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COMMONWEALTH OF PENN8YLVANIA
~ N~~ ~~s~s DEPARTMENT OF HEALTH s~~
c~.+~Bc~~.. !tm) VITAL STATlBTICS N~ r).) ~I IJ ~
LOCAL REGI3TRAR'S CERTIFICATiON OF DEATH
Registercd No. 5~__._...._____ .
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HAR~iY---------------__.___..._._---_______M,.---------.._----•~---------
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~t 12 Hauiilton St k.cK. ^
Addnss ...___._._.____.---u± .~~~s._~__._____essport-------------------
A.l.1S.g.-------_..... Pe.n~?..~.....1;~1~2-----------
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Death ~SC~espOY"t A~e.~'a_~_..._.~__--------___.__. Pecasylvaaia
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f Date of Death ---.-----~'s'~X-3Qf---~~--_.__.--•-------------_.Social Security No. 1.~~.-0~.-.~1~.~-------------..~«---~ite- -
~ Marital Status _..--------•--~':8Y'r.]
Cd_........_.._-----_._Sez----..~i81@- .
; - -----Date of Birth------A~j,],.-?.~jy..--~,$$~--•--••---..__.-•----
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i OccupationU..S..~+~i.Z1T.1.4~~--Pc1Tk-----------------~.....--._Birthplacc __..__...-------P.E'.i3i18.---------------°------•----.__._._..._...-----__..
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~ If Vcteran. which War -•-----•--•--.Veteran's Serial No_
~ MEDICAL CERTIFICA'IE - Interval Between
~ Fart I. Death was cauxd by: fLED htrr ~EG~R ' Onset and Death
~ S~. ~UG~f •..~UMT1' .
~ Arteriosclerotic Heart Disease ~~'~t L ~T~~~'
Immediate Cause (al---•---------------------•---.__.._~._----------------•-------------.-_-_•---•---6~-f~K ^.I.~.;;l:I-LCIJRI--~..
R~f.fR : ti~ = "~C~
Due To (b)-•-- ~
~ 25~6'76 Jua~
13~ Tt1~ o~ -i~'~'3
D~e To
Part 1l. OTHER S[GNIFICANT CONDITIONS: contributing to death bnt not rclatcd to the immediate cause qivcn in
~ Part I (a)
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's~~-, Accident. Suicide or Homicide ---•------•-•-•---•--------•---...------------._How did injury occur •
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Name and TiUe of erson
Hr . D.I. `Lubritzky
Who Certificd Cause of Death (M.D.. D.O.. Coroner) -
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N.cKees __rt Pa
Address.-----•--------------------•-~--•------••----.. . .
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`t; This is ~
o certify that the information hen iven is coaecdy copied from an original certificate of death duly filed with me
as Local Registrar. The oriyinal ccrtificate will ~ forwarded to State Vital SWtistics, Harrisburp, Penasylvania for permanent
~ I fiiing -
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