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HtOS 112 4QiM REY. P-Tf
' C°~~ ~O°~`~ COMMONW[ALTH OF PBNNSYLVANIA ~
DEPARTMENT OF HBALTIi N~ 2 8 O ~ 2 7
SZ•~ VITAL STATISTiCS -
LOCAL RSGL9TRA~i'3 CBI~TIFICATiON.OF DEATH ~
. . Regiatered No. ._._..._Z
Putl IVame yI 1 " , . . - W
of Dcccased W~~...~.._.~_.r....._...._.__....~..._.__-----.~_.~..r__.__ ' -
ws~ • x~en. ~ ~ t.a , . ~
Ad~dress I ~..~~u`!~~__._~_ - - ~ ~F`,S~`^,~~_ !C~,~.r'tr'~.._ ~,.~!?~s-.ad`~..
N~.Mr Str~N GM « t~.~~~ ~ ~ Cewb "bbh
Ptace of < . - . ~ ~
Death _s.~~'-~^_.~ _ Pennsylvanla
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~ GM. M~+M6 ~r T~ru~ , Gv~b _
Date Qf DeatFi~ ~~~'~P--rZ..~._.Soclal Secu~ty No. l_~'...3.-L'~~--..3~-2..~?_._Race..~.f~'~?-~____
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Marital Statw +LT~. ---.:------Sex-. ~~__.~..._._._Date oE Bi~rC:~_'
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Occupation`~Wk!~'~__:_._ . ' ....._..__Birt6place
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...._._.Veteran
s Serial No. - ..~~v
I[ Veteran. whic6 War ~---1-~------------_°-____~____~-.---_•--~- ~ Z ' `
MEDICAL C:ERTIFICA'IE - [nurval Between
Pact i. Death was cawed by: - Onset and Death
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, Immediate Cause (a)_~.~y ,t~w s•r~~
i . 7 ~ _ ..w._.._.._._.._.___~_~__....._.~__ . -
~ ( Due To (b?-_1_~~ ~`~~"~r.~_------_.w.-- '
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: Due To (e)_._..~.__._._.__..__.._.~__._._~.._~..--------------_._.._..w.._._.___..__~_____._-----.._~....r -
~ Part ti. OTHER SIGNIFICAIVT CONDI110NS: coattibuting to death iwt eot related to the immediate cause givea in
~ Part I (a) . '
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' Acciden~ Suicide or Hantcide .................._._..--••--._How did iniury octw
~ Name and Titk of Person ~ ~ ' . ~
Who Certificd Cause of Drath IM•D., D.O.. Coroav) ~.•'~'7Fi~':-~--_~..__
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~ . This is to ccrtify that the information here givrn is cvrrcctly copied irom an original certificate of dcath duly fiied with me as Local
~ Rcgiuru. The original cercificate wi0 F+e torwarded to tht Smte Vital Statisties Office tor permanent tling.
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