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H105 1 t 2~ODM REV 9-7~
: tto0 Cert. p~ poot> CpMMONWEALTN OF PBNNSYLVANIA
~ a~ DEPARTMENT OR HEAL.TH N~ 2O 3 Z{~ Z_
VITAL STATISTiCB
LUCAL BSGI3TRAB'9 CTEtTiFICATION OF D~ATH
Rc~tstead No. ~
Full. Name __1~~ ~ _d'~
oF Drcea~ed ~
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[,isaal ` Q>
Add~css _ _._...___._._.._!'._.._Y._._
H~~b~r Oh ~r fe~~ ~~~e~~~ Steh
~ft Of ` •
Dtad1 _ ._._.~,~E P[ODSy~V.'lnii
G?r. ~r i~~wslJS Gwb ,
Dace of Deat6 ;.ci~~.../..~..Z~`__._.._.Social Securiry Na~~.~~.~1_`:_.~P_~~.~_..R~_. s~~._
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Marital Status---..___ .w_.___e _~Sc:_..~~:~~`_~~...---._._Date of &rt6.:_~~.._.~s~.~.,~~~..2_.........__...
Occupation J _ _ .--•----•__fl~Je~fl.Y_'Q-11 :....._.._.Birthplace .._._».r._....._~._.___._~,._.~
: If Veteran. vvhich War ~-fJ :.~'_.__..._._._._.._..•----••-----•----_...Veteran's Ser3al No. ~
MEDICAL C~RTIFICATE Interval Bctwecn
Part Death was cau9ed Oaset aod Death
; - _ '
, Immediate Causc (a 1--.._ - _ .
Duc To (b)-------•-•.~...__._.._,_._------__
~ Due To (c)_-•--•----•------._.__.-------~-----------•---•----- -
Part li. OTHER SIGNIFICANT CONDITIONS: co~uibuting to death but not relatcd to the immediate cause givrn in
; Part I ( a )
~ Accident. Sutcide or Homicide •---°--•------....__-°-------••--•---•-----------.How did iajury occur .--••-••~--•--_-w...•-------_._-------------.~_....._..
Namt and Titk of Person
V1%ho CertiEied Cause of Death (1~ D.O.. Coroner) ----.~3..._...~
Address...__.~~..~_~__._.~:!!a:'!c*_'!~.. ~ ...____.._._..._.Y' .~Y QG.`_~_
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~ This is tu certi[y [hai the informaticm hare gi.~ert is corrrctly copietii irom an originaf ceniticatc of death duly filed with mc at Local
Regist~ar. Thc original certificate w•ill he (orwanlcd to tht State Vita1 Statistics Otfice for pecmanent Gling.
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f~LE 0 AIF9 RE49NOtU '
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