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H 105.119 SOOM 1~ :
' (100 C~n. p~. boo4? ROMMQNWEI?LTN OF ~BNNBYLVANiA
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DEPARTMLNT OF H~?~TH No 253579 ~
t~ ~ VITAL OTATi1TIC8
Ca~htut~ 52.00)
LOCAL REGISTRAR'S CERTIFICATION OF DEATA
Re~isternd Number ~ .
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; Full Name ~~~L_~.------•-.__..__-__~._~-t-.---_._.~_ '
ot Deceased
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! Uswl - :/or~dri . ~
~ Address _~L ~ .Q.'~.----Qt-lC.G.Is--.G.QILrT _---..t~.!"~.~t_.~.~ ~ 4-: -------.c~l!~K~
Hwob« atr..t c:ryr o. w.~n . • i~d' ~
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i Place of 'L/D~•~,.-_; P~nasylvsaia
~ Dtath ~~-L~_--_.__-~__ ~ew4? . .
~ ~ Cih. ~
! ~ ~Z_Y__._____ Social Security No.,Z~.~-:~~-= ~-2~ ...Rsca 2~16 ~T
Date o[ Death _-Q-G.~.~.._.~.- ~ . - •
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' Date of HirtA ~ -
riarital Status _..~21~!'L~~.----.-------_Sex -~4-1-t---_.___-
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; ~'Ja i.vTo.si~~91K«~_&~L~i~.~~a L~.-.._--.B~rchp~ue __L~C~t.~R- -
, cupation - .
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' If Veteran. wbich War _Jl~-.?~•-f _ Veteran's Seriat- No. _.11-~-~._.$-~~----- ~ ~ ~
- - Iaterval Betrreefl ~ .
~lED1CAL CERTIFICATE ~ . p~~.~-p~~ _
Part I. Death was caused by:
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~CL._L___"~~_1~~~a~ t1~ ~~.~L!-d.l.~--- - - i
~ Immed'+ate Cau~ (a) ~ ~
~ Due.To (b) ------;~-~X~--~L
_T_.P..sC1l._I~cT!~--~='.T---~.G,itQ.s•4.. . _ ; ~
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Due To (c) ...G~~l./._ .:C.~C~{~1.---,~~~-i-T:_._1c"-4-~~u-/-'-~--__~____:,.._.....~ . ~ ~
Part lI. OTHER SIGNIF[CA?~iT CONDITIONS: contributing to death but not related to tha iu~media~ cwse ir"E° ~D ~
Part i (a) '
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Accident. Suicicle or Homicide ___.---------------~____~___..___._How did injury occur ;
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I~ame and Titie of Persoa Q~~~`~~ f- ~
Who Certified Cause of (M-D•. .0., Coconu) . ~
Address _~____._____~y~
.L` ~'~~AS~L-~Q-~------_____.~~__.~_---..------~Q ~ i
; 7T- ~s.e with me
I This is to certity that the iniormatioa here gi~en is carrectly copied from an origin~l certifi~:ate of death duly flled
~ as Local Registru. The origina! cutificate will be forwarded to State Vital Statistia, Harrisbur6. pe~sYi~~ ta
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