HomeMy WebLinkAbout2151 I . ST-25 ,164 261~6
~ ~-IAtARNiN~: It is illc~al to duplicatc this copy by photostat or photograph. 1
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' % ; -.~~~r No.
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~ Th~s~.~s. ti~, ~crtify_-that•~~~is~-:s a truc copy of thc mcord which ~s on file in thc Pcnns~•lrania ~
~ 1)c~ar~ittent aE H~aT~h;=;iv-atcordancr with Act GG, P. L. 304, approvcd by thc Gencral
i Assci`fiblr; jone ~9,'1A5~.,~0
i • Y', - , J`~ tILEO AND RECOROEO Ty , n'~
~ ET.lUC1E COUMTY fLA.
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~ (Fce for this c~rtificate $2.00) RO;fR POITRaS Finton S eller M.D.
• ' CI~RK C~~CUI? COURT .T• P ~
REtOR~ VER:f1E0.~~~~. Secretary of Hcalth
a~ 3 sz PH ~~3 j-%arrisuur~, Fennsylvania "
. 261'7~1
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.~,._o~u wev n/s9 CO/AMOInWFAITH QF PENtvSYlVAN1A
' iCC:.t FEG. NO___ DEPARTMENT GF NEALTH
, VITAL STATISTICS
~ "v~IMARY ~ ~
; :;,sr. r:o._._.___ . _..~G.._~'~C'..-//~__ CERTIFICATE OF DEATH .
, 1 GEATH u. County b. Gi11r-or borough 2_ DECEASf~J'S o Street address, R. D_, or Box Numbar
OCCUP.R~~ : i I MAILING ~
, IN: ~ ~ / ~C 1e r j l~ :C~L y ( ACDRESS __~~LI. ~
~ c IF deot6 did not eccur in City ~ o. ~ost Ollice, Zone, ond Stote
~ or bwough, give name of tov~n~! E,^ " ` ~
` (Du oot use R. U. or Bo~ Nomber) ---"~-z_r.. ?r: . ' j r ( y ! ji ~ ~ - - -
~ d. full Nome 3. VEtERAN ~ Yrs NO
r of Ho!~itcl j :
cr institui~nn (if r.cl in hospitol, qive slreet odclress) o. Wfiich Wor b. Serial No..---.-.-- '
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' 1 NAME OF a. (fint) b. (Middlel e_ (loet) ` 5. DATE (MoMh) (Dayj (Yaur) ~
~..~.:a:.~0 , ~ vF
(T~pe or priM) •,1 ` f~/? j/ 4C'1 ~ ~Jii:.'~ ] _ I DEATH ~ _ / 1 /Z.
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~ wHERE ~ID '~j c. Did deceased live in a townshi~
DiCEASED o. 51ete--------~J-'~ ~es, dcceoscd lired in....r'CJ~_~ ~ J-i ~-.--------._towesbi~.
aCTUALIY , - e* O r
IIVE? b. Co~rty ~Ch~----- ? No, deceased 4red within eduo) (imits oF - ------at+}-o~ ba~ougl.. ~
7. ~EX (8. COI~Q 0~2 Rl+CE !9. MARRIED [~NEVER MARRIED ? 10. DAiE OF BIRTM ~ 11. AGE (in yrors If under i yeor I( und_r i4 houn
~ lost birthday) Months Doys Ho~rs ( Mi~. Y. ~d+.
WIDOWED DIVORCED G7~ - I 5-~ r i ~
tl Lv I ~ ! o~?.
12 U S UA L O C C U PA T I O N ;even i f tetwe d) 1 3_ S O~ I A I S E C U R I T Y t~ 0. I 1 4. B I R T I i P I A t E ( S io te or for eign t oun t~y: ~ 1 5. C I T I Z E N O F W N A
T C O U N T R Y? A F~,, ~
r~~ sc . ~ G _ t,.~ _ ~ l s;, i J S R ~ ~ ~ ~
15 FUII NAME OF SPOUSE ~ 17. MOTHER`S MAIDEN NAME ~ p~
i.`•. F/ i i !~1 C/,_ / r~i •L~4'15 C* ~?i
i"o fqTHER'S NAQ1E r ' , ( 19. INfORMANT'S NAME AND A~DRE55 ' ~7 ; v` _ ~y ap
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.r~ h !yi e ~ 1r ~ N r"i.: .t O:...•. ~ n _ ~ C: ~ . i . ~ : o s• ~
I~~,EDICAL CERTIFICATE c~+~~s To ~h~o~ h 23 must be ~o~ leted b h sician o„i ~ `~~w
g P Y F Y IN7Ee~VAI BETWEEN ~ p' N
20. CAUSE OF DEATH: Enter onlr one wux per line for (o), (b) 6(c). ONSET AND DEA1H N, .4 ~
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PART 1. Deoth rros couxd by: r J /'~j~ , O A+
' fMMEOIATE CAUSE (a) --Lt~t~'t~c----------- ~`-j^rs--``---- ----~t;r-f - J-~`=----------------- ~i o e* ~
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` -c~:d,tic.m, if eny, which ~ 1
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ca.. r.:r oSc~r cn,aa DUE TO (bi i-/-= -=--'~^-`~f ~ -----I-= - - - - r• ~
,
r
r,1 statina thr unoerlr~ng I i/,' r , Qq
:
:o_~r lost. DUE TO fc? - :..~..._,~S_-:CL-1_1t._.s ~-•:i - ~/~r=-`- ~ " ".:~!`"•G_.~~ ~^`~^'~-s..-~' ''`~"'t^"< OR ~
~ .:.~:T 11. OTHER S{GNIFtGANT CONDITIONS: coatributing to dcath but nol retatF•d to the immedia:e ceuse giren in Port 1!o)~ 21. WAS l.UiCf. SY ' •
I PERFORN.ED?
- ~ ~ Yes ? ido rt
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_t c. ACUCENT ~T2. b. DESCRI6E HOW /.CCIDENi OCCURREO (22. t_ TIME Hour Ntonth Doy Yeer
_ 1'`s j] No [J I OF m ~
ACCtDENT E.S.T_
~ ACC~DENT OC~_~!RkfD 22_ e. PLl.CE OF AGC:GEi:! ;e.g., home, f2?. f. UTY. BOROl1GH, TOWNSH:i• CUUt~iY 5?A7i'
_'•`.'6:Ic ot Nol rvh~l. I form, SfICN~~ efcJ I ~
w,•rk at work
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- 1 her~by erhrfy l~fnt 1~0 r.ded the obove r.aroed ceceaieJ end '~ot deolh p~S~rre from the cc~:rs ond sr. ~e dot~ stated obo.e e+ in , E.S.T. ~
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S~~ndo~e- -~.(j./'i ( D. n.-/b. ~dare~s J c. Uoic siqc.-a , f_i j_ ~
BUR1~11 24., 6. OATE 2•t. ~ N:.NE Of LEMEIER': O' CR[MAiORYi?:. d. IOL:.'•:UN (City, Bc~c., Twp.. a ioumy? ~5to•~) ~
CPEAIAY:ON I~' • ~ r j'__- ~ ~ C
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i ^S - %•7 - / ; i.~ ~ , ;,~w, : L.inCC-:.t : i.,..'=~ ~ir.-,~,.~~ <.'.~r•.c'J7iAr~ i ! .
./•'OVtiL . ~•Ji.
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~ntE F.tCO dY f.EG. ; 26. REC=ISTRA~'S j•• 1•i~ C - f ' ~ SIGNA:CRE AI:D AJURE:.S OF FUN~f~AI FtCTOA
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