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H1Q5 11Q SOOM REV 9-75 COMMONWEALTH OF PENNSYLVANIA
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,FEE FOR TNIS DEPARTMENT OF HEALTH ~'5 ~ O 7
CERTIFICATE S2 W) ~
- VITAL STATISTIC9
LOCAL REGISTRAB'3 CERTIFICATION OF DEATA
~ Registeccd No. 551...._...___..._._..
Full Namt ~ E~
of Deceased ....................•-_.-••---_...~.___---_.._.____.---------•.___...._...._....__.._.__--•-------____..._._..__~18~N
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~ 2017 Ave.
Address ~~t~ _••••_----__..__._._1!Io~it8• a
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~ N..e.. sr..~ aa e. M.. c...n aa~.
Place oE
I Death ~nt~'.~._._____ Pennsylvaals
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Gy, Mnw~ a TM~W G~b
I Date of Death 10-22-~-•-•-----•------•.Social Sccurity No. 18.~~'~~9 --•---------...Race..__.
i Marital Status ~r ____.._--Sex---_•_---•_-••-• 1':l-•--- Date oF Birth.__......_ 10-1---19~~
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i Occupation $C~ld_ P!@a~ $LP.el Birthplact _P~A~~--.-•-.----------•--
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If Veteran. which iTVar ---•---•---------•-•----•-.-..•--•-••-~---........Veteran's Serial No_ -•--T-._._,__.__--°
i MEDICAL CERTIFICATE intrrval Bctween
Part Death was cauxd by: Oatet and Dtath
Hetastatic CA 6 Cell CA of Lung ~
i Immediate Cause fa) - ,
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' ! Due To (bl._._,._._..--•-------------
` ~ Due To •
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E I; Part II. O'I'HER SIGNIFICANT CONDITIONS: conuibuting to death but aot rclated to t6e immediate cause given in
! ~ Part I (a)
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~ ; Accident. Suicide or Homicide •-----------..-___.__.-------•-••---•----......._.__How did injury occur
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~ ~ Name and Title of Person Dl'. ~LOIIS~ I"l. D.
Who Certified Cause oE Death (M.D. D.O.. Coron~r)
~ !i Abin ton t~fea~rial Hos ital Ab
aM
~ ii Address.-----...---~--~----- --~~---------------_~__..8_----..__.__~__~~__ P.__ 1nHC.o~.
nt_ PS.._.__-
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~ This is to ceni(y that the information hcre given is torrcctiy copied from an original oertifcate oi death duly file8 with me as Lacal
x ( Regisuu. The original • iGca~e will bc forwarded to ~he Swte Vital Stati tics Oifice for pertn ~ t fi6ng.
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~ i ,J' i ~ ~1~ 46-~427
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p77"1NDIAN CREEK ROAD. JENKINTOWN
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` OCT 2 4 1977
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