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Home My WebLink About0979 ~ WARNING: It is illegal to duplicate this copy by photostat or photograph. `~,~'79~ NfOS.li2 SGO.N 2J2 ,t00 Cc~r. ~e. 6cok COMMONWEALTli OF PENNSYLVANIA DEPARTMENT OF HEA~.TH ,F« f°~ ,h~s N° 112 G 4 0 Cerr±~cntc 52Ct'i VITAL STATISTICS LOCAL REGIStRAR'S CERTIFICATIO\ OF DEA'TH ^ ReL~ Number Futl ~;,me / ~ - - ef Ll.:ea~~S - _ - - _ - - - ~t--- . _ - - / 7 F'utt . Middle ; ° t-_'~t 27~0 a~. _/~i0/ :~ddre„ ~ - . - ~ - - - sro:. - - - - Num Meet C~ty w to.rn C ' p~3:c' Oi ~ ~ - - . - - - nnsyl~ania llc~th _ _ I~ Q.'t~. Borough or To..n ~ ~O~ - t ~ 7(~ • /s~ 3 ` D.;te of De:,th ~ ~ . ~ S ial Se.urit • Iro. f. Race ~ r ' - - - - - - - ~ ~yo~ _ ~fa: ual St.eeu~ ft ~ - _ Scx _ ..__.Date of Birth - - _ . . - - - ? I' (.(/liCff' ~ - ~ - O:cup:~:i.~n ~ Birthplace - ~ . _ a. Veteran's Serial tio. ~ Z~/~~ ~~'2O lf ~'eteran. whi:~~ \~':ir _ _ ~ - - - _ \tEpi(':~l CI:RTIFICATE ~ Inten•al Bet~reen i1~E0 JIM~ RECOR0~0 Onset and Deaeh Pa~i I. U:a:l, ~.~s :auk.l b:: • St.IUCiE C0t1MtY i A. ` ilOCE4 POITR~S 3- D~s }A/c=ll/YIO.t.~//3' - fmm~di.,te C~u=e ca! ~ . - _ _ -GL6FR L'+~iCWT-CaIIRI---- f~'.'.- / ~ Rcr,ORD V£Rlf1E0~ -~-1~--- s ~ Due To Ihi /L(:ZlGO /~EJI///~'. _ - - - - -f - ~ - - ~ pn~ iT 12 k3 P~ -Mos _ . ~i1.ec ~~lo m r~--- m~ c t,~- n~ _ _ _ _ - un~ T ~.1 P:,rt 11. OTHER S1G~IFlC:~~ I~C~~UI"IIl)\S: contributin~t tu death but r.ot related to the immzdiate caux Ri~•en in Ya;: i !a} :lc;i~~~nt. ~~icide ~,r Ilun~i.i3e Hoa did injury occuT _ ~ \,rr.~ and I i:ie ef Per~cr~ ; • . - ' - , l- - ~ihu Cerutitd C'su~e of lle h ~~i.[).. t! - - - - - - - ./z~z - . - • • - - - Aa,irc,s _ _ _ _ _ - _ _ c~ s+reet Thi< i; to ccrtif> that the inform:ition herc gi~~en is correctly copied from an original ceriificate of death dul}• filed with me (.«;~I Kcg~str::r. ihe uri~inal certi(i~ate uill he furwardeJ to State ~'ital Statisties, Narrisburg, Pennsylvania fvr permanent filing. Hf-N7 Or ~ ~ ~ ~ i d~~~ ~i~ t~ ~U Z~ D c~ locol ~str F V~rol Sf~tistics - Dislrid No. ~ ~ / - --u' /sa/~ • - - - ' - r~et Add ts ~ Cit~, ovyh, i ip n+a~' /0 ~g~~3 / _ . - - ~ pcte Reaived br low - ~ftrw _ ' ~ 197~ $~~~`1.~ ~scE ~~7 Dv•. o/ ~ss~e of Tti' Ce.tif~ca~:on . ~ - ~ _ ~ - _ . . - . _ - xg,s . . . - . _ . . - _ . . - . . . " d ~:;5.., : ' ` . x. ; . . ' ti.