HomeMy WebLinkAbout0889 3~6`74'7 / . "
V1tARNING: !t is illceal to duuliczte this copy by photo5tat or photo~~aph. 34f'7~~~ '
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Thjs is to cc~i~r~ti~at t1~is is`.a,ttyt copy of thc record which is on filc in thc Pennsylvania
. t . •
Dcpartment .d~iHcalth~ .in a~cordaiicc with Act 66, P. L. 304, approvcd by the Gcncral
Asscmbly,.~~e.29,1953. - . " .
r
' ` , ? r. . . , . . - , ~ ~T _ .
1 Issued ~ree on rinilitar status ~
~ - Y ) - I.ec~nard Bachman M D
. ` Secretary of Health
- Harrisburg, Pennsylvania ~
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Mt05-t43 Nw- 3-73 COMMONWEALTH OF PENNSYLVANIA ~
LGCAL REG. ~lu. L~'~ DEPARTMENT OF HEALTH ~
V1TAL STATISTICS -y t• ~
o s~
o ~t: r c ~ - ~ ~ 7 CERTIFICATE OF DEATH ~ ~ ~ ~ ~ ~ -i a
;
t. DEATH +~~b • b. Gqr or borouph Y. DECEASED'S a• Strwt ~ddru~, R.D., or 80: Numbw
O~CCURREO ~r,~~~a 1~?~.ti4_-~t~ AADDRE S IZ~ . C ~i
b. Post OfRq. Stat~ and Z Cod~ ~
, c- If d~ath did not oecur in Citr ~ P ;
~ o~ borough. g~vs nart» ot bwnshi ~~`~C.J~K~ ~l~/. 1 '
(Oo not up R_D. or 8oa NumbN) ~_G i ~
j d. Fu11 Nrn~ , ` / 3. VETERAN f YN ~ No. ?
I C} Np~pitl/ ~'l:. / i..l~~ ~l.I.JL+L~ .
~ w insdtution (it not irt hoapW.9~ svs~t addr~ss) Which Wu ~ j~' b. S~rial No.
~ NAUAE OF (Frst) b- (Midd1~) a(l.~st) 6. DATE (Mon1h) (Wy) (V~M)
: DECEASEO ` • OF r
~ (TrP~ or Prinq ~ 1 S~ h / DEATN ~ 5 - S '
F 6. WHERE DIO v v~ o. Oid d~cNNd liw in ~ t slypl '
~ DECEASE~ Sule P L' Q'l~p. d~cws~d liwd in~IS / N 6~~ 'V townsl+ip
ACTUAL~Y
~ LIVE9 b. Count~ ~Y1 ? No. d~eNS~d liwd within setwl Ipnib of titq or bwo~rph.
F T SEX 8 RAC~ 9. MARRiEO NEVER MARq1E0 ? 10. OATE OF BIRTH t 1. A(3E (in M ued~r i r H w?d~r 24 lww~
/ I~tt birthdaY) MontM O~rs ~ Min.
~ ~I I K./r WiDOWED? ~IWRCED ? rllf/T- ol~ I~9G rJ ~
~ 12. U L OCCUPATION ( if ntir~d) ~ipn caw~try) ~u?
19. SOCIAL SECURITY NO. 14. BIRj~'~~~ CE (Suq or ~or 15. CITI2EN OF W T COUNTRY
~ L-G~S~~ //~'/L R v -~4.
~ ~6. FUI.I NAME OF POUSE 17. MOTHER'S ~A/11DEN NAME .
~ K' ~Ak~c..L _ ~ . ;
F
~ 1B. FATl~FSS ~~N t9. INfORwtA S NAINE, ADaRE55 AND Z~ ~DE .
° ~J C /C ~ ~a-,+.,. 3i
~
..c~?irn~ CcoT!c~re7~ rN..,.s ~0 •Mn~.qh 23 m~st bs opmpl~t~d by Qhysi¢ian pMY INTERVAI BETWEEN
20. CAUSE ~F UEATH: Ent~r only on~ ews~ pr I~M tor (bl 6(c)- ~~E 1~?r.D aEI?TH
` PART 1. DNth wa~ qus~d by: ~ ~
~ IMMEOtATE CAUSE (a)_~~~J:~' ~r1'~ L~JL~
~ Cpnditions. i1 u~. whiCh ~
F 9ir~ fisl t0 ~bOV~ buM pVE TO (bl
~ iqOng lM undK•
~ ~r^9 uu.. ~a.t. ouE 70 (o) ~ ~
:
~ PART 11. OTHER S~GNIFICAli4 CONDITiOHS: tonNibutiny to dtstA but not rsl~bd w 1h~ imm~diat~ q~v~n in Psrt 1(a) pt. WAS AUTOPSY
' ~CL~F~ ~~7l GC ~Ll//• ~ C ~ Y«
O RME No ?
e
f 22. ACC~OENT 22. b. DEiCfi~BE HOW ACCIDENT OCCURRED - 22. c. TIME Now IiAor+tA ar Y~
r..p nop oF ~n.
ACC~OENT E- T.
' 22 d. ACC~DENT OCCURqE~ 22- e. PL/RCE OF ACC~DENT (~.y., homt. 2p. /.•CITY, BOROUGH, TOWNSNlP COUNTY STATE
' Whil~ at Not whiN /arr~. svNt. ~to.)
~ ~
~ work 0 ~t vwrk (J ~`i ' f
; 23. 1 Mrebp cKti/r thst ~ttend~d tM n~rn~d d~cused and that death occwr sut~d abow ~t / ~~n. EST.
; GQaSSM7.? M~ Y~
_ _ ,t~'~
Si9n~tw~ ~ . _ 7 D.O. b. Addr~~s ~j ~ 7 4.~e. Dat~ sip~»d ~ ~ ~
2+ ~ BURIAL ~ 21. b. DATE 24. e. NAME OF CEMETERY OR CREMATOR 4. d. I.OCATION (City. Boro, Twp., 8 Countr) (SIaM)
_ REMOVAON ? ~~Z v.Z 0 C/'~-LT. T~ ~I~ .i/~. ~ a
? S~ ~'~L C. SC= Y G+ ~ t N'GL~ ~ P
_ 25 DATE REC'D BY REG. 28. qEGISTRAR'S S~GNATUR 27. S~(3NATUHE AND ADDRfySS pF fUNERAL DIRECTOR
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