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Deputm~ `~if'~1~'• ~fii. i~ ~1
Assembly,_ lrt~,~.9,:7~53: ~~~`;~ .~,~.
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copy by photo~ •at or photograph.
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No.
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; topy of the record which is on file in the Pennaylva~ia
ite with Act 66, P. L. 304, approve d by the 6ener a l
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Leonud Bachman, M.D,
Secretuy of Healch
Harrisburg, Pen~uylvanis
... -. zo„~ REV. ~~~3! COMMONWEALiH OF -ENNSYlVAN1A
i~~~~ ~tG_ NU---------------•--------------•-------------- DEMRTMENT OF HEALTH -- ------
VITAt STATISTICS 0 7 9 7 2 3
PRIMAR'i ba ~ 3A- G . CERTIFICATE OF DEATH
~~sT. r+o-------------~ - ----J-----..._ ~- -------------
~. DEATH a. Covehr b. City or boragh 4. OECEASEO'S o. Streel oddress, R. D., or box N~a~bv _
OCCURRED Allegheny ~ewicktey ''''"'~'N~ 12 Gtenwood Drive
IN: ADDRESS
c 1( deolh did not ocar Gn Ciy b. -ost Olfice, Zon~, and Stat~ ~
or bwoug6, g'~re nowe o1 fm+ns6ip Ambridge, Penna. 15003 •
tOo ~wl nse R. D. o- do: Nuwber)
d. F~II Now~e Sewickie ~- ~ERAN Yes ^ NO ~
of Hwpifal y Valley Hospitat -
or ~nstit~tion fd wot in laspibl. g'~re dreef oddr~ss) o. Which Ww------------•---------._ b. Seriol No----•------••--------
s NaME OF o. (fint) b. (Middle) e(tosl) S. DwiE (Moe16) (por) (Yeor)
°yP~"oE~p~~ Harry Levin DEIITH Sept. 19, 1977
6 WMERE OIO ' e D~d dec~osed Gw ~w o fowwshi ?
Pennsylvania P
DECEASED o. Stofe--------- -.._ ^ Yes„ d..., J lived i~--------------------------------------townsbip. ----
--------------------------
AC7UAlLY Beaver Ambt'id e a' '~-"
t~vE? b_ Couny ------------------------------°---- ~] No, d... J Gv~d wifAin oclrol liwits oi------•--------~-------------._citp or bwoug7~~%
7. SEX a. COLOR OR RACE 9. MARRIEO~ NfYER MARRIED ~ 10. OATE OF dIRTH 11. AGE (in reon If ~nder 1 reor If vnder 44 Iwirs•,
~` ~ WIDOWED ~IVORCE~ Feb. i8~ 190~3 74an~'d°r) Monlhs i Dops Hours ! Mu~- ~
. ,.~ le ~ihite D ~ ! ~
12. USUAI OCCUPATION (eren if relired) 13_ SOCtAI SECURIiY NC. 11_ 61RTMPLACE (Stote w(oreign camtry) 15. C 1 N Of WHAT COUNTRr?
Pharmacist ~175-28-8222A ~ Pennsylvania ! ~ ~.A. ~
15 FUII NAME OF SPOUSE t7-.- M TMfR' MAIDEN NAlNE
Helen Wolken Levin IMir~am ~ess
t? fAiMER'S NAME I19. INfORMANT'S N E D ADDRE
Sar~uel Levin Helen Levin t2 ~enwood~Dr.Ambridge,PA 15003i
~~1ED{CAL CERTiFICATE l~tems IO through ~a .,,~ a~o.~~.~ ~, ~tiri~:;,, ory~ ,~.T~av~, EFr,,EfN
~ ONSET AND DEATH 3
0. CAUSE OF DEATH: Eefer onlp one w~ne r(ina (or (o), (b) 6(c).
PART 1. Dwt6 wos . , . . I by: ~ ~ ~, _ _ ~ / / ~~ ~ ~ ~ /~ •
IMMEDIATE CAUSE (a) --- ------------- ---°---------------WI~{~------- -----~~--~rsrr~- --------
Corditions, if ony~ vbKh • ~` ~
g:.e rise to ubore wuse DUE TO (b) ----- ------ --- ------ ~-----'---'---------------V -
---------------------- -- ------•------ - ---- ---- ----
~ c ~ siaring 16~ ~ndedyiny '
ca~se fosr. DUE TO (el ---------- ------•-------------------•------••----•---------•----------------•------------ -------------•- ----••--------
~A?1 II. OTHER SIGNIfICANT CONDITIONS: coMrib~tu~g M deotl~ but not ~eloted to t6c " ,liote cous~ g'neo in PaA 1(o) 21. WAS AUTOPSY
PERfORMfD3
Yes ^ No ~_
2Y. a. ACCIC::iT 22. b. OESCRI6E HOW AC~IDENT OCCURREO Y4. t TIME Hou~ MoMh Ooy Tear
OF iw
Ycs ^ No~^ ACCIpENT E.S.T.
:2 i ACCIDENT OCCURRED 22_ e. PUCE OF ACCIOENT (e.g., hdoe, 22. f_ CITY, 60ROUGH, TOWNSHIP COUNTY STATE
Vlh~le of Not while ~ora~, streef, eic.) ~
..o.lc ^ ol work ^
_ I hereby ceAil 11wt 1 oMended the obore oomed deceaxd ond that deoth ~c~ed an tAe couxs~d on the dote stafed obo~~ot. Q m., E_
/N. D. ~
~ p
o S~qnolvre ~!O. b. Address ~Li./L /w c. Oote signed'~A~',2~ •~
~ ~ ~ ~`""'1
' ~. BURIAL (~ 2~. b. DA7E 21. c. NAME Of CEMETERY OR CREMATORY 24. d. taAtiON (City, boro., TMp 8 C6unty/ (Stole) ~
~`fcaEM~lior+ p- Se t. 21 1977 Beth Shalom Cemeter Shaler Alle hen PA
~/ F.EMOVAL Q P s y _ g Y
'S DL~Er~~6Y~' 26. REGI ~ T s I,p~~ IBurton LE[llYSCll ~SII.riOiIIe lACR.Ki~e104 MurrayAY.
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BOOK 346 P~GE 1355