HomeMy WebLinkAbout0086 4i~~6 ST- 39,198
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' WARNINO: It U~Mi !a ~MaM t~ ~ry ~f ~tMt~! K~MopyM.
H103 11?~OOM REV 8~75 .
ttOO C~n pYr bpOk) COMMONWEA~.TH OF PlNNSYLVANIA ,
~FEE Ff)R THl8 DEPARTAtENT OF H~/1LTH ~
CERTIFICATE i?001 N~ 450778
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LOCAL REGI3TRAitS CERTIFICATION OF DEATH
Re~isteced Na . ~54
F~u Name Anna E _.~•~Bu_t~k~,4_._..__.._.__.._.._..._.____.._
' of Deteaxd
uswt Rll S t~ Pottsvi2lex~ Sch. ~ P nna
Address e •
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N..~.. s..« aa w»•• c,..w sw.
Place of Pottsvil~ Sch.
Death ..._...._._._-------------.._._•-_.Y....___._. ._..._._~.._....._..M._._._._----••--•--•------••_---••-...._......_.. Pen~ylvaaia
an. « T....w
i?ate af I?rs:h 2~.~.~6 _..__._._Soc[a! Seturity Na .---•--•--•--._....r.--••----_.._._..---_._.Rate___..__~1.~c8_......_
Maritat Scat~u Marl`18d.._-----_ ._.___~_Se=__ . Fe m81e----- --------Date of Birth.....
J Ut1,Y_12-~-_ 1_Q 10_~.._.._~._._..___.
Occupation _____.___.------_...._.._____........_.--•---w....__.~_ Petlil8l.
HOL16@x~.f@ _Birthplace
~ [i Veteran. which War ................_.__....Veteran's Seria) No.
j MEDICAL CERTIFICATE Interval Bctvrcrn
~ Part 1. Death was cauted by: Onset and Drath
~ Immediate Cause (a) ..............~~~tcaL~.._~QA~~t.--~l~.@J~l._.--------•------,...._.____..._------.~_.._.-
I Congestive heart failure
Uue To (bl--.-•---•---------__~.._~
n„~ Ta <<~.__.__......_$evere coronar~r arteriosclerotic heart dieease
Part U. OTHER SiGNIPICANT CONDITIONS: cootril+~ting to deat6 but not rciated to t!u immediate cause given in
~ Part I (a) ,
~ .
Accidcnt. Suicide or Homici~+e .-•-•-_-----•--•-------..__...._....--•--._._.._•-_-.._How did injury occur
iVame and TiH~ of Person
Who CertlEicd Cause oE Death (M.D., fl.0.. Cwoaer) .------------..___._.._..-aI.0~1~-~..~BLl88~Q.~.~Is~_----------------•-•-----,----
Address - ~
y~~~~4-__.~....,--------•-
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This is to certify that tht intormata?n hcre gi~rn is correcUy cupeed from an original ccrt;Gcate of death duly filcd with me ac Local
Registrar. The original certificate will be forvrarded to the Statr Vital Statistics Otfice tot pcrmancnt tding.
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twl tN~shar rf YIYI S1sti~Na Ws?kf W.
3~7 Mauch Chunk St. Pottsville .
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~ . S1nM Addr~n ab. M?~sf?. Trwws~y
- Apr
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976._
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~ OeN twiv~d !s low~l blislnr
Apr. 28, t 976 19---•---
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