~,aL.--
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~ 'I This is to certify that t6e information herc given_is correctly copied f•om an oriyinal certifiwte of dcath duty fikd with me
; Ii as Local Registrar. 'Ibe oripinal ccrtiEicate will be forvvarded to State Vital SWtistics, Harrisbury, Pem~ylvania for permanent
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~ FILED HND RECORO~~
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