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t~OO Cert per book> ~ COMMONWEALTH OF PENNSYLVANIA
' CERT~OCA E~ s2 00) ~17Fe~ll~i1~/ DEPARTMENT OF HEALTH O
VITAL STATISTICS Ir.. 804171
' LOCAL REGISTRAK'S CEATIFICATION OF DEATH
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FuU Name
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; of Deceased ----•---•.{'!^1L1~~~~_~___--------------- -•--•------------------._._.._---••~'~-~'-ti}~'(~-----°------°-••------
iddN LaN
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Address ------•----l._.~
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Place of ~`7 ~ . _ Pennsylvania
Ckath 7~~,~J!'~d"Y``."~~---..__.__.--------••-----~•----•-•-••-------•--°--•------ v't
il Cih. ~«N? a Te~nNO - ~h .
' ' ~ -°----__.Social Securit ~7~---4!~.1_ ~5,~ y~..Racc._~_.ll.Ld
~ Date oi Dcath ----•--°-~-----5-=~---------•-- y No-
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! ' Marital Status ----_...Sez__.~~•- ---~Date of Birth---------•--...---•--- •-_••-•.r--' - -
f ~ Occu tion ~ ~ ~ ~ = ~ - Birthplace ~~~~~~L. j--!_~'~".:..._.
! ' Pa - ---~-°----------•-------------..__.r.
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: (f Veteran. which War _..._....__...`_"_J_-.~- _ .--.-.-.Veteran's ~rial No. ___Y..~~_~~~~
• MEDICAL CERTIFICATE Interval Betwccn
; Pa:t 1. Death was caused by: Onset Death
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: Imm~dia:e Cause (a1-~~~...~~~`~~C~1%_5dr'`.^.~!~.L-.-`.~!'1-• -l-'~'-L~-a=---!---7C----_..--••-------•------------... ---1.._..~~
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' Due To (b1---..._....-~------------
~ Due To (c)-----------•---~--°••---._._._...____...------••------•---•---- ..............W._..---•----~-•--__-_.•---.._.__._-------•-- -----~.__r.._.~_
Part 11. OTHER S(GNIFICANT CONDITIONS: contributing to death but not related to the immediate cause given in
' Part I(a) i1lE~ AND RECOROfO
~ : - - - - ~ ST:LIICIE GOUNTY fLA.
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= ~ ___.How did m'ur _ CLERK C1RCIlIT CCUR?
~ . Accident. Suicide or Horoicidt ' 1 y occur R......:._a-Vr-F+~IF$•...~.~..~--+
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: Namc and Tid~ of Persw~ - ~~Z:.C.(r _`i/~~~~------•-•- S~~
Who Certificd Ca~ue oE Death (M.D., D.O.. Coroner)
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. : Address....------• - - ••--....._....-sti..~---._.._._.._._..__._..~_.---------•- •---~_._~u!'~_`.~`..'.`__.~_t--~~2-•--------
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~ : This is to ccnify that the information hcre given is correctly cop~ed fran an original certificate ot death dutyfiled with me as Local
~ . Registru. ?he vri~ina7 certificate uili be (orw~arded tu the State Vital Stanstia Office for per anent filing.
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