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This is 'to certify that this is a true copy of the r~c~~rd which is on file in the Pennsylvania Department of Health, t'~ "
in accordance with Act 6G, P, L. 30~, approved by thr General Assembly, June 29, 1953.
,,..t~ ~ . 4+0061
(Frc for tlKs cerii~tcat~t• s2~~
i- : - - Leonard Bachman, M.D.
WARNIN~a::Ct
is-illegal to clpplieate this copy by photostat or photograph, Secretary of Hca)th
- MAR ~i 4.179 ~-39,3
,Dat~° ~ No.
- :ti'- ~'~ED'AND RECORDEd
- 4~4t)061
'79 AFR 6 AM . 11: 12
Ht05.ra3 REV- 5-72 COMMONWEALTH OF PENNSYLVANIA
LOCAL REG. NO. "j DEPARTMENT OF HEALTH - - • ~ -
PRIMARY ~ r VITAL STATISTICS ' ` -
a~sT. No. ~ ~ CERTIFICATE OF DEATH '
DEATH a. Cou ty -City or bor ugh 2. DECEASED'S a. S~eet or Box Number
OCCURRED ~ ~ `'p` gDDRESS ~ 'a
IN:
c. If death did rat occur in City . b. Po t OHioe, ate and Zip Code
or borough, give name of township
(Do not use R.D. or Box Number) S
i
d. Full Name ? 3. VETERAN 1 Yes ? No
of Hospital S l~h r~li J
or institution (if rat in hospital, give street address) a. Which r b. Serial ho.
E DECEASED a• ( 'rst) b. (Middle) c. (Last 5. DOFTE (Month) (Day) (Year)
(T or int) T ( b DEATH o
6 WHERE DID ~ ~ c. Did deceased live in a township?
DECEASED a. Stets ? Yes, deceased lived in township.
ACTUALLY - ~
` LIVE? b. County ~ I 0 No, deceased lived within actual limits of city or borough.
I!
E 'r SEX 8. RACE .MARRIED NEVER MARRIED 10. DATE OF BIRTH 11. AGE (in years 1 under.i ar 1f under 24 hours
j ( ' WIDOWED? DIVORCED ~ _ stb~rthday) Months ys Hours Min. .
n,
IJSU OCCUPATION (even if retireid) 13t SO~IAL SECUf~I ~IQ 14. BI CE (State a foreign country) 15. T~N.pF Y1'HAT COUNTRY?
j , f'` ~ ~G " O~ v 1 (C''~1
~ t 6. yFt.lt;i. AME F S~ ~ 17,E MOTHER'S M N NA~
i t ,F~i'.~ ~%,~r~ tit f~ ';'~~r.P(~Ft G: Li
' t E_;/\THER'S AME 19.1 O MANT'S ME. DDRESS AND Z P COD(iy
t ~
~J E DI CAL CERTIFICATE (Items 20 through 23 must be completed by physician only) INTERVAL ETWEEN
+ r ~ - ONSET AN DEIFTH
~ 20. CAUSE OF DEATH: Enter only one cause per Ii for (a), (b) b (c).
PART 1. Death was caused by:
IMMEDIATE CAUSE (a)
Car.ditions, if eny,
watch gave rise to (jZ /
=hove cause (a) slat- DUE TO (b)
mg the underlying DUE TO c ,
c~~se last. ( )
F:-RT Il. OTHER SIGNIFICANT Cbf~DIT10NS: Contributing b death but not related to the inxr~ediate cause given in Part I (a) 21. W AS AUTOPSY
PERFORMED.
Yes ? No
_ a. ACCIDENT 22. b. DESCRIBE HOW ACCIDENT OCCURRED 22. c. TIME Hour Month Day Year
~ Yes ? No? OF m.
ACCIDENT E. T.
~ ~ ~ d. ACCIDENT OCCURRE 22. e. PLACE OF ACCIDENT (e.g., home, 22. f. CITY, BOROUGH, TOWNSHIP COUNTY STATE
{ while at Not while farm, street, etc.)
work ? atwork?
~.s I heresy eerti t I attended the deceased and that death ooairred from the
mouses a~oq the date storied above .EST.
a Signat~ b. Addres9~w~~u ~ c. Date sign ,
{
i 4 HURI 24. b. DATE 4. c- NA.NIE OF CEMETERY OR CREfY1ATOR 24. d. LOC~TiON (City. 8oro.. Twp 8 y) State)
CREMATION Q ~ r'
REMOVAL ? t..~~r,_ "lam ~l. Coi1~F_ "•F. ~r^ic1~;~1t ~~(')'.i l~r !~/ti . Rr~c.
; D<,TE RECD BY REG 26. REGISTRAR'S SIGNATURE 27. SIGNATURE AN ADDRESS OF FU E)iAl DIRECTOR„
~ ~ 7G . S.S. No.~-}e ~ ~ ; ; • ~ .l . ~~,/,~~1~`,~~-, , ,
-
a ~ _