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WARNING: It is illgal•ro duplica» this copy by phorostat or photograph.
NIOS.112 SOOrw? 2-n .
(100 C•n. pe. hoek} COMMONWEALTH OF PENNSYLVANIA
(F« for rhis DEPARTMENT OF HEALTH ~i
Cortificoro 32.00) VITAL BTATIHTICta N~ 3 8 0 01 J
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
- - Registered Number
Full Name !7e'~tsrisle Fr~l
of Deceased - F1i4h~Y`t~
Hrst lctiddN - laA
ASS _ --_--500---li~rninsa_ii~._ Dr:._-------L~w~r Burr~ll ----Yleat~~r~lsn~ pa~.150G~
Nwnba Sk«f Citrr w ~ovrn Cowb SMN
Place of New g~nei •li - ~~eta~r~laat
Death Pet?nsylvaoia
Cib, tMr«oh w To~rnfl~ Couab
1 ,
Date of DeaW ._Q4~~g.~~~~____..__.....--.--•--_.Social Security No. _...~.9Q_~1-1~$. ---.--.Race __GanO>iei~
Marital Status ____~fiZ'T~e~__:__--_________Sex __.~>~!______.-__Date of Birth
oecupa6oa -$~p~~-;7.M~------ -------_Buthplsce ---$TiLZlG-~'~-y-Its.-----_
If Veteran, which War- -------_---.------..-..---•-----_.----Veterans Serial No..-- - -
MEDICAL CERTIFICATE Interval Between
Part I. DeaW was caused by: Onset and Death
Immediate Cause (a) _
C~r~bral 2lur~>eb~ei~ -
Due Tu (b) ._---_--!~hr'~u~~sel~r-it~•s---Gars#~~r~lee~:ar--y#s~rwse-------
~ -
Due To (c) - - -
Part 1I. OTHER SIGNIFICANT CONDITIONS: contributing to death but not related to the immediate cause given in
Part I (a)
' r
I Accident, Suicide or Homicide - -----_-_How did injury occur _
Name and Title of Person
Who Certified Cause of Death (M.D., IB~laacs~er) ___-.$3,~~__~r~
~ f
Address ------Ttll[Rl'._BL11'TG~.tP->i~--_
sr.«~ - cite
This is to certify that the information here given is correctly copied from an original certificate of death duly filed with the `
as Local Registrar. The original certificate will be forwarded to State Vital Statistics, Harrisburg, Pennsylvania for permanent
tiling.
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loco) bp~strar of raol Sroticrics Dirtnd Na.
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sr.wciE courtTr.lta.
ROGER POITRAS
CLERK CIRCUIT CMlnT ,
+:~K 337 ~«~F 584