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P J. P176C~Y, ATTOi~'Y I9+O ~U
i 22 34
1990 E. Sunrise Blvd.,
Ft. Laud~xdale, Fla. 33304 Fl~t{3•lit: s:: cca;.: u
Si.tUC1E C~L'N1Y.Ft
ROG~ R f'OITItA
CtERX CtSCL'~T CC:G^i~
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This is to certify that this is a true copy of the record which is on file in the Pennsylvania Depaztment of Health,
irl accordance with Act 66, P.. L. 304, approved by the General Asscllsbly, June 24,1953.
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(Fee for this certific~t~~~2 '
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WARNING t is~legalplica ; COPY by Photostat or photograph.
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COIAMONW EALTM OF TENNSYLV ANfA
OEpAHTMENT OF MEALTN
VITAL>;TATISTiCS
Q'~OQ1 CEpTIfICATEOF OEATN
P R i M ARY OIST. NO. STATE FILE KO.
Nana Of OeCaafW (Flntl (Mwdte) ll.astl Sea Oste of death IMo.,Oeya Yr.1
THOMAS 1 BROaN :.~E , OC'I'4BER 2 '1 9
Ra:° - (a.0., WAits,Btack, AtN INt OlAhdaY under 1 yr. II under 1 day Oateof bbth Stole or Iprei n County of birth !ty~ 8oro, or Ttrp, e
an,.rlgn to ert,ete./ iYn.l aYa ::pure 1,,, IMO.Awrvr.l country of b:r;lt ~r~t
• t~~lite s,~, 82 Ss, t Se, t aA$-20-97 as. PA addle hen ,ioPittsbur hpp~~
County of depth Cite, f3oro; or Twp, of dtoth Nod ~isi~ °r Institution (II not sithar, give street 1(p~sp~ e~ irn+potirnr (sFscibl
,A. :1LLr.GHENY jj;, PITTSBURj^atH ,c, ~?LLEGHLNY GENERIC HOSPITttL ~o. RI PAT r
.Mci 1 any Address (Street or RFD No.) (Cite w Town) lStote) (Zip Cods) wNtal Sutus Swvwrn/ Spouse tlt wife, f~ nterden nanMl
5 Crestvue Manor Driver Pittsburgh, PA 15228 aMarried to. Susanna Large
a.
Ctt~:en of whet country: Wos decedent ever in US Anwed Forces? Social Security Number tJtuel Occupation /tcirw 01 work done dw• Kind of business o? Mdtrsvy
Yes QNo Seriol No. irt, molt of wo?kirq tlte)
tt U.S.A. t2 t~83-24-8807 t~ACorporate President to
nh"° ` e. State Pennsylvania Did deceased litre Yes, deeeossd litrsd in Mt. LebdnOn towwsbip.
d°ceasad a in o township? No deceased Iiwd within actual limits of city a ben?
~crualiy litre. b. County Allegheny O
is.
Farhar's name IFlrst) lMlddle) !Last) Mother's maden name (firer! (Middle! (Last1
James Brown Bella MacEwen
1r+fo.mant's name :Type or hint) tn/o?mant's lStrNt or RFO No.l (City or Town) ISu[e1 (Zip Copal
Mr. J. Duncan Brown /Maihn,add..,a 15 Crestvue Manor Drive, Pittsburgh, PA 15228
taA. tes.
~ Oaa of bwid, ate. Name of cemetery or crematory Locauon IGcY. tloro. twp.) (Staa1
Burial ? Removal
~ O cromation[70th.. tit. 5, 1979 t9t: Mt. Lebanon Cemetery 19fl Mt. Lebanon, Allegh. , PA
t9A.
S. gnatura o IuMrM dir.espr end ante nu ama a • rns o unara .su r m.nt
Fo- 0 1 2 - ~ 13. UIUGHLII`L ING,
o e~..d er :.~+t•« 3310 W. LIBERTY AyF.~
a°9`.tr•'.St Yr. t.~ ~ ~y79 PffTSBURCH, PA, 15216
To the best of my 4nowledpa, Death occurra0 et the time, date, and pace Y = On tAe basis 01 eaamination and/or invst,yation, in mY opinion. Wash oKYrrad
o and dw to tM cause(s) stated. ~ (1 ~ ~ S W ~ at u+s tierw, data end :Han and dw eo tM eavw(al toted.
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Sr~tatY1!
~ < < $ienature Q ~ ~
~ O ??A. and t.1N O.O. ~ y O 2~A and tale r. Nour o
ate ,yrw0 Moy aY~ A.M.
U i ~ pate $iltned lMo,iOayr Yr.l Hour o1 A.M. ~ ~ 3 Wath
• U 3 p Death
> > ?2s. `O ' 2 2ac. 2.- `
t r.M. r ' 2se. lac.
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~ None end Address of certifier !Physician, Medical Eaaminer or Coroner) ins or G Name of ettendrny physic
J:a Tf~GHIZAJ.'~.',H .il•L~GHLNY G~lr^•i~L ~iO:;P~'1'aL P~• ?s ~t 1~•~~'~- ~ ;
?4.
s Inernet Wtweat
i 6. Immadlate utrse: . t Enterpn~i~Y~ o///r/c~~ause per t}^~ for (AI IB1 a}~nd ICI
12* 1 w~t.'l~AGtlts. (1,•"K IIe ~»~et-}.O^~.e~ ~ 1 r1'\t•ttir+^b~'i 'on Mt end Watfr
t cal _..r_
ow to, or as a t:onMpuenq ol: t InwrtrN Wtwwn
yi P,.t I ona.t .red do.n+
1 1 tel
Due to, or es a eonsepuenee of: IntersN Wtwesn
. onwt end deeM
(CI
Ps rt I I. Other SlOrtifa:ent Condillona -Condition cortttibtrtirty to dNth but not rNatW to ceuq yi.w+ in f
a+t 1 la/ Autowr was nse •etened to Medial
eta Eaeminer o? Coronerf
?O Y DLJ No ?S. ? Yes i~ No
t, cc., Suicide,Hora., Undet. Date OI injury IMe., D•Y. Yr.l HoYr or A.M. OtRrioe now irywy occurrb .
or 'end, Invea?. (apeeilY) njury ~ ?.M.
j 2~~s~. 29s. ?9C- 290.
f ,urr at work? Pgee of u+jury lAt home, brm, strew, etc. i-ocatwn (5tr.et or pF0 No.l (City, Boro, or Trvp.) late
1
? Yet ~ NO r-
?vE. ?9F. 29G.
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