HomeMy WebLinkAbout2602 ""S 306'~OS
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This is to ter6fy thaf the follcu•ing informahoq ~ t eD ,(rom a certificate lr ~ 2 9 9 0
of death filed in thr Division of Vital Statistics. Pcnns~+ISt~fii~~tQart~nent of Health.
ac directed by Act G6 of the Grneral Assembly, ~;•j;. ~y~j
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. . . - • . --ISacr~tory of FI~ahA)--
C~ ~FILEa ATi~ PEC0~9Ed ~ ' :
.~Q~ST.IUC;E COUttfYfitA: ' : -
3~ ROGER ~~i7tt4Sr t ; ~ . ~ _ .
CIERK ::nCUIT CQU$T- ~ " • '
RECOR~'J VE=::FIEI~.~i~~
•j~!Vy/EAL'TH ~~F•'BENNSYLVANIA File No. g
Pri?rary • DEPARTMEN~;pF H~i?LTH - `O
Dist. No. 1 t VRALnSTA~~S S
~ fif~-E3 t--4~ ~~ERTiFIG~1~'IOl~' ~ DEATH Rc9~stered No. _ _ ~'D~Q~ _
i. D.•ath a. Coi:nt~• ~"Deceased's
Occurred a. Street Address
In: ~ ~ r ~ Mailing
' ~ S~ - Address
` b. City or Bor-ugh t~'~~- '
~ - n b• Post office. Stat
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- - - - - ~j~~ ~
~ G T'ou•ns6i -
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3. Vcteran
es ? No p
' a. Whi.h ~'Var . _ _ _ b_ Serial No.
~ - _ _ -
4. Name af a. •irst b. hliddie
-Deceased ~ . ~St ~ S. Date R{onth Day Year
n`~'~ of
- -I_1_/~ ~ y Dcath
6. Scx ;7. Racc ~8. Married S~~'~'s~t~_----~--------~~- -u
~ Nrver blarr~ed
~ ~ 9. D~~te oF Birth i 10. age (in Yrs.' ~E Under I Yr.;If Under21 Hrs.
last ir a
T _ / _ t ~ ~ ~'Vidau•ed [1 D~vorced ~ E ~ thd y ) Months ' Days ~ Hours ! Min.
- - 1~~~' ~
11. Usual Occupatian (even if Retired) ; 12. Social Securit • Number ' ~ - -
'~y~~C~! ' ) i 13. Birthplace (State or (4. Citizen of What 1
! F ign untrp) , Country'
, 1~~1f ' ` ~ jls,~~j; ~ ;
15. Full Name of Spouse - - - - - _ ~ - ~t r ~,.c _
= ; 16. l~fothcr's ~1ai~~ Name
t _ _ `~2Cz _~~?">?~u,o : n~
17. Father's 1~~ - ~ -~l
~ - . _
-
- -
-
~ V 1. Informant's Name and Addrz~9
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19. . Buria~ ; i9. b. Date ! 19. c. Namc of Cernetery ~r matory ~ 19. d. I.ocation (City. B~ro., Tw•p f~
~ ! f- t Y lState)
~ - - ! ..~-~1~_.(~_- '
?0. Date Rec'd by Reg. j 21. Reyntrar ! 22. Name and Addrcss of Funera! Direetor
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~ 800K~~8 PAGE259V
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