HomeMy WebLinkAbout2767 .
•
-1
4i'8553
r
WARtilN(i: ~ !t is illeg#1- a this copy by photostat or photograph,
R
This is to c ~i~` t this ~'r i . ' +~the record which is on file in the Penns 1
r . Y , ; y varw
Deputment~q~~; lth~~ ilt~' iic p ~~~~tAct 66, P. L. 304, approved by the General
-
Assembly, Junt~4+ 9S -
(Fee for this certificate,. _ Z. ' - ~ Leonud Bachman, M.D.
' - Secretary of Health
Haaisburg, Pennaylvanial -
M10d.tI4 REV. t-73 -
CpMONNEALTN OF PENNSYLVANIA
LOCAL REa. I10. DEPARTMENT OF NEALTH
f X VRAL STATISTICS "Y 1 s1 .v
OA" 1~ CORONER'S CERTIFICATE OF DEATN '
DEATN a. Ceaar7 b. Cit7 tw borws? 2- DECEASED'S Street address. R.D., r Be: Nu r
IM: Alla~~ ~Om98'tr@aCl ~o
wE~u 206 F~erson Ave.
e. U oat acct: i dr7 b. flyer Ofiee, (tree sad 2iP 4dc
mb :r
~ R
a :~a~ `
a~-i Ktinhalh Pa. 15120
a ~ HOme8te8d RO$pitah S. VETERAN Yet ? N.
r blatiatiae (If set is bsspirrt, Agee .acct sddreu) tiilit? •st 4 Serial Na
4. NAME Ot' a (First) a (MTiddle) r~rt~. l~Laa~t) DATE ~(Ileatk~ (Da7) ? ~(Yryear)
DECEASED ~rr~ La 1~t,AiT1$ ~ DEATN °~5~ v i 7l S
6. RNERE OID c. Did deceaad liner • teeasbipT
DECEASED P$ e
ACTUALLY a' She ? Yea. daceaad Geed is taerasbip.
LIVEt Cair7-llli aaher~_ ~ Ns, deceased Decd oitkb yyasl li.:t..( ---~~u{~".~T ~ - ~ wro+sti-
i
7. SEX S. RACE 9. MARRIED ® NEVER MARRIED ~ 10. DATE OF BIRTN f. AGE (la )coca It aader I Ter If trader Zf ka~s
d~t n IG..
1'`K11e T?r'hite RloowEO ? wvoactao ? ~y 21~, 1912. b.~7)
12. USUAL OCCUPATION (ecea U retired) Il. SOCIAL SECURITY NO. if. BNtTNPLACE (Slue ar frcip eartatry) IS. CITIZEN OF ttNAT COUNTRYt
Steelxorker 1 -07-P071 test. Vic nie U.Q.A.
tti. FULL NAME OF SPOUSE 17. MOTMERY MAIDEN NAME
iTirginia Lloyd Thomas kaai-garet ~emore - -
FATHER'S NAME Y~].u.1ZAt Thanes 9' a. ( R E, ADDRESS AND 21P CODE
Virginia Thoalz 206 r~lerson Ave. Y.unhall, Ps a 15120
fAE01CAl CERTIFICATION 19. b.RFLATIONSHIP
20.CAUSE OF DEATH: Enter only one cause per line for (a) (b) 6 (c). ltd/ rL~
I. a. Arteriosclerotic CardiOVaacular Disease -
4'8553
ILOther significant Conditions w~,~ t- ww3 AUTOPSY
trslew,. PERFORYEOf
Yta O New
22. a. MANNER OF DEATH 22. b. DESCRIBE HOW INJURY OCC Naar Moatb Dq Yer
~Bt~'tl.~i INJURY E. • T.
~22. d. INJr)RY OCCURRED 22- e. PLACE OF INJURY (e.s., bostie, fro, 22. f. CITY, flORrkKiH. TOwNSNIP COUNTY STATE
bile at Na obite l~crer7, street, arc.)
trwk ? at cork ? •
23: ~b~erpeb7 eenif7 iu iacestiplioa el eke death a( tlK .bogie as.,cd der i redu f - c st t sad r6at rise eldearb is esriasred as
~ \GJd..i~~. E.De T.. w rbe dare .rsreJ aLo,e. Per ~ d/t.~'.AfLl1~ ~ryr
a. Sidsalve e( roroaec 4^'~i t. ~ ~ _ t-- ~adres : . ' .e Dace Biped t 25 • 17 (,T
24. a BURIAL ~ tR. tw PATE 24 c. NAME 4F CEMETERY OR CREMATORY ZA. d. LOCATION lCiq, Bero., Top., R C..s» (State)
CItEMATIDN O : 8/26/75 Jefferson l;er:. t'2rk
REMOVAL q - ~ _ Pleae~nt Bills-klleghery-Fa.
23- DATE REC'O BY REG. 36. REG~RAR'S SIGNATURE 27 NATURE ANO OORESS Of FUNERAL DIRECTOR
. .~JS 3 i i l~.ain 5t }:unbolt Fa
5
8~~26 :,~2~5