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~t~ G~t e?~r book) COMMONWlAt. Or KNlV:YLVANIA ~
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GOCAL RBGI87`~tAit'8 CBRTIFICATION OF DSATH
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Fult Name
of Deaaud . ..._.,.r......~.,,. .
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Place of ~ ~ -
D~at6. _ t~ P~sylvants
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D~ce oE Dcat~~ .G.~..,1.,~_.._..SocW Securi IVqr.~~~~'~~,~.,.R
s~:~ - s~ .~..._..ns~ ~r a~~...~s'~...~.~~~'
o~cupa - • Slrthpisoe _ . •
If Veteran. which War 'i~ --..._...Veteran's Serlal ~ ~
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MEl~ICAL C~RIIPICATB Iaeerval Between
Part 1. Death vras wuscd by: ~ On~et and Death
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Immediate Guse (al-•_..• - .
Due To (b).._......_....~
Due To (c).
Pare li. OTHER SIGNIFICANT CONDITIONS: aonttlbutlaq to dcath but aot rdated to the immcdi~te cauie pivc4 ta
Part I (a)
Accidtn~ Suidde or Homicide __How did injury occur _...y...._..__..._
Name and Tide of Person ~
Who Certifjed Cause of Death (M.D.. D.O., Corooer .
Address.._._...._.._.._..._.._.__..___ .
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This is to cenify that the informatioo here g~ven is oorrecdy oopied [mm an ori~iaal oertibcate o[ deat6 dulr Ciled with me as Locaf
Registru. The original certificate will be (onvuded to the State Vital Statistics Office perm 6~~eg,
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