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Hvs-m~~z-aoor ~-a9 ppMMONWEALTH OF PENNSYLVANIA
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DEPARTMENT OF HEAL.TH `
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~~KO~, s~.oo~ YITAL STATIST~G3 N°- J S J 7~ 1
LOCAL RTGISTRAR'S CEKTIFICATION OF DEATH
R red No. ~__1_l_~..
Full Namt ~ -
of Dectased
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Address ^ - - •
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Place of • . ,
:
Death • • - _ . Penasylvania
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~ Date of Death ..fl-- ~ ..-~----------------___._.Social Security No.~~.!~.._~_~_..~c0_~ ~__~Rat ~ E
~ ; Marital Statu~ .._.__w~_.._...___Se ~ .Datp~of Birth__
I'~ . ~~..~1-~------. d~---_.____
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Occupation ' _Birthplace • - -
If Veteran. whic6 ar -----------------------------------___~_---•-------•------•------Veteran's Serial No. -
~ MEDICAL C~RTIFICATE Fti~EO ANO aE
s Part 1. Death was ca by: Oaut and Death
Sj. IUCI ~ COU~TF F ~LA.
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~ ' Immediate Cause (a) C ~ _
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~ Due To (bl-----------_.--- ' • ~ ~
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Due To (c)--.__.__.__-----•------_.__~..____._..~_~__..---..._.._..____.------------'
Part Il. OTHER SIGNIFICANT CONDITIONS: contributing to deatt~~~, t~~immediate cause given in
Part I(a RK C RC IT
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Accident. Suicide or Homicide .----~---•_.w--_--__-.----•--_.__.____How did injury otcur
Name and Tidc of Person L /
~ Who CertiEied Cause of Death (M.D., D.
-
~ Address----•-----------------------------•------°..__------•°---------------°- - ~
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This is to certify that the information here givea b rnrrecdy copied from an original certificate oE death duly fikd wit6 me
~ as Local Registrar. The oriyinal certiHcate will be forwarded Siate Vital Statistics, Harrisburg, Pennaylvania foc permanent
Filing.
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