HomeMy WebLinkAbout2247 WARNING: 1~ k ilkpl to ~~licate tl~is coPr by plwros~a~ o~ P~~os~,o~. i~~42~
Mvs-ZOii2-~oor 1•69 GOMMONWEALTH OF PENNSYI_VANIA
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ta~~ DEPARTMENT OF HEALTH N~ 4 6 3 7 31
fi~ttt~ca», f1.00) VITAL STATISTIC$
LOCAL ftEGISTRAit'S CERTIFICATION OF DEATH
• egistered No.
Full Name
` of Deceased - - _ - - -
fint iddb losf
Usual
.
Addre - • • . • • - - .
t h ro.e N
, Place f -
' Death . - - - Pe ylvania
~ Gh, brwa~ w To 'P ~O°`~
l •
~ Datc oE Death - - - ~ --Social Security No. ~~~~.~~------Rate---•••- - -
~ ~ / ~
Marital Status - - --------------°-~x-- - ---Date of irth----~ ._~_~~~..f•=
E ~ ~
Occupation ~~Ir7'-w--~r
f-•----- - - ----------W_.__..Birthplace - - - -
,
•-•---•---------•------M_•--- `
li Veteran. which War~-----~----------~ -~--Veteren Serial No ' ~
MEDICAL CERTIFICATE Interval Between
Part I. Death w~as cauxd i ~ Oaset and Death
. ~
Immediate Cause (a)----• - - - - - - - - - L3~-•
Due To ~b?~ , - .!!L~-_ . .
- - ~
a
Due To (cl------- • • - - • ~-~k'-~--
~ Part II. OTFiER SIGNIFICAN ONDITIONS: contributing to death but not rrlated to the ~mmediate eause given in
~ Part I (a) ~~---=~Ca--=-.~. -
-
-
~ Accidcn . .----------=-----How did injury occur
_z
` Name and Tide of Person
~ ~~ho Ccrtificd Causc of Death (M.D., D.O.. Coroatr) - - •
> Address ~i G _ j_ ._Q__...-••----
~
~ This is to certify that the information here given is correctiy copied from an original certificate of th duly filed with me
~ as Local Registrar. The original certificate will be forwarded to State Vital Statistics, Harcisburg, ybauia for permanent
~ filing. ~
~ ~ yT FiLEO aND RECO ~ ~
.
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