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WARNING: it is iliessl to i~olicats this copr br Phoeos~ar or pho~ogaph. •r
N10511?4COM REV 9-7A
:tOOCert oerbook) COMMONWEALTH OF PENNSYLVANIA
- 33~225 ~~P~ TALESTATOISTIGS LTH N o 3 9 3 0 9
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LOCAL REGISTRAB'S CERTIFICATION OF DEATH
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Registered No.
FuU Namt
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Address ...~s---~l--~~~~.!•i-~-~--.~~iti__._~~.~.~~~~~?~?.7.7~~~.__.~~~ir~ ~.a.______.
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Place of ~ ~
j Death - - -.Ci~--~--~.#e~bu~ --~Q~Y---~_!!~~_......•----.__ Penosylvania
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~ Date of Deaeh _....._._JUI~~.t_T.•_1__~~~.___- ----------------•---Social Security No. -
i 9 --~~•-~----...---._Race------ •
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~ Marital Status - ----~--Se:.-•--.._.F~.~-.._.._~.Date oE Birth---------•---•--u--J~~'~~---+.7~•----
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` ~ Occupatiun . - ~ - ---~1'~~'X.-••--•-••---- •-------•------.Birthplacc ---.......~ti~bLil"~}~0~.1~----
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i ~ If Vcteran. which War s--~--•----...- - ~ _ ......Veteran's Serial N!! .s-----------.....-
~ I 1~fEDICAL CERTIFICATE interval Betweea
~ j Part i. Dcat.ti W;as ca„9ed by: fIlEO A!!Q REGORDEO Onset aud Death
fT. LYCIE COUNTY FIA: ~
' ROCf~s 'O~SAAS
Immcd~ate Cause (a)....~tB~~iC...~!'~~te._.----.---.--.--.. .._.CLERK-ti+~CWY•CQIIR2---~----•- -
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; Due To (b1. _.~BBI`ti--.YE~.1lZ'0--------~--•- - • " ~ - ~M
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a I .~~~--r-----~Q--31 ~'7~------,-- -
~ Due To (c}..---....~•._~.u~__.~_~~ZLlT~----.._..... -
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Part 11. OTHER StGN1FICANT CONDCTIONS: contribut~ng to deat6 but not related to the immediatt cause given in +
Part I (a)
~ ~ StAt.us P!OS~i Rsa9C'l.3Ct1t.. ab~~•~._ a~2't.iC_
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~ ~ Auidrnt. Suicide or Hom;c~de How did injery occur -
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; ~ Name and Tdie of Person ~
`r ~~Vho Certificd Cause of Death (14i.D., D.O.. Curoner) --......---.J~--~-*---ROb1.I~/~~-.-K~D~...__
~ ~ Address St~.-• ~'~:~.-~~.__Bospital..-- -------Pittabur~~.
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; This is to rrrtif} that the inturniau~m herc g~~~en is cvrrecUy capied from an oriKinal certificatc of death duly filed with me as Local
~ ~ Rcguttar. The onginal crrtificate wil! he f~~rwarded t~~ ihe State Vital Slatist~~s O(fice fur ~xrmanent filing.
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~ ~ MRS. J. W. 90NISTALU luel bpisUw of Vi1of Sbtit~cs D~~aic~ Ne.
~ 421 ROOSEVELT AVE. B~L~Ja' BaAOUGH ~Z O~3
~ ~ PITT38URGM. PA. 1S2Q~---------------------•----°--•.~...--•----•°---•-•-----••--•-•-°-•~--
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~ - Oa~e of luw of tAi• Grtifico~~ow
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