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HomeMy WebLinkAbout0883 ~ ~ - : ~ . WAANINt3: (t is illegal to duplicate th~s c~p~~ b~~ photostat or photograph. _ _ ' ~ f ~ x , _ . . R~ ~ ~.~i ~k ' ~ 7?1~, r ~ ~ ~ 4 ~ ~ : a~~a This is t~" , 7~,~i3tt ;thr~a~ ~ a~ t~t cbpy' of the 'rrcord whicfi is ~pr~ ~lc .in, tl~e~ Penns lvania Y , Department o t~,=~t~i~.;ccofdance with Act ~ 66, P. 'L. 304, :aFPrc~vcd b~ th~ GGa4ra1 Assemb~y~,~~ ,.~~5~ . ~ , f~,~~ ~ ~ ~ ~ ,r : 1'~`~,~ r Y ' ~y ~r~j j . i ( Fee for'~1~~' ~Z~'~Q) . ~ ~ . ' _ J:'~'irtton~Spe~l~r; M.D. . . . . ~ ~ . SecreEary Qf Health: M103.11,1 REV. t.7i: w • ,j~i4~'C~SDI~T~?-;i.~1111$y`1V1IIL'~, . LOCAL RiG. NO. , ! MMMQI~ANN.O~ ~rAMA i~~1~R .a , PItuMARV ; ~ . . - . h~ cisr: rro ' ~ , - - - - ~ ~ . ~ ~ ~ TM . 1-. o°~"cc a~EC c°"~" c~,''o: s o~as. . i~M~; iddr.w,,'R. 0.« sac NreM~r t?~h , ~ . , M111tlf~lfi . ` - ~ Ff d~NA dd na1 . - ~ ~ - . . . . ' . ` htt E~aM~, Sla1~ ewd « ~ ~ M~i, ~ - ' M Cef~ (DO na Q~ +r M~c 11~~ ~ - . . ' ` d /uq tiMw , . ' ~ ~ . . ~ . . i: „ : ef Flo~piW ; . . . ~,.t~G~. ~ ~ ~ _ , ~'ss.~ . w W+MMuliew pf pet iR .www~ vw~__G~L~_.~' a«w K. s~"~ ~ _Y a. n+r~ of _ ; ~ , ` ~ . . ` ~ ~?tE pAenry or e~ , ~ ; ry~ : ~ ~ ~M ; . ~t1f«.l a w~+~ : ow . , r7 ~ oa?tN. ~ . ~ ~ o~d ~e.~e ~Iw ~ • ~ 7Z. - ~ a t~n._ 1. 3 ' . r.~ ~ 1~ _I~,1,K'...C~ ~ . y ' ~ ' 11VE9 b. ' ~i.CJ..t~l~ ~ WlNw ~wl; i~N~ qf_-.__ ' - . . ~'M~ ~aa~d ~Nd - ~ - ~ R~ ! M~:(~J- i~EyR MA~R~. iQ. a111E 0l~~',M_~~ fIt. I10E Os ~iMes if.,Md~? t.~~^~ ~ ~ _ ~ a~ _-,;~'r?,?~T yrb~"~ w*~ ~ ~o~?r• ~{~ww,. 3 12. ~AT N'~._:# 4~ SSlCiAl~l!!i'k:fKl~ i'1,' , tA . - : . . t * ~,h ; . ~ . • ~ ~d?1Ze! Of tcou~vi~+n w~ oE . - t j ~w~roe~ _ i~. . - - - ' " - ~rs :ww~ , ~ , , ~ ` . -zi c ~ EDIC~?k ; _ M . ` • ~O~-MirauOh~~ wMUf b~ qe~Md b1? s~ ~ UrT~VAt ~ i0. . G?N6E.Qf ~A~lh:~wr My? an~ e~ P~r Mi» Ii. ~,1 i(d ` ~AR7 ~MI~~~!MM ~ta~~.d by~ ' _ ONSF7 Al,q DEA11t : . - W ~~'~s~~~~~1~ ~ t ~ ~ Conehriw» if a~r, MAAAIA(A~E GU6E . . ~ - - - - 9aw ?isi M iboir~ tau~ bl~ 10 ~ (a) sr~tieq th~ _'.'nderlld^y - - - - . cwse last. ~ ~ ~ _ ?ART II. OTFER S!GlI~iCANT C1p1~OlilqrSs w.•--_~_~~---- , ao~rlin0 w a~h bu~ i+e?..u~Nd to lh..~.f. aw.;otMa M.aet t W II: w~?s wtlfOlSY ~ . ~ ` . . ~ ~ Yp ~ 2~. a AOC~H~ff 2Z b. .OfSCRi~E 110W AO.CIOENT QOq~ ~t. c 11ME llour ~ - Y~ O ~ ? ~ . . . Of ~M Yw _ d ACCIOEI~/T O~ Z2. a ~tAE'E Of AOCfOENf ~ ACCIOEM . E. T. ~M1itb M No1 w1~W f M4. ti~? I 2Z f_ CtTY. ~q~pf~, TOWNSH~ CO(N~tiY . ` wark ~f work w'n' ~trNt. ~eeJ : . . STAi! . ~ ' ' +hae ~ ~n. .bov. ryn+.d d.c.«.e .nd ~d.. M ooa,.?.a froin N+. auu. «+d on ~t.ad .bar: S~P,... f. _ : = f ~C ~1.>-~ , ~ _ , , ~ . ature •M~. , ~`.~J_ ~ M ~ / ~ vC ~ ~ L~.. d' Aden... ~ ~.5 C ~-3 C D~M ~{y~.a 7Z ~ ~ 2{. b. OATE 21. c NI1ME Oi CEMETERY OR CRfJIMT 24. d LOGTION ( ~ . wa-, a Cou,~r) tsr.a) RiMOV ~ ~ ( ly - % - ' ~Y, iwo.. T / ~ .I t . J . ~ T~ ~Y REQ I 26. REG S1G I~T . / " ~ ~ ~ , I~f1, S~G TURE A SS OF ERAI DIR O~ I v , r ~ . ~ ~ ~ . ~ _ ~