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H1o5 1/2 500~A REV 2 78 COMMONWEAGTH OF PENNSYLVANIA
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IFEE FOR T?~IS DEPARTMENT OF HEALTH-VITAI STATISTICS rf 6' 1 O
CERTIFICATE 52.00) l~ / 1
I LOCAL REGiSTR:~R'S CEftT~ ICATION OF DEATN ReQistered No. _
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! E ull Name ~ - ~
i ot Deceas~ed d~~ ast
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~ Residence~~ . •
I ~Number Straet C~ty or Town Cou St~t
i Place uf ,jj /~j~,n ~ ~/1~-Penns~~lvania
( ~ee~h - C~tV, rouph o~ Towntihip
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i~= j^/~ ' Uate ot Deat ~ ~ 7-~ Rac .
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Birth IacA l~iarital Statuc~-_._
ii Date af Birth~.~' P '
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I '!V ~4 ~ 3 ~ Occu tio Veteran's Ser'ul No:3'3 f~' 3(~+
Sucial 5ecurity No. Pa
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! ' Interval Betrveen
j 1fEDICAL CERTIFICATE •
~ Part 1. Death was caused by: Onset and Death
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~ Immed'eate Cause (a}
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~ Due To (bl
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i Due To (c -
' Part ti. OTHER SIGNIFICANT CONDITIO:VS: contributing to death but not related to the immediate cause Aiven in
I' _ Part I (a1
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- ~ How did injury occur ,
Accident, Suicide or Hom~c~d
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~iame and Title of Person ~ fY1~ ~
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~ ~tiho Certified Cau.se of Ueath (M.D., D.O_, Coroner, M.E.j ~CL
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Address~~ ~ '//il~~~~~r rr'r'1/Y~~1" r ~ ~t -
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This is to certifv that the information here given is correctly copied from an original certiCcate of death duly filed with
I,~ me as Local Regiscrar. The original certificate will be furwar to th State Vital Statisti Offi for permanent filing..
i L 40001-388
;I ocal eqistrsr f Vitsl St tis cs District No.
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; KIRBY 1-~cw,lTh C=:•i' t ' _
F tj ~ Strett Address~ City, Borouqh, TownshiP +
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p a Receiv by Local Req~strsr
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Date o Iswe of his Ce~titicatio~
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