HomeMy WebLinkAbout0649 WARNING: If egal fa duPlicata fAis eop~ br PAofostat oc oA. ,eaok.
?Itt)1 1524UJM REV 9 7S I
ioO Gert r7c+ Ceor. COMMONWEALTH OF PENNSYLVANIA
'FEE FpP. 1N1S DEPARTMENT OF HEALTH
CEFTIFICATE 3?OOi NO 774854
VITAI. STATISTICS
I LOCAL REGISTRAR'S CERTIFICATION OF DEATH
Rs9Lsccred No. 22.._.
' 1767
Full Natnt _.~@.Y~.w ..._..._._......_......_.....~ti.,.. ..........._...._...._._....__......~jL.._..... I
of Deceased
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• Address 4.r2~_.S,t...~ $.~ca. ..._~~c1~~Y.~.~~Q .._._._..._....._....~T$1~0~..._._.._._...._.....i..._..._...._...
Ne~Nr ilreef Ot? w te.e ~ G+eh SnM
Place oI '~t118Y~11@ Cr81tf~
O,}+d Penns 1 aaia
Death _ y v
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' Date of Death ..~'.~~+._2~ _._.._..Social Security No.._..~Q',~:.2(Zr~,cjQ........._...Jtace._.....~1.8.._.._..._.__
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' Marital Status Ses_....~~.~~ ................Date of Birth.._....._...i.~.•.•.~Q
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' Occu lion eSe~e_._.. ..Birthplace `(S1 O ...t:4.•o.._ ,R..-._..._...~__.._._____
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ll Veteran. which War .....:....................Veteran's Serial No......__.........-..._......._...-.._...--._..
MEDICAL CERTIFICATE Interval Between
Part I- Death was causrd by: Onset and Death
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immediate Cause a C,.H..F - Y7CS.-..._...
' Due To b A.+S-..~..~.__._._._
Due To (e) -
Part Il. OTHER SIGI~IFICAI~'T CONDITIONS: cootrlbutinA to death but not related t jmr~ealate cause ~n in
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• Diabetes Hellitus ~_,.~~=~:i
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Accident. Suicide or Homicide _.-_.•_...._•••._......--_.._...____~.__Hoa did injury occur _
' Name and Title of Person ~ = C~
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Who Certitted Cause of Death IM•D D.O.. Coroner) .......--__~S@~I-•p1.•_Dl]1'lTl...___.. "fl j..„
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40 Third St
• Address-............ -..r..._....._.__. TiLl,lssri~e,~-~--
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Thts is to certit~• that the intotzttaticut here given is correctly copied from as original certificate of death daty~ tiled with me as Local
Registrar- Thr original certiticste will t+e forwarded to the State Vital Statistic OtTice for permanent filing.
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level te~isuer of Yitrl sMK.fic. oislitf tde.
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