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This is to certify that this is a true copy of the record which is on file in the Pennsylvania Department of Health,
in accordance with Act 66, P. L{{.304, approved by the Gent:ral Assembly, June 29, 1953.
Fee for this certific .
r .. . .
~~r' ~ •~ r~ Charles Ha;~ester-
~~ -'~ r~ ~' State Registrar
WARNIN6c ~1; is iite0al ~q duplicate~lis Dopy by photostat or photograph.
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COMMONW EALTN OF pENNSYIV AN IA
OEIAIITMENT OF NEAITH h e'~ /\ h
VITAL sTATItTIC= U 1.uj J
OZ ~ ~ ~ CERTIFICATE OF OEATH ~ •
PRItdARY DIiT. NO. sTATE FILE NO.
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dame of decwsed (Flat~)t/~ / IMddhl lU•t) /~ Sea~p Oah of death Itbyday, tlr.)
irate - fe.}, WAIta, Black. Aoe last blrtAday It under 1 yr• It under 1 day ~eo: birth Che
or (g b„h
f County el birth ix ro, r T..p. of
A Jcen tndlan, etc.)
~. e 1 Vn.1
s ! s. eys
s9. tours n.
sc. ' I
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as. ~~
sc. r~e. ~ . /L . _ _~
do. ~(/i~(JLO
County of death
~A. ~ -/•~~i ~~ Ci Boro, or Twp, of death
n(~
~s. tV1~< .~!/ Hospital or Institution (11 not either, give street
address)
i'c. ,/~~r ~/1/(1 ~-~li~ If haspp. or inst. indicate DOA,
P/ER, er i^^~~o~ient (s •cify)
o. QT >`' f
Ma. I my Addrese (State or RFO No.) City a Town) (Store) (Zip Code)
$. 4 ! L.ucvra Diri,.ve 1~~.t~e6uir4h PA 1522! rNaritat Sta
a Alaaaied furr.rrrp Spouaa frt w:te !~ madam nerMl
,o. Leonoa AI. ~'
C~n:en of what countryT
t t (ISA IA/os decedent ever in US An,ed Forces?
OYas 1~41o Serial No.
t2. Seewl Sacwity Number
,~.19a-0I-U714 t/sual Occupation (Kind of work done dw-
ie3 most of workiry lihl
,.A./? Kird of bus:MSS or indwtry
Gel, % n~
°""` °1° ]~ ,(~,Q Cid deeeostd lit wjf~?i nA tovmahi
deceased o. Srote Yes, deceased lived in _ p.
actually live? b, Covnry rn o township? []No, deceased )iced within actual liwits of city or bores
IS.
Fathx's narM IFtrat) (Middle) (Lest) Mother's meden nerve (Pint) (Middle) ()earl
5 , R ~o/In keir/eva Plt,ilome,~a Sn~dea
o ~
.... ~ ~. ~.y...... s.,. r..~ .....°f., cavn,rwr yr
narM or
2a. `--. i Ira ~ /c' lirt.,/~C-/ nor // ~ -~ ~/j /~ ~-
76. Immadiae cause: Enter only oM a par lino for IA) (BI and ICI InservN between
(AI ~.r /r G ` ,~ w/~~L .rL- ; onwt and deatA
lX ,/7 _ ! a
Qw to, or as a eoneegwrtee o1: ; InsanN Wtween
Part Imo.. ,.yC ~+
1 (9) ~ (r'~d F/ 4 ~r c ~ t[ rt ;^ `Q r c / ~~O-zy-~t lancet and death
ow to, or es • conwpuenca o1: InaprN Wtwean
onset and daedt
tCl
Part tl_ OtMr Siyni/itant COndaioM - ConditiOM cony.bur:n9 to death b-ut~not refired to cauw given :n Put 1 tal Autopes~y.,. was use gtxred to r.ted:ul
G' iC ~/t G.G 1 r L H ., ~ {~i fCOIC 2O r iLll~io 29~i V.osr Orl oerl
17`/' J"
Acc., Suic:de,-lom., Under. tiara of Iniwy (4Ao., Oay, Yr.) Mour or A.M. Oescnbe how ~nlu•y occurred '
o. Pend. Incest. (specify) tniurr
I.M.
?9a. 296. 29C. 290.
i~~ory at works Plata of mlury IAt home, farm, ureet, etc.) locat,on ISaeer or RFD No.l (City, Boro, or Twp.) tau
t7 yes O No
~ ??F- 29F. 29G.
SU9090
190 DEC -3 AIR ~ 18
FLIED RNC FFCURtkD
SLItlCtE COUNTY.ft A.
ROGER POITTtrzs
CLERK CIRCUIT COUA1 ~
RECDRti VERtr~rr __ `~ ~- .
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lnrorrtNnt'a Mme (TypeMor hint)
~t?Q/b/L lrl
He~r~ava tnlorr..ent's (Street or RF~~jjNO.I (G~lt~yl~o~r Town) y~S ae)
M«l:ny address ,(~/ ~ U/LLVe Pu.ZOt7ILR~t !~ (Z: Coeel
/~/
.
18A. 189.
?Q Bw:al O RamorN
OCnmationOoth ON• of bwiN, ate.
199
~//8/7rI Nsma or cemaary or crxnaory
~''~,Ll/,~ Peruc Ale-r>n/riu,( Po~/z location (Gtr. Boro twp.)
Cheesel+~,~,~ ( tact
~',~
ar
t9A. . 19 ,90.
Si gnatu • fuM/N d:rett0 I:c nufnbff
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FD- O ! /~ 5iT~1-~ me • rap O uneee eta 1 men)
ce L.. Knee Limited
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Ray7rtnr ~~ ~ twe
~ ~ Oaa rece:wd by rao:atrx (
OW C ~~~
PA.
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P~e6u/r
/5221
/ 19 ,
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209
To tM trNt o/ my 4nawladya, dNth oecu a tM time, dati, and place ~ ~ On tM tree:a of eaamwut:on and/or inreatNet:On, in my op:nwn, dYM occwrad
end dw to tM uwa(a) crated.
o M O n ~ ~ at Ma time, dale and place and dw to the cauaa(sl state0-
c
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` ` E ~ tg &onatwe
E = ~ 2?A. and GtN
~" o.o. o b 23A..nd titre
o
u : ~ Oae S:ywe IMO.,Oay, yr-! Nour of
O A.M. It are rpnad . y •- trout or
~ ~ ~
catA
• u 3 /
c o ~ 228. W ~S/ ~ ~ 22C. r•
~~_ -.M. OenA
,a, o ~ 238. 23C. A.M.
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