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HomeMy WebLinkAbout2569~" 5~15'~1.~ PS-4044 ~ Mto~.~f= soa~- a-» WARNING: !t is iUe~al to duplicat~ this copy br phorostat or photoy~aph. ' ~~~ ~'n• ~ ~~ COMMONWEA~.TH OF PENNS:'LVANIA ~~ ~ ~s • ~ DE'PARTMENT OF ~HE/-LTH ~~~*{;~ f2.O0~ VITAL, STATIBTIC9 N~ 1'77660 ~ I.OCAI. REGISTRAR'S CERTIFlCA'TION OF DEATH ~ Registered Number ---- ~ 7 ~ ~--- Full Nune of Deceascd . - -•----- • --..,..- - - - • - --- - -~~ _ ~__ • -- ----- -•------ -- ------- - - --•=-•--- - ~i.u a - _ te.~ -----••--------- Usu~l ' ~ /Sae waa«u _.1.~ . - ~--~-'- -- ---- -- - - ~ - - - .. ... __ .~t~txt...__._____-~ rsbw ShNf Cifr a tourn Cow~ SfoN P~eCt OI ,I ~ f~~ ~ Death ----.....--- .----- --•-- ~!1~LQ.d.t.[u---.•-~- . -. •- - PentJsylr•ania - _ .- ---... --•-- -- - - ---- •- •---- - - - --~ Cit oupA or To~rmhip ' t~r Date o( Death _.__.---- ~ ~ 1_7~ - Social Securit No. ~!~.(- 0.9_-. b_~s~..~_..Race ___~~~~~ - -------f---•.... _. . _- - --- Y Muital Status -- --- ~L~L1-----•--------.-----Sex ---~~~V.1~GX1----- Date of Birth --- ~GfIY.LQ,. -----~.~P f--L~L~Q ~ ~ Occupation ---•----- -- ,~~~~-~--- ~1~~l1,4t1~,~ ----•_ -•--- . Birthpiace _ . -.- - ~.~G!1'YYLGL__~_. ` If Veteran. which War ~_. ----- -.....-_-_. _- _ ..__- - _- ._ - Veteran's Serial No• - _....-----.-------.--_---- NEDICAI. CEIt7'IFICATE ~ tnterval Betvrecn Put 1. Death u~as caused by: , Onxt and Death lmmediate Cause (a) - •- - - - - ••---•- ------ -- •--- - . ... .... .... . . .-- •• ~-----~- -•- - ------ ---- ---- Due To (b) ------- -• •---------- - - ~ - --- ---- --- ---- ------- --- Due To (c) -- - -... - ~-- - -------- ---- --- --- ~. Part IL OTNER SIGNIFICAI~T CONDITIONS: contributing to death but nut re:ated to the immediatt cause ;ivea ia Part I (a) Accident, Suicicle or Homicide . _.._._.. ._ .. _ _ .. _ .__ .. _ . __ __How diJ injun octur - Name and Title oi Person /' '~ Who Cer~ified Cauu of Death (~i.D.. D.O., Coroner _ • ._ _ _ . ._ ._ _ _. _1__.__.(.rt/ ____ _ . _ .~.____~_ .1dJress ~7Q-~---- - ~J~~ - - - •- - - • /!~~~~.GL_'.~L_-_ -. . - - --.. ~l~i~~-- -.A.- -~----~•'S~~b StqN - --- Cifp This is to certify that the information here gi~en es correctly copied from an original certificate ot de~th duly filed with me as Local Registrar. Tde original cenificate wifl be forv--arded to State Vitat Statisti:s, Harri~t+urg, Pennsyltia~ia for permaneat filing. ~~ ~~~~` --- ~ - -~G~~---~'~`~/ ~- - ~s~?-11iCS' locel yiitror ot Virol Stot+~tic~ Oi~fr~d No. 1 ~ "' --- 7QQ _ ~.~~.~.,~.--~-~---- -~._ ~ ~.1~a37 _. ` ~ Stnet Ad~~s~ Citp, Boro~ry ownJ~ip ~H a '7' / --- -~-- ---------- --~` -7`~------- -- --- - --_ _ __ ___ 19----- Doh R~n:wd bp locsl Rpi~trae ------- - -~--=- - -" --~-------- ~--- -- 19-7`` ~ pon 1u~r~ 's CMiffaoNw 5 i5ri~ I~61 F~~ -3 A!': ~I~ 3~ F':Ef t~C ~'f~.r.•::~ S' !l'(.~E ~ G.\T +:F t ~ f, f . ~ R(~G~ a ~'i~...• ,~ .~ ~, ~i c i t ~~r'}f:, ..,..,_. ~ . • ~~ i ~ - ~-,~K 3 7 ~~,E 2563 E _ ,~ .~ , _.~~°'~:~.~ _: : ~.. ~~.~:::~,~ -