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UOC+ Cvc. P.. boo4) COMMONWEALTH OF PENNSYLVANIA
h. Nt~ DEt~ARTMENT OF FiEALTH
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LOCAL REGISTRAR'3 CERTIFICATION OF DEATH
Reglsce~ea t~to. ?~h._..._--_---
F~ll Name t~iarie ~ G. Sullivaa
of Dcceased -------_.__.-----._...._._._..._....._.._..~.._.._.._._.._.__._____.....-----------__.------------•-.___..r_.----.___.__________.~_____---•-------•-----•--
fint YiddN l~q
U~ 523 Romine Ave. HcKeesport Al1eg. Panna.
Address "
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Ptace oE MCl~ees ~'t,
Death
A--~aB.s..___.._...__~___.._.__ Pena,ytvanio
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Datc of Death ._w_z
~2~~_ ~Z..~ ~_Socia! 5ccurity Na .~~,j._:.~.$-,E~rtQ____w._~._Race_~?1hi~ _
Marital Status ~3.dO1/ed Sez__.~4~~.-------------_Datc of B(tth_._Ja__-_.~-
Occupation H0118CU/~~.--...+_. Birthplace
If.Veteran. which Waz .._...---•-•-•--..___.._Vcteran's Serial No.
MEDICAL GERTIFICATE Interval $etween
Part I. Death was cauxd by: f ~EO ~Ma ~3463 t aad Drath
' Diabetic Acidoais - marksd tUGf COUNTY f~~.
' im~oediate Cause (a)__.-----_..._._ .............._._..._._---~¢~q.~fg}~~~'___.~.~. .
` CtERK C~RCUIT COUItT
. RECORQ YEFti'tE0 i0
! Due To (bl---.__..._~_
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E Due To (c)~......___ _
Part Il. OTFIER SIGNIFICAIVT CONDITIONS: cantributing to deat6 but not rrlated to tbc immedlate cawe given In
f Part I (a)
' .-----_._,--------Brainste~e_ischeiaia - Arteriosclerotic .besu~._ U~e~e-CQ~cn
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i Accident. SuiNde or Homkide _._____._...._...~...__...._._.__~_._.,._How did iniury otcur
Name and Tick of Pcrson pp . Bernal'd G. I'Ii{CT.os
' Who Ccrtified Cause af Death (M.D. D.O.. Coroner)
~ Address..--•.---••-----..__._------•---••-•-•-•--__..._._______._..____.___..__._..
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; This is to certify that the information here g~ven is correcdy copied Erom an original certificate of death duly fikd with me
as Local Registrar. Thc original certificate will be foraarded to State ViWI Statistics, Harr9sbury. Peansytvania for permauent
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