HomeMy WebLinkAbout0830 . ~ 430~'~ .
~ WARNING: It is illcgal tu duplicatc chis copy I,y photostat o~ photagraph.
O CT i 1976 ,~4,~; ~
Oatc ~ No.
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'fhis is to certify that this is a true co~y of the ~ecord whicii i3 on file iri• the Pennsylvania
I~eFartment of Health, in accord.~nce`rvith Act 66, P. ,L. 3Q~; approved by the General
Auembly, June 29, 1953. ' ° ' ~ ' ~ ^
~ . _ _ ~ ~"A ~ ~ ~ V
(Issued iree on milit~ry stztus} , -f.' = konud Bachman, M.D.
~ ~ ~ ;:~~:~n~ Secretary of Healch
t ~ Harrisburg, Pennsylvania •
- , ~~+os ~~3 R~~ 3•:3 ~ / COMMONWEALTH OF PENNSYLVANIA
~ IOCAL REG. NO. OEPARTMENT OF HEALTH
VITAL STATISTICS
D ST, NO _ %c , /'~~C~`~
' CERTIFICATE OF D~ATH
t D[ATH + Cay{nty b C~y or borough I p. OECEASED'S • Stre~t add~~ss. R D,'o~ Bo~ Numbs~
OCCURREO ` MAILING Q
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' 4 NAME Oi' s(F~rst) b(M~ddt~1 a(L~sl) S DATE (Monlh) (Oay) (Vea~)
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b ur,~' reign ~yynt~y)VIS C~TIZEN 9i HAT CUUNiHY
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i'AN f~ [~nath v~as c.+u~rd by •
InAA~EU~ATf CAUSE Ia) -
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~ a nCC~OE~iT ~ 2? DESCR~BE HOW ACC~DENT OCCURREO ~ f 22 c TI.L1 Fkrur MonIA Day Year
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: d 4f.GlDElVT OCCUNREO ~ 22 e PLACE Of A~CIDENi (tg . ~ome. iyQ. GITY. BOROUGM. TOWNSH~P COUNTY STATE
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