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?11~ is to y of the racocd whitb ~ oA Rk is the Paansylrania
Departm ` ~_~ch Act 66t P. L. 304, ~ sppc+owed by the .General
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(Fee for ~ ~ ~B ~ Laoaurd &ichanaa, M.D. ,
j~ ` " o ~ of Health
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HtOb-III) Rw. s.» cwoldN~iR+T~~ AN1A
LOCAL REf3. NO. CEPARTMENT OF HEALTH .
VITAL STATISTICS 7 ~
UIST. N10Y CERTIFICATE OF DEATH - ~ ~ O ~ ~ f,
t. DEATH a. Oowrh awl OECEI?SED`s a• Siraat eddrasa, R.D» ar 90; Number
1 "iD~ AoOaE~ss W Art a tG tt s ~t -
a N dasdt did rqt ooatlr in Cih ~ b. Pbat ONios. .and Dp Coda ~ ~ 1
(Oa
not~iraa Q Ovtt Numbar~j~~e si O C r
d. fill Kowa , \ ~ 8' Y Q N0. i
e< inslttution (N mt In tM. ihw saaet addnp) - ` a. WMt:h War b. SeriM No. ~ }
4. NAYS OF a. (Firer) b. (MiddN) a (last 6. GATE (Day) (Year) I
6. WHERE OID _~~ar~~O~. e. Oid deoeaeed Ihre an a townsNpt
OECFJlEEO a. i~t..rr..j Q Yes. dsoNMd lived M to~wnahip
ACTW?LLY D'
LIVEt O. County No, deoee.ed livee within aotuat Hmks M ~ / ~ or borough.
7. SEX a. RACE i. MARRIED MARRIEO? t0. DATE OF t3iRTH tt. AOE (fn yeah N undN t N under Y4 hours
W1001MED? DIVORCEO? OtbirNtday) palo Hours MIn.
~2. USUAL OCC A (even N 18. IiOC1AL SECURITY NO. 11. BI THPLACE (SUM a Ioteipn country) 6. CIT12Q~1 OF T COUNTRY
A! C.C
t ti. FUII. NAME OF 8POUSE w r V G f 7. MOT~IER'S MAI NAME
18. FATHER'S NAME IY. INFO T'S NAME. A ESS 21P COOS
l,~.Prf ~ ~T t w w/teTt rt t i
MEDICAL CERTtFiCATE (Ihrrts 20 eMouph Y3 must be oanptahd by physician only INTERVAL BETWEEN
ONSET ANO DEATH
20. GUSE OF DEATH: Enter Doty one oust per line for (al (b) i (cl
PART 1. Oesth vets posed by: t '
IMMEDU?TE CAUSE (e) ~ ` w~ '
Coeditiorre, if any. vrhieh -
f (sj es~tag Un undar~ OUE TO (b) ~
lyirq aura last. OUE TO (e)
~ PART IL OTHER SN3NIFiCANT CONOITiONS: oontr~rrtinp to death but not rslsted to eM irtutfediah oawe given in Part 1(a) !t. WAS AUTOPSY ~
_ PERFORMED
- Yee ? No CJ ;
22. s. ACCDENT Y4. b. DEiCA1BE HOW ACCIDENT OCCURRED Yt. a TIME Hour Mwrth Dey Year
YpQ No~ OF nt• i
ACCIDENT E. T.
22. d. ACCIDENT OCCURRED 22. e. PLACE OF ACCIDENT (e.y.. tame, 22. f. CITY. 00R000H, TOWNSHIP Wl/NTY STATE ~
While at Not vvMN farm. street. etc.)
work Q at work Q
23. I hereby artily r at i attended ayw~ deceased and tl+at death occurred from tM cruses and on tlw e.te sated above at )Q : ~ m.0~
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I~~ ~b~
4 siEnatun _ O.O. b. Address • ~.`o. Date siirwd 8 aZ3
21. s. BURIAL 21. b. OATS I. a NAME OF CEMETERY OR CREMA R 4. d. LOG lCiq, Seto. Twp., i Cow+h) (she)
RGEME
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A~ p ~ .~.f" ~ ~ O.if/7re. , ~8 R c ~OA/T D irl~ r • ~ a •
26. Dj~ REC'O B RED. Ys. R 'S SIGNATURE T. SIONA ~ANI}AODI~yS OF R/11. OIREL'TO
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