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ST~~1lCEPOITRAFSA. t c
tIERK CIIlCU1T COURT ~ ~4V
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noo con n.r cook) GOMMONWfieAL,TN OR t~L'NN>fYLVANtA
tFfiE FOR THIS - - DETARTMt;NY'- Otr HtU1{.TH
CERTIFICATE 12.001
V ITA1. nTATItR1CS{ N° 9.7 7 3 9 0
IACAL REGI9TRAR'8 CERTIFICATION OF DEATH _
Repisteced No... 403
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t~ --itt~t. t.st
--66~W~lncrolt Lane Lancaster Lancaster Penna.
Place °f Lancaster - - Lancaster -
Deaeh ~
D:te of Death _ ~.Y?~..~..:.~.~~.....__..__..Soclaf Security Na .....1 -0 -68'~A--,;-,~~_ Whii1
Marital Status Married ...st7G Male ._Date of strth. March 1..~...1216...r...._..._.._
occupation weldt:r _ ~ ________Birthplace Penna.._~.-._____._
if veteran, which war ~ II -.-----__..Vtteran's serial No. -
MEDICAL GERTIFICATB _ -Interval Hetwrea
Part I. Datb was nosed bye Onset and Death
Immediate Cause (a) DvBrhvn f d
Due To (b)..._...illy.QCardial~~r~f$ts~~ion_---____._._~__. _ _
i
Due To (c) ~L,X_..~~.$4aB.Q___.._-•-...__----•--------------•--_.4._.._... ---_w....._~~
Part II. 01'IiFJ2 SIGNIFICANT OONDTTIONS: contributing to death but not related t° the immediate cause given in
Part I (a)
Accident. Suicide or Homicide -__..._.___~...._---How did Injury occur
Name and Tick of Person
Who Certified Cause of Death (M.I), tt~oacsar~a~ _..giehard.__D.entsle~.1~~__~Yl~r_---___..._...._._._...._
Ate,-._._._____--_~~ N: Duke 3t. - Lancaster~Penna.
_ _ - at, .
This is to certify that the iatormation here given is correctly copied from as original certificate of death duly filed with me as Local
Registrar. The original cutificate will be tonvarded to the State Vital Statistics tJf6ce for perm pt filing.
36-340
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53 North Duke St. Lancaster,. P~nna._.~._
May 26 ~ t.~.t
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