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HomeMy WebLinkAbout0061 ~:3s4o~ ~ , i ~ . WARNlNG: It is il~c al tu duplicatc this rupy by photostat ur ~rl~~~tugraph. _ Y ~8--- ~ _ ~ C. (c, - . _ - Dat~;c; Na , ~ ~ ~ _ ~ 'fhis .is 4o c~ctf~j~ -tT~at' this~i~~,ri^`t~ue copy of che record which is on filc in the Pennsylvania ncFaitment 'of~ Health, i~ ~4~e~~nce with Act 66, P. L. 304, approved by the General : ~[LE~ f~ECQRDED rlsserribly; jqrie 29, 1953: ; . _ „ U`JTY. F~ , ~ ; ~ \~~J) + ' f l . .T+ ~ ~ ~ . , - . V (Issuedlfree on iq~}i?3~y status~ ~~0~ ~onard Bachman, M.D. ~ ~79 FE? L7 ~ i 23 Secretary of Health ,y~~. HarrisburR, Pennsylvania COMMfjr.WEALTM OP P~NNSYLVAN~? . OEPARTFfE'~TAr'NEAL?N~ . v~Ta~~SLai~{F!c;s ; ~ ~ _ . CERTIFICATE OF ~EATH ,:~.~ARY DIST. NO. ~^~t ~~LL_ STATE FtLE f~0. •.~~~c of e~cws~d IFi~stl iM~aoie) tuatl S~¦ DateGi oNth 14o.~0ay~ Yr.1 . ROBERT 5, BLAI~~FORD ?tSALE ,,OCT.14, 1978 (~.Q. Wh~U.Bl~ck, Ape~~ttO~nhd~{ [f under 1~- ~i u••.'~.e~ G~teOtbv~lf $!cir t~ f~•' i.our.ty e' b:rtn ••~rc. Cr iv.Y. oi ~Ma.~DaY• Vr ~ cccn~ry r~~u~ ~nd~~n,etc.l (V.~.1 Mos. •rs Ho~rc ~f...' ~ ~"'y~'~ 1 'iJ ~ i F c~ ~ca ' (Sr t ~FEt 'i,' /Y~•'i 6:i. `t.l~` ~C_ ~:.:w' !l ~.l; Lc,~7~~7 ,;I deofh C.'y, do~o, c~ T..p. oi dear~ ~iosp~'oi cr :ns~.-_••c- ~'f -~~e~~~e., g~~e st~ce+ •'-es_. o• ms•. ~na~cc'e DOA, cjdressi = =Q, or inpct~ent (spetify) F:RIF: 7s. ERIE CITY -c.VETERAI~S AL~~iI3~1STRATION bfEDICr1I, CEAITF.R ''=-7!~TP ~~I . , caress :5'rcer n{ii No.) :C~•. cc ~S>ax ~Z:p lcde; M~naa 5:~;~a Sur.~unp Sco-se +I~ ~n~ie. p:ve R~.Cen ram~1~ ' L'L-i1.~~1 h~,~CL~ F , ~ ~ ~ ~-i K F= ~ • . 9.~1 't :o _ ' ~ i t A~s dreedent evr.r ~;S A~ne. ~i,rces' Scci~~ Se...~Ry h,:mta. Us~sl Oc_..~' 'KmC of work oene C..• w.na ot b~e.netto~ ~naustry :r~ O Mr~~lSC4u t.y. ~ ~Yes ?No Sc~:cl ~:o. 7 ~n~mostot..~c•. -3f~t~1 ~ .5 %~F~ tf L.t 12. C. ~ ~ ~ l',' ~~t! / i< ~C' ~ f - ~3 14A 'T , - , i • =~d a ~~a~~ _-FJq ~.d deceosee ~~~e ~ves, eeceosed I~~ed ~n ~~1 Vs~a~(~Y +o.•nship. ~ c to~nsh~ ~ i t~~e~ b. Caunry ~ u~~L~-lt' ~ ~':•':o. deceased I:ved w~!h~c c_•_:' ::~*~:s o} c~ty er bora ( - ~ . ••'s ,~~ne (Fnt) !M~da~ol llu~i Mo:e~r's m~ae~ r.ar.~ = •s:! IM.GC-e: Ilas~l ~ _ ~ C ti' ~ 5~ ' ~t.t.. . ~ , ~ /il ' ' ~C - - u.'.q ~ h~ ~ •^.n~~n:'s n~rr» lTypO or Printl !nlorr-rantY - :j••tei o• iii-D No.) lG:.,or ;Cwn: ~S:a-rT (2.F CCCe1 ~ , _ M~~.ny~Od~ess, ~ _ ^ ~ JI -INA.;'r_ (~j~~;~.JFCr.t~ :Pe ~(~rv At, _ *qiC ~ 6 JIG_ .k: Bw~N ~ R~moval Gu~ o( 5una~, etc M~-.e at csmete.y o~ c~e^6~orv Loutwr. (G:~•. ro•a. :wo ~ ISt~~e: \ ( l {~EiE'~-k~iv ;?J/~ ~~Cr~m~tiOn~Other , B.~ ~7 i41~ 19C ~~JI -h~7Lvf~ ~ -.'~~i. ~ ~~LJ~/LrJ 190 ,1~~ li` ~ ~ ,;~.e~..:r~ ollune. I d:.KtO~ ~~a I~c6n~p n~:mb~1 h~:T~~ ~RC ~CatY{~ Oi ~ c:e eauc:+a . ent ~ ~ . - - _c_ ~ l~,.L(..~..7 c~. ~ca~s I: :z'~_. C ~ .~i~s"~S.yn~co.e'' Gete r c. a by r~p~~t.a• ~afC ~.~..~1L~7:' ..L.st'~ c~ rJ ~ / '.L.4 / 1~ / 4t/ .r} . ~ 208 ~~/l-1d.iC/9(:~% /t-'f" ~ , ~ To tbe be+t o1 my ~knpwllAQe. ~feec~ occu.reC :ne t~me. da'e, a~^_ , ~~ce o G Gn tna Ds~ + Oi t~t~-..~.~+~On ~ndlar ~nvest~pai•o~ my oC~mo~. tleatn cc.urred ~ : anC d~e to the cwte(A N~tad. : J p at tAe [~m~, dat~ ~n0 c~~ce ~nd due eo t~e uuse +1 s'~ted ' ~ ~ ~ ' J S~pn~~u~! ~ C e V S:~'+~twt :?n •r.! n~~e 1 i / -""?i ` o - ? )a a~~ ~~ae ~ - 1~ ,s u-_ Ja!e s4 ~r/o Gav r• 1 Nou, c~ " ~ 1 ~~^L~i lu~'ai~ 97S tio..~ o~ _ a „ _ ~ _ -~r . i _ ~ ~ : l 5 EDT - f : ~.r,,, . cta:~ ~ ' i2B. 22G ° M = = 1:f8. 23C. ° ~ _ ;r N~mo ~rW AEC~~st OS uryit~E~ (R:ys.c•~n, M.M.~u~ E.~-n+^a~ or Cc~onr:: {p:,r; or typ.l '.am~ o~ attendinq phyi c~en ' * .~,TIN K. MITRA, M.O. VA MEOICRL CENTER ERI :5 SAME ~ - (tnme.•ete uuse: Fnte. pn:y o~e ca~te cer i~ne ~cr cp, ~3: enA ;C: (~^~ry~~ a~~^ ~ I,~,6P,O~CNOGEtSIC CARCIhOl~A ~°~~U1~~I~S"`~' r..~ f~"a tn, or ae r co~se~uenc~ 01~ ~ Int~rva! eeM«n ! IF)) ~ OrMt M.d dNth ~ ~ Uuf t0. O~ 1f 1 COn~tObM[! 01: ~ InbfVil OtLWMo ; OIIML M1A C~~111 ~ 'C~ ~ - _ Wss us~ ~~t~•reC co VeO~ca~ ~b~t ~+I. 71fi~r 5+4^.~~cant Co~~d~AOrs - Co^~! •~ons ce~t••~..c~^~j IO dFilr~ '-.v• •!~J'P.7 LO Cluf! t.ren ~.n P~rt Au~oGS~ ~ r Earr..ne- o. Co+onsr~ ':OR ~ ICAL CEREBRkL ATROPHY , "X~ No 23. e: L. o p p _.:~c~de,Hc^... ~jr.c~et.jOat~ ot ,n~..~y lMo..::av. ~'e•... e.~ ~ y Oes..~bw now ~r.~„•y vcc..•:eJ V T. cn1 ~ ~ • }nvez~. ts.'cc•~v1 ~ i V va~`r Vi . ~ 79P ':r3C - J9D ? , st wort • PleCe et .n~u~ 4t ^G^~ t. ' S' r~T. l c'..~.G^ ~,°-~treci C• '.O 1 IGtr. 90~0, or T«p ) ~ tr.e. Sc r~ • y _-f. . ~ec A. i,~~.:c ~ 19(. - - - ~ , _ - . ~ ~ , - - - - . - - - ~ ~ ~.M ~ ~s"a ;''T.~~~~. ~ r -~,."~.^.a _ ~.k......~ ~ - _ ~~.~.'??~r' -