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This is to ct:rtify that this is a true copy of the rece,rd which is nn tilt in tht• Pennsyl>,•ania Uivisiun of Vita! Statistics
in ~eeorda)~ee with Act GG, P.L. 304, apprttvrd by the General As~embl~, Jw)c 29, 1953 ~ '
,(Fee for this certificate, 52,00)
4~zso3
C.~,,~,.~. ~
ARNI~. It~isill~al to duplicate this Dopy by photostat or photograph, tZlarles Hardester
- State Registrar
R -'S- _t~8 . ~ ~f o
r.:. - • Date ~
No.
' ~w
..la.
Htost4s Rw.>l-7s ~ COMMONWEALTH OF PENNSYLVANIA ~ ~ ~ 1 b ~ s
LOCAL REG. NO.., DEPARTMENT OF HEALTH
PRIMARY VITAL STATISTICS NyNy~)S~ i
olsT. No. 2 Y O O /r' 2 Z y'' CERTIFICATE OF DEATH II~L77
K
t . DEATH Coin ~ b. Ci or bo+ouph Y. DECEASED'S Stmt address„ R.O~ or Box Number
OCCURRED ~ MAILINO ~ ~
tN: a,1 ~ v~ ADDRESS 7 ISO t+t J C E
c. It death did rwt occur in City b. st Olrioa, S M and Zp Coda _ ~
or borough, yiw name of Wwnship l
(Do not tree R.D. or Box Nurnba?) V.. ~ 1D ~ p:K [ t S -JC~u ! vs
d. Full Narns u 9. VETERAN YN ~ - 1'10•'-
of Hospital ~ ` ~ ~ ~ ~ S P ~ a. yyAieh War b. Saris) No. I
or mstitulion ( not i spitat• gi s t addr )
4. NAME OF ) b. (M' a) G (Last) S. OATS (Month) (Day) (Year) '
DECEASED F
OF
(Type or print) d l lc\ Q r Z ~ A tI G E R oEA~ll ~ ~•9 7 3 ~
6 W+1ERE OID c. Did dacea~ed live in • towrwthip9
DECEASED a. Sbb Q ? Yas, diowaad lived in township
ACTUALLY ( borotrph
LIVES b. COwrty Ct,A ~.+~q ~ ~r. ~ a v~~ ~ Noy d~M~ lived witbin actwl limits
7~X ~
CE 1). MARRIEO~NEVER MARRIED? ~O- TE OF 1RTH 11. AGE (in years N vn6s[ t H 24 hours
eat birtldey) Months Gays Min.
WIDOWEO? OIVORCED~~ O ~ Q
2 ~Sl1AL U ( it retired) 18. SOCIAL SECURjTY N . 81 THPLACE (Ste or for )Ili. CITIZEN F WHAT COUNTRY
16. F NAME OF SPO E 17. MO •S MAIDEN NAME
~ 8. FA NAME INFORMANT E, ADDRESS AND ZIP
MEDICAL CERTIFICATE (Items 20 tMouph 23 must bs twmpletsd by physician y) MtTEAVAL BETWEEN
[0 CAUSE OF DEATH: Enter oMy orr pose par line for (s), (b) 6 (c), ONSET ANO DEATH ;
PART 1. Death wet caused by:
IMMEDIATE CAUSE (a)_ 1 v~'/t t1 /~v:.L~e r•.-~2.,~0.,,~•.,~.~
Conduwns, it any, which
gave nse to above pose DUE TO (b)
lal stating lM under-
i
iy~n9 cause last. DUE TO (e) ;
- t
PaRT I1. OTNER SIGNIFICANT CONDITIONS= COnVibuting to death but not related to the immediate cause given in Part 1 (a) 21 W45 a•UTOPSY
~~~II ~ 1"j rC~' i~?'- iC:Ca ~.i./~E No ?
22 a ACCIDENT 22. b- DESCRIBE HOW ACCIDENT OCCURRED 22. c. TIME Hour Moran Day Ypr
Yes? No? " OF m.
ACCIDENT E. T.
2 d ACCIDENT OCCUA8E0 22- e. PLACE OF ACCIDENT (a.g., home, 22. 1. CITY. t10ROUGH, TOWNSHIP COUNTY STATE i;~
Wh~ie at ~ Not while i farm, street. etc.) j
work at work
23 !hereby unity the! 1 atterWed the above named deceased and~~that death occwred from the causes and on the dale stated above atFr;.jxAtn• E17r- 1
a S~gnatore ;i _ D O- b. Address • / y rq Date ugneo Y' ~'"'7
24 a BURIAL kl 24. b OA 24. c NAME OF CE ETERY OR REMAT 24. d l T10N (C ro. Twp - b County) (State}
CREMATION [J 7:3 I
REMOVAL _
DATE REC'O BY REG. 26. E ST,RAR'S S16 TU E 2T~SIGNATURE AND ADDRESS OF FU R~IRECTOR t
3~_ ~ • ' C_?.. ~r E ~c~ ,~..n ~ s~ OVA v+^ ~ s
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4t~2503
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