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Home My WebLink About1102 ~ 203C~~ is itle ~l to du ticata this copr by photostat or photo~sph. ~ ~ w~tNircc. i~ R p . 0 3~3a ~ ' oace ~O• ' This is to ccttify tb~t this is a troe capy oi ihe trc~ed w1~~c6 is on file ie th~ ~'cnnsyl~a~i• . [kpaKment oiliealtA, in accocdanca ~itb Act 65, P. 3b~. at+pt'~vcr~ by the Ge~ecal Assrmbly, ~unc 29, 1953. , ; ~ ~ ~ ~~;i;~`1 f Il (Fee to~ tfiia ccnificate. 5~.04) -Y'. " . Cttswu~ch R, arow~ulk~, M.l~. ' ' ~ . ' ~ Secrcta~y of Hcalth . = , 1 • ~ Hanisburg. Pennsylvania . ~ _ .~s ~ • . ~ _ - - - . . , ' HYS~lO~IO-JO~f-~ ~a•{0 '~YypNyyEALTH I~R`PE~II$YLVANIA :r . ~ ~ FMEIlT.;Qi:-~{EA~TM Fil~ Nw ~ Ptin~M~ ~ ~'~~.'~TAT~STICS a ' ~ os.t w. CEF~`~E ~ ~F DEATH ' s.a.tv.s t .i ~ , ~ . 1. PL/1CE OF DEATM 4. USNAL RESIOEN (W?ere ~ieew~ed lired. H ia~titntkw: ee~ide~ee , ?~1~rr a STATE b. ff~NNTY EAon v~foirioa), ~ . C1TY llf aotside tc ~~it~, ~eite RURA4 IENQTM OF CITY (f w te ' vRite R}f14?L wd ~iw to~io) ~~u~ ~ ar1 ~n to~rw~Aiy) STAY (fe t?i~ ORW(iN " t+r+K) ~ i, iULL NAME (If uel i~ bl or y~tilntion. rt net ~d- 8TREET IN wal. t I tfos) NOSPITAL O or iow) 11GDRES8 ~ 2 G tNSTITUTI J /Uv1 S. NAI~E OF a. IF' e, (Yiddle a(I.ut) 4. OATE . , Z oEC~,?s~c ~ . , ( ~ cx~u~ ~o~.r~ ~ 1«~, ; ~ _ ~rw. o. r.t,~) o~w~ ` S ~ i 5. SE~ ~ i. COLOR OR RACE 7, YARRIEO. NEYER YAIIRIE0. ATE OF BtRTH A(iE ~t. 1t w~Nr 1 rw ~t wN.r 2; M. ' WIDO , arVORCE I la~t b=rt?d~l) ~~fontM~ DV~ ~ Hwn ~ Yi~. l'~` ~~l C2yy 1 s . ~ ; : ~4a USt1AL OpCUPATION (Ui~e kiwd 100. KIND OF BU$iNE88 OR 1L BIRTNPLA tALo ~i~e ta4 ar~l2. ITtZEN OF WHAT .~t ~ort dcre aat d~rorkuC IN RY cQ~ntq) i ~ ~ COUNTRY? ' ~ . ~ en if ' 13. fAtNER'S 1i11 ~ • 11. N YA1 NAYE j _ _ ~.~Q S'~ ~ . t5. WAS DEtEASED EvEtt /n U. S. ARME~ FORCFSt lf. SOCIAL SEC RITV ~ ~NFGRW~ OVyM SI~iNA~URE AOOFiE88 ~ ~1•es, na or wk.o~.t ~ eu Jea. ea.pkt. rE.ene .3de 1/0. q ~ ~ ~ of eertibcate ~ . /e~ .GO~+ ! . ~ 1$. CAUSE OF OEATH YE 1 L C RTIFI T~ ~ INTE ~1L BETWEEN EnLr~ oalj o~c catrt 1. OISEASE OR COMOITION ~ ~ ONSE~ O OEATM f ~ ' .rr l~nc tot i~). A). DIRECTLY LEAOINO TO OEATlM ~ U.t.C~• _ ar,~7 (c? ; ~ ; AtiTECEQENT CAUSEB ~ f ` ; •This doea wot DUE TO (y . nrcn the wode ot Yorptd cowdi~iow~ i~'swY. a~~lr ' - dtino. ttid Y 1?a~t ~ .•citYre. osuaea~a. to t7~e s0ove esws ts) anti*o ihe lJ ~ e:c. It msr+~s tAt ~d~tt++~o Ca~te Cast. OUE YQ (s) , dueau. ia~wy. o* 11. OT?~ER 81fiNiFIG?NT CONOITfOMS ~ cvrrDiiC4LW~? ylt~ . ~ caYSed detitll. Cm~dltiows cosdriDYtiwo to tAt desth brc wot telatM W tke di+sa~e w towditio+? esti++so d~ath. , 19i DATE OF OP•I 19b. MlIJOR FINDIN(i9 Of OPERATION i Tb. AUTOPSYt ~ ` , i Ar~o~ 4 tr ~ YES MO { ~ F 21a. ACC~DENT (Spteiy) 21b. PLACE OF INdURY (e: id 1 21a (CITY. TOWN ANO TOYVKSMIP) tOOUNTY) (STATE) € SULCIDE ~ at~.wt io~ae, tan~, taetwj~ st I ~ E NOMtC40E o6ee blds., ete.) k 2.0. T~ME plaaM) {O~I) tYear) (Hav) 21s. iPNURT CCCURREO 21t, t10W OID IMJURY OCCURf : ~N URY ~ ~,~T. ~~at N~tWNb t ~ Woric ? at Work ? ~ • r ; ~ / hmA certi that I attewded t/?s dece~sM 7.. . tlut / Iwt aw tAe dtc~a~ed ~ Y Jw lros~ l~l.,~ w..••-.. 1 ~ ativt o+t l~.S. s~u! tl?at dtatli occytrred at.. ..../.Q ..rn. ES-T.. frotw ths Cawta snd ow tJ?t dFtt stattd sbovs. ~ # 2)a. SIONATU • • n N.D. M.~~Mr ~ 43?. A~~Q~ESS ~ • Y]s. DAtE St(iNEO . ~ ~ A/ rnr.~.~~'1/ ~ i~' J v~ 2Aa. B U R 1 A L REMA- 2{i. DATE 2M. N OF ET OR CREMATORY 24~. LOCA ON 1Tn~np lnwtuhy Ir+d t~ivn:.l {P.rra1 ~ ; ~v'~ REMOVA4~ ii1) ~ / ( ~ ~ ~ tt! } ; L . ~ D~TE FS~C~ g~ ~ Oli7RA SIGMATURE - ?S ~~S~i TUR F NERAL OIRECTy~ J?OORfSS /r~_ ~ . AFA.S- Y L - :~v/'+~ I.:`'i"~"'~' ~ ~ `!'i~lWil / ~ f~i'^..~~ !4 ~ w ~ ° ~ ~ ~ / j~w _ ~ _ , _ ~ ~ , ~ ~ 8 ~ ~ _ ~ ~ ROCER PQ~TRAf ~ CLERK C~aCU1T COUItt It~- ~ RECORD VERIf1E0~ ~ ,~u~ T 3 sa PM'1 i , ° 2030Ei9 ~ ~ ~ ~ ~ IOOK ~~9 PAGE a.U97 ~ ~r> ~ = - ~ _ . .