HomeMy WebLinkAbout2461 WARNING: It is illegal to duplicate this copy by photostat or photograph. 442543
Date No.
This is t ~ tbat this is a true copy of the record which i3 on file in the Pennsylvania
.
Deputr~~l~~: ,in accordance with Act 66, P. I.. 304, approved by the General
Assembly~,iJun "ra~j9, 1773. ^ ; . . c? ~ • t ~ r~
• ~ t.~~. - --t 1. L'^l-t. D ~ ,i
(Fee for~t~?i~ certifi~'~2.00)44?54~ ~ t,eonard Bachman. M.D.
'!mod ; ~ on , _ ~ Seuetary of Health
'i9 3~,~L_, 35
7[~.13t,a tutus
Harrisburg, Pennsylvania
- t
} J Ht05.143 Rev. 3-73 -
/ ~ O ~ ~ - COMrMONWEALTH OF PENNSYLVANIA
LOCAL REG. NO. ~ DEi'ARTMENT OF HEALTH _
PRIMARY - VITAL STATISTICS
DIST. NO. ~~.aal - -CER''!FI~TE OF DEATH - -
i. DEATH a- County b Gty w borough 2. DECEASED'S a. Street address, R D., or Boa Number
OCCURRED ~ ti•At:t•.G
tN: ~h /A I / .ADDRESS ~ .7 ~ y ~
e. If death did not occur .n City - b. Post Offtee. State and Z.p Code
or borougA, gwe nas:e of township
(od not use R.O. or f3oa Number) 4 /Q~a ~j
d Full Mme ~ V . e ~ LJ ~S P F f ~t ) 13. VETERA. --ti
of Hospiq! /T rl /7 L. 'its t.~ Ao.
o: incbtutzon (if not m hwsptal, gwo strert address) If a. N~h~cA War ~ p Sanal tlG.
_ i
4. NAME OF a. (Fntt) p (Nl,ddle) - - )
DECEASED o. (Last) 5. GATE (Month) I~ay) (Yoari {
i -(Typo or pant) i ro f'h~ S /lint cr ~OF ~
~ ~ G ~il
i DEATH I / % -7
4 6. WHERE OIO PA
/Y e. Did deceased t~ve ~n a townch:p9
DECEASED a. State ? Yes. docesstd tived in
ACTUALLY n township
lIVE1 b County _ f l~'
.t`-ret;, deceased lived w~;hin actual lim.ts of Phi/~~ c,ty or Dorougn.
7_ SEX 6. RACE 9. MARRIEO~ NEVER MARRiED? /0. GATE OF BhRTh i t. AGE .•n ears
r , Y a^Ccr t ~r-, r~ V unrcr 2S r,c..rs
E ~ last b rlhdsy) Months C..,s Ho,,rs rA.n.
WIDOWED _ ~ ~
t t~ DIVORCED I
i t2. S~UAL OCCJP/~L~TION (over
n ,f r`t;rW) ~ SOCtGI SECURITY NO 14. BART LACE (State or foro~gn country)~15. CITIZEN OF WHAT COUNTRY
3 _JL.L ~ t I- Lj d ~ ~ I
16. fUl AME OF SPOUSE It~.1
' ~c~~, ~ roh N s n? tilL~~`~vR~~ t ~ E
10. FATHER'S NAME _ QQ~~~~ _
• t~U~ r11~[ A~T~ Q A O R~~~ND.ZIP t~~~F' ~ , .
MEDICAL CERTIFICATE (Items 20 through ?3 must be completed Dy phyatctan onl t
f Y) INTERVAL OETWEEN =
?0. CAUSE OF DEATH: Enter onty one puso per liner for (a). (b) 6 (c ONSET AND DcATH
~ PART t_ Death was uused by:
IMMEDIATE CAUSE (a) -A '
~ Z% i~iGL~,r%v
Condifions, iT any, which
~ ' gave rse to above causes t)vt lG Ib3 s~ ! - v~ yeq
~ (ai cta4ng the under-
tY'^g cause test.
DUE TO (c)
p PART It. OTH R SIGNIFICANT CONDITIONS: contnbu4ng to death but not rNated to the rmmtd,at• puss wart in Part f a
~ g ( I 2[. WAS AUTOPSY
a + - PERFORMED
I Yas ~,r - No
22. t. ACCIDENT 22. b. DESCRIBE HOW ACCIDENT OCCURRED -
Yts? )y°p 22 c LIME Hour Month Gay Ycar
Of m. i
22. d. ACCIDENT OCCURRED 22. e- PLACE OF ACCIDENT e. home, At:CIDENT E. T. +
Whine tt ( g'• 22. f. CITY, BOAC UGH, TOWNSHIP COUNTY STATE j
work ? Nol while farm, suaet, etc.) I
j et work C
t
23 1 hereby terrify that t tttendod the about named dectaced and tl.at death occurred from 4ha caus.r: anJ tin tht date stated above at s E. T i
0
' Sig"°I"r• °r YARKYTEI: i,USI'. 11 /1~~y ~ -
e : D.O. b Address a Oata an~ed
j 21 • BURIAL .J 24. b O T 124. c NAME OF CEMETERY Oq CREMATOR 2a r r,
CNEMATION r ~ 7 „AT'CN (y ty, f2oro. Twp., b Co:,nty) i~r.~: ~i
i REMOVAL x 7 ~~/77 CI.ELTL~ ,tiLl.S 1'[;~`~.r? t .
26. GATE AEC'D OY REG. REGIS R' SIGN TU ~t g y~, E, y~ ~j ES~,,p
~o i / ~ 1~. U .Yi~LuP LrJ laOt~lORl ll.. FJ~~~C DINE~TO ~j_'~~ 1
y .
1 i~J77 i S.S. N° I 1 t 19 . ,.t:,,rc;,. ~~v~:. t ~t','~:~:v i~t~t:
~ "SC~w~..+ear.,.-.~F.st.~s,,.,._._,,,_•=-~'Y,f•.:~..%M1!.~v.-.,-..--~. -
gC9r t)lJ~ ?ACE~~~ _
• ~
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