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H1W 112440M REV ii•76
(tt>D Cert tsor book) COMMONWEALTH O!? PENNSYLVANI/?
(FEE FOR THIS DEPARTMENT OF HlE/1LTN
CERTIFICATE stool VITAL STATISTICS N~ 45540
LOCAL. REGISTAAIt'3 CTATIFICATION OF DEATH
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Full Name ~~R~~~
• of Deceased ..._....LG~.1.~~T~-Q ~ _ .
Usttal t~ saet. ~
Address _-...-..~1-~~.~~r )~t ~n,e *,yr~ ~_~~~f~?~31~.~:4 _
Sreel Cttn K lee -~/L!~~L~ SNb
' Place of t ~
Death 1+~5' -~f ~*~.~5 r Pennsylvania
Date of Deatb . . _ ~ t..~l~.-._____Social Security No. _...----._..._.._.._...__._..--..---------.Race._~rS~--d-- .
• ~
Marital Status .-.--~'.l!LQ~ __~_..__.__.-.Sez_.Y_.~.~~-_.-...Date of Birth.._
~~?~t!~'?:z:K-~!L.1-'i/ t--.L91J
Occupation ~'3:g.._.___-. _ Birthplace .i,~ltet~. _t1_:Ct ~n.~t,2~
It Veteran. which War --•-•----.--.-----.___..------_....__..------_.__..-..-•-•----•-.-•--.-•--..Veteran's Serial No. _
MEDICAL (~RTIFICATE Interval Between
Part I. Death was caused y: Onset and Death
Immediate Cause (al• ---...it~.,t~~-C~ Q~ _ _
1~-y ~ ~
Due To b
Due To (cl---------•._._.._.._____.._._.___..
Part !l. OTHER SIGNIFICANT CONDITIONS: contributing to death but tsflt related to the imrncdiate cause given in
Part I (aj
Accident. Suicide or Homicide ................__..._.___.___.__...-____-_....__..How did injury occur
Name and Titk of Person ~ ii~ ~ f
Who Cer 'fled Cause o f Death ( .D, D.O.. Co r) ~
'G~~.L:.~~~ _ .u~__~~ ~~J__
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St~eef ~y
This is to certify that the information here gis-en is correctly rnpicd from an original certificate of death duly film with me as Local
Registrar. The original certificate will be totwarded to the State Vital Statistics OtGce for permanent filing.
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