HomeMy WebLinkAbout0546 WARNING: It is illcgal tq.duplicatc this copy by photostat or photograph.
. y ` ~ .
« No. 'j~~ :
, . ~ 4--.. __$t F~ ~Y ~_1_ !
. V
This is to certi~i tha1~ u-ts e-:true copy of the record which is on file in thc Pennsylvania
Department of Healt~?, in ~tCtordat~te E~~~1E L. 30~, approved by the General
~IICIE COtI
Assembly, June 29,1953., .~'~8 ER POt f~,~~
- ~ CIE~? ~IRC~~
. .i: S , `
. . ~ : ~ f ~ r.~ k ~~rT~•ti ~L~1~~/~/.
, (Fee Eor this certifitatq ~~.OO~s'~~ ~y 16 49-AH ~ J. Fi4ton Spel~ei, M.D. _
~ . . ~ - Sea~cary of Hcalch ~
- Z18925 ~ ~
Hariisbu~, Pennsylvania ~ _
tt,. . = _
-..t-a- ' `--...__'.i ~
~ s _ _ - ~ ~ ~ - _
HVS--20t~3 Rev. tt-34 ~ / ~ COMAAONWEAITH O~ ?iNN3Y[VANLA . ~ ~ .
' tOCAI REG. NO. j~~ pEMRiMENi O! HEAITH • ~
PRI.'1MRY ~T~/~~-- YtTAI STAi1S11Cf • :
' asr_ t~o- CERTIFICATE OF DEATH . .
1. DEA1H e. ~wH+y b. Ciry a 6woupA . Z. ~KEASED'S a. Street ~ddreu, R. D., w Eox Nve++b~r ~
' OCCURRED / / / MAIUNG ' ~ • ~f~ ~/y~~` :
IN: ~H t ~QN e~ ~1 ~G4 Q ~ [~j/d ADDRE55 ~.~-~`e'r l"'_' ' fi~-
~ e If death d~d not oaur in ry 0. Pwt Oif~ee, 2on~, ~nd S~i
~ o. bo.ouyA, 9ive narrN of townahlp G a
(po no~ o.e R. D. or Eoz Numba) ~t~'1 1 ' t
i d full Nanv , 3. YETERAN Yes ? Ne Q , '
'r _ Of Hotpital ~~C ~ NQrT~ nw ~o S~/rRl ~ \ ~ " :
i. w instit~t:on ~f not in ho~p~td, 9rve ~trce ~ddre~~) whtcl+ wa---------_-`------- b. Sertal No~ -----------1 .
r NA11E OF (Fi.,t) b. fM~ddt~I ~ Q/~z/I 3. DATF (MontN (D~Y) (Y~ar)
~ Ep~inr) Mi ~r • / I DfATN ~Q ~ ~ l7! ~
6_ YYNERE OID e Did dece~sed Gw n~ townthipT
DKEASED St~» a_ ? Ye~, decea~ed Iived in_._-- ~ownaNp?
, AC7WllY Chester CO• QIUe~ _
tfVf? b. Coun No, decea~ed lived within ~etwl (imih of~l-------~'------dtY o? b'°r°eph
~1'---------
~ I 8. RACE 9 MARRIED ~ NEVER NtARR1E~ ~ 10. GATE OF 61RiH 11. AGE Gn ye~n ff urwer i yesr ff vnder 2+11+ax~
w I wioovr~~ p DIVORCEG Q~ ~X ? Q"~ ~~1 ~b'uthdaY) ~ Allo~ths ~ D~ya ~ Hovrs I Ml~t
12. USUAL CCCUPATIQN even i~ rot~rec~ 13. SOCIAt SECURITY NO. 14. ~RTHP CE (Stete a foreiyn country) iS. CIi12fN OF YhlAT COUN7RYt
secretary-sel~' emn2ov~d ~ Phi~a,Pa, ~
16. fy tl NAME Of SPOl15E / 17. MOTHER'S.,y1y128beL1'l BTOWl1 1
J. ~a~~¢ ~~ln~~~i,~c , L12
lt. fATHER'S NAME T~ ( 19. IN~R~M ~ ~ D~DyE~
Henry Charles i~~ ~ 5'Y J.Earl Philli Ps ,
T MEDIGAL CERTIFICATE (~tema 20 tFvouyh 2~ mu~t b~ compltted by pAyfid~n only) IMERVAL 6ETWfEN ~
20. CAUSE OF DEATH: Enta only on~ uu~e per lin~ fw ~b) i($ ONSE~ AND DEA7H ~
?ART 1. Death was uused p~ ~ ~ ~
WIMEDIATE UUSE __C~3YG4---`-,'~ --o,T_':fil_~-R~--------------------------°--- -
- _ V ~ •
Cond~r~~. ~i ~ny, wh~ch
ys~e r~se to abo.~e uuu WF TO {b) " - ~~~'a--- -
- (a) st~•:ng rhe u~derly;ng ~
uwe I~st. DUf TO W---------------------------------------------------------- t1
_ pART 11. OTHER SlGf:IFlCANT tONDITIONS: co~tributiny to d eath but not ~el~tcd to the immeduro tause 9iven in iut ~ ~l. WAS TOFSY
IfRFG~NIED
r~, No p
?2 ACCIDENf I~2• p- OFSCRIBE NOW ACCIDENI OCCURRED 24. t TWIE Hovr AAa~h C~y Y~~t
Of ~
Ye~ O~ wCCIDfM CS_T. ~
22. d. ItCC10EM OCtURRFD I 74. PIACE OF ACCIDENT (~.Q., Aom~, 22, f. CITY, 60ROUGH, 10WNSHIP COUNTY STATE
V~'fiite ~t Not whil~ farm, street, ~tc.) ~ ~ ~
wat ? d wwk ~ - •
IA 1 Aereby uAity tha 1 mendrd tM ebow rumed dece~ud •nd tfiat death ucwred /rom the twse~ and a+ tht d~te ~t~tcd ~bov~ at~ ~~,~t nt, E.S.T.
IIL p. ~
5:9~~w:~ ~ h- f 0. O. b. Add.~u phila.PB. ~ Oa» ~?flrnd 7~
2~. dURIAt `1~ 4 Q11T 2~. t NA.AE Of CEMEIERY OR CREh1TOAT ( 24, d. LOCAflON {Gty, poao~, Iw~., b ount~;) (SUt~)
CREM.ATION ? ( j/ lts~~ 1 I~,r:ood, ce~etery (Fernwoo3, Del. Co. Pa, ~
RE~AOVAt ?
7S DATE RK'D4
rf • I 26. REG;~~?f+R j~~ t!L'^F !J' 27 SIG~tAiURE /ItJD ADCRESS OF fUnERAI DiRECT,?it
~ 1~~~ ~1-~ ( ~~ii n~t.l:-r, %~~S-ti-::!' -~~arby~pa•
~ -
~ - - --r---
- ~ ~
eooK 197 E ~~E 546 ~
= ~