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HomeMy WebLinkAbout1477 S• , h.;:.fi~ , R~ ~i ~i. ?IAR ~1 ~ Z~ ~ ~ ~53~~ iir ~~cJ~J~ HVb~1pI~~' y ~~7 ' • 10 ( Ferr ~ ~ ~ ~i < ~~z;ob . ~ ~ ~ ~ 4 4 3 z~(s•b~ "~db muowln~ b a aue aaa oa~recc oors ~ s oertl~ce or ae.th slcd~iti 1Y : Baciiuon. Penne~inuls Dep~rtmmt ot Heaitb, as bY ~.6Q Qi 3!M . ~eo~1~. 1l61. P. I.. ~01. _ _ _..-~t~'_A~,~~' - _ - , , ~n~. ~`'~•a'f~h ~ - ~ ~v) 4~ : :~X~,. . '"7. ~ ~~i~~~k ~ _ CdW10MYMEAITH OF rENNEYLVANIA FlM Na ~U O~~: / I ` OErARTYENT OF MEALTM VITAL ~TATIBTICS • o ~~'iw. _Z ~z~! ~ ~ ~ CERTIFICAIT OF D~ATH n.~,.k,.~ N.. - ~ 1. PLACE OF ~E/1TH 2. U3UAL REi1DENCE ~ww~ IFvM. H i . nM~Ma ~ ~ a. dfab I~~ G~I Cwa ~ A. Nrw~A N Twn~Al~ I a L.~ptA M Nq i~ 1?. s. Citr. ~wp~ or T ~ i FULL NAYE ( 1 ~NN riw tfrNt ad~rw) ANrw ~r lMSWw 1 « ~'ru ~.S-d `~li. / ozT ~c~ - Is Plaa d O~alA IedM No1pWb U~olbt a b i4atN~r~ IaiM ~sNIN13 Ll~lbt I f. It tiKiN~w ee • F~t Y~ 0 p~ ? YM O Ib ? YM ? No ? 3. pEY~O a(Flnt) R(MINN) ( 1. D~ 1A) (Oq) (Yw) lrrw rrlnt) I DEATH S. SEX 6, COLOR RACE 7. rl1RR1ED~ NEVER rARR1ED ~ 8. TE OF B 9. A6E (is rirf M~~Mr 1 rar M ~Mn ~4 ~ I IDOWEO? DIYORCED, -+/I I ~~r I~~ I M~~ ! 10. L.L E OF BPOUiE 11. el (AM~ ~i~n sfab ~ h~MM ~ 14. CITIZEN OF WlIAT ~ Nw R < < ~ FA iR'S NAYE 1 HER's W11DEN ~ ~ I 15. U OOCUTATION (~r~a H nUrN) I ia s.iw s..~rib N.. , ~N IR AO ~ ( MEa1CAL C 1 AT hbnai ~ {I 18. CAUSE OF DEATi1 I tcr onlr oM q~ ar Iis~ h? (a). •(e) - Orwt ~nI DwtA ~ ! PART 1. OwM rw o~uwi ?y: ~ i IYMEOUTE CAUSE (y _L?rr_~['~eLe~3~._~le~l~(r~ - ~ - ~ CondlUonb H~. vhkA ~IiE TO _ ~ _ _ - - _ - - - ~ Oar~ N» te ~ber~ sauw - _ - 8 (a) Nadq tM ~~Mry. ~ tnp Aw~ tatl. , DUE TO (e) - ~ PART ll. OTFIER 6NIFICANT CONDITIONS [~W~~M ~^~~~~~+~M b tM tasieai ~iw~r oir~n le Part 1(a)~ 1!. WA8 AUTOPiY ~ - PERFORYEOt ~ Y~Q No ~ 20a. ACCIOENT bU1CI0E HOYI- 205. OESCRIBE IN,IURY OCCURRED ~Oa TiaN Hwn, WntA, Dar. Yw ~ ,I ? D O I ~ t~~ ~.s..L ~ ~ 20d. INJURY OCCURREO a I 20~. PLACE OF IN,WRY (~.o., ~ 20f.CiTY. BOROIJQH, TOMIIIiHIP COUMTY 8TATE Whib at N~t wAib MnM, tarm, I~eMry. strw~ ~to.) ~?erk ? at werk } 21. I htreby certtJp tlt~i 1 stfenQed the dereaud Jrorn . . . . . t9. ,~.,,.to . . . . . r..r.rii.. . ..-~kai.l isrt asfo iht deeea~ed aiiat at 19.....-sf[a thst death occrsred et .~~~f'~i,~w. a.s.r.. /?ara tht os~su snd on the dstt atattd sbout_ 22a. S ~ M.D. ot 4iOr ADDREBS I 22e. DATE SfOMED ' ' ~ / ~ = 23~ BUAIAL CREWTION ~ 274. DATE i . NAME O1TCE ET pR Z3A, IOCAT N Cibr, B~n.. , E Coa~)~ (S ' REMO'VAL? S- I ~ ~ • 24. p~ATE REC'D BY 23. R IST 81ANATURE • I tl ATURE OF Fl1N O CT '~ADD _ ~ ~ ~ ;::3 ~i . lt-i . .i' • . ~ ~ ~ , ~ ;S ' Y ~ ~y _ e. ~ ~~,L(- . ' _ 'Ci ~ ^~i.' ~ ~ P~~.~ ~~R+r-~_~s, e.w_..?".;~"i~.~p _ ~ _-.~'X`v.. . . ~ F_~~~~_'+,'^_