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WARNING: It is illepal to dupilcate this copr by phorostat or photo~raph.
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t~~ G~• D« . COMMONWEALTH OF PENNSYWANIA j~~
DEPARTMENT OF HEALTH '~"~~3
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CMificoN SY.00) ViTAL 8TATiSTIC6 ~ T~ ? O n~~s ~
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LOCAL REGISTRAR'S CERTIFICATION OF DEATH
` Registeced Number ~ -
' Full Name •
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Address ~~03-~----h-t..~~~---_f~_~1_ f.~-
Nwwb~r Skwf Cit~r or tmrn C StoM
' Placc of - ~
~ Death -~d Q-3---~t~t.ll~----.Q_~;~` ----------------~O-•eQ~~~~~___------~ll_E;,~1'~~~~ Pennsylvania
titY, ovph u ToweaNP CouaM
~ Date of Death ~~PT ~~-LQZ~_--------------.Social Secwity No. /~_~_QL=___~~~~__Race .~lT~
~ Mazital Status _~1`L~3_~i'.L~~~--~________.-----_----------Sex ---__/1?,tg1E__.~_Date af Birih ~22Lt~~~ ~.L~!
;
E Occupation ~'all.__.~~P~.~ ---------------sircbp~ce ~~~rn!~~~
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± If Veteran. w•hich War _-----~u_-.-- u-'-: -_---------•------------____.._-------Veteran's Serial No. ~4~ ~
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~ AfEDiCAL CER77FICATE Z°t~rval Hetvvan
~ Part 1. Death w•as caoscd"by: - Onset and Death
~ .
~ Immediate Cause (a) ~~S:F~~~P1`1.Td~~C.._1.eL~~?
~?J_`1~1 ~L~/vc~1 ~----~~_..._~_~_______w
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Due To (b) ~F_~_I~RT--F/-t11s~~t=---=-- ~•r~~~'~1f~,~~__
Due To c~~ l~Rr~t~-~~.~~1~~ os~,,f
~ Part li. OTHER SIGNIFICANT CONDIT[ONS: contributing to death but not related to the immed~te cause Qivsa in •
~ Part i (a) ~
~
~
~ -------------____How did injury occur ,
~ Accident, Suicide or Homicide _ -
~ :
E~! ' Name and Title of Person ~t~
Who Certified Cause of Deat~~,D?, D.O., Coroner) '
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`Y Address .fLL'~" '
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~ This is to certify that the information here given is correct{y copied from an original cutif"~cate of deaW duly filod with me
~'x as Local Regiserar. The original certificate will be forw~arded to State Vita! Statistics, Harrisburt, Penrtrylvaaia for petmaaent
~ filing.
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