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HomeMy WebLinkAbout1239 , ~ , . : _ . _ . . - . ~ . ~ ' . ' . . . : . _ : ' . . / . . i - - wa~rnxa: i: ~n.nt to aq~.a u~ ~p~ ~•~«e.t.o~ r~v+~. ~ ~ ~ - . t~os.n s-i ts~t ~~s . - . - ' !!i Cwt. ~ee i~t) ' CO~IiONR'F.,~LTH QF PENN3YLVAYIA ~ • : _ . ° _ _ _ ` DBPARTaiENT- UR HEAL7'H . . : ll~+ t~e tii ~ ' u...~ = - _ : : . - vrr~~. srATrsrics : = - ~ I~~ 2104 5 0 ` ; _ LOCAL RI~GISTRAIt'S CSATIFICATION OF DgAT~ , ; . ~ _ ~ Re~~atued Na s M o~f ~DeNi~.e~ d _ _ , ~ . ~ . ~s.~ - - - - As~`' ,y~6~...- . J _ ~ .2~, 3 ~ 'a'ense a... - . ~C..sss ~w` ~ Plue _ - . - . _ . _ PeansYhaa~ $ Deatb _ t . CrYb ~ ~ - - Qib. ll~ewsti K 7rwa~F1~ - ' - • • . . _ - ~ ; _Date oi Death _ ~..~.~1.!~...s.L._0 ~:l .C.a~ 3oeial Secaritp No. - d..~~...'-' .0~~4~ ~ ~ _ y...._. ' ' ; . _ ~ , ~ - , ~ x.~at st~ _ . _ na~ or B~b 1.:: ~ OccapaNon~.__ . . BirthDlac . ...s_.,..__....._._._.~..........._......._ _ ~ . • ~ It Vectrsn, w1?ich Wsr Vetcraa's Serisl Na MEDICAL CERTIFIGAI'E -Y._..^.~_.... Inteival Between Part I. Death wss tauaed by: Onset and Destth 7mmedi~tte Csuse _ . _ • - . . . ` Dne To (h}-.~`~-.(,C~Q.~I.~~~y t... . . • ~ f , - . Due To (c) . . part IL OTBER SIGNIFICANT NDITION3: contributing to desth Dnt not selnted to the imtnediste ranae Sivc~? _ in Psrt I (s) . • - • . . ; Accident, Suicide or Homicide ....._.---..._...__...--•---•....._.........~..How did injnry occur ~ ~ ASame ard Title of Peraon • " ~ . . t Who Certified Cause of Death (M.D., D.O., Cornner : Address _..._.._...-•---•-••-•-----•-•----~sir.ei . . . _ . _ . i . cur~~~ This is to certify that the information here ~iven ia correctly copied imm an origin~l certificste of death duly rled 1 with me as Local Registtar. The originel eertif~cate wiA be forwarded to 3ts?te Vital Sta~stics. Harrisburg, PennsYlvania for permanent filing. FILED ~ti'~ AEC~?DEO• - . q, sT. LUGlE.COUMTY FLA . L • ' RGCc',• ?fr!.RAS ._...a~~.~- .i~i.~~..... . . . _ _ CLE~R Gi'~CUiT COURT .r vu,i s~.~+.~+d x•. FC~+A~ V=F.'F~E~ ~p~ ' • " - .~l!.-.~.-, t0 3 3Z PK'7~ . ~.__a•...~.~.~t~. str..~ wa... a+s. w~.:r. T..w~. vw 2 I~~`i~.~................_..._....__._...~~.t.---••~-..._...---------._.._. 19 • • ' _ a`~ \'`~t, D.e~ ~«.i..a rs L.wl ~nr - • ~.j~_... _ ~~~.w ~ • d7~K~~ V : • ~ Dat~ Lw~ ~t 'i1b Certi[MrtiM ~ {~~i _ i~~,\IW - • • - ~ . . . r ~ , ~ . ~ "~~u.~~ ~_-'~~°s ~.~~z ~ i . . . I ~ ,;,a, , , r~s r~-~ ~ . . ~~~~.~~~~~~s~ > _ _ ; ~