Loading...
HomeMy WebLinkAbout2754.r J`~1$80'~ w~~uro: ic ~~.t m d~pttic.c~ cbu ~opr br Plwcaa~ a ph«~.pti. • -a r ' ~~4 ~~~ ~i3';. , ~ . .~ - .~ - ;r ~,~~ ' ., : , .t ::: z:'~,: t This is to.~~ ' '~. . . r ~, Depaitm4~,L-Qf ~, ~ . . ~ -: ;~~ : ~ f i~ 1. OEATH a. ~~~ b. C:~y o~ eo-aqh 2. OECEASEO'S a. S~~~e~ ala~ss. R O., or Bo~ NwnbN f OCCURREO YIAlLINO ~ ~ ' IN: ~~ ~ ~ . ADORESS ~DU jI~ P e. If dpih did ewt otew i fy b. Po~t O1fiq. Sut~ ~~d Z~p Cod~ or bworph, piw nsnw ol town~Np 100 .we ~.. a.o. o. eo= Nun+w.) )~ SQ.~f/ ~r ~T ~~ O/ 0. Full ~i~n+~ ~~g~~YS'' t/~ ~ / 3. ET RAN Y~s L: No u ot Hospiul S h ~S/~ ~fI(/7- „ J ~ ~ " ~(p~ or institut~on ( not ~ s t. strN add,~ s? a- Mllr~h W~r b S~r~a1 No ~ 4. NAIdE OF a. (Fnt) ~b {M:dd1~j e(L~sU 5. OATE (~~~~) (~+y) (YN~) `~ ~ Ot ` ' (yp~MspMt~ ~, ~~~~tx 1 1 ,1~.\ ~~~~1_ 1~• DEATH ! i '-,l ~ : 6. WMERE OIO e. b:d Asee~s~d I~w .n ~ 1 h~p7 OEGEASEO •. Sut~ P~ ;~ Y~s, d~c~~srd li..~d ~n ~ownsh~p ACTUAIIY LIVE4 b. COU~+Iy ^ No. dKMS~d liwd w~tA:~ ~tlwl Gm.It of t.t~ o- borOUgA. 7. SEX •. MCE 9. 7NARRIED ~[ NE ER M/1RRIE0 ` 10 OATE OF BIRTH /1. AGE (M rH~s 1! ~sntler f rea- ~ 11 und~r ?I Iwws ^ ~/ Issl birthdayl Abn~ns ~D.~~~ ~+~s ~ M~n ~I i ~ W~OOWEO(_ OIVORCED~= Ii /" ~~ ~~~ v 12 USUAL OCCUPATION (~ven d ~ttircd) ~Z S~C~ 3^[CU~~23 NO 1~ 81pTH?lA~ (51~1~ w 1w~~9~~ c~n+~~~ry~t'S C~J~.f~; WNA1 COUNTRV • • O ~O f~'~ L ~ f-~ 16. FULL AME OF SF'OUSE 17 OTMEH 6AA10EN n M .g y~ 1t. FAT Eit'S NAME r ~~~ ~. INFORM NT'S NAUAE. AOOpE55 NO 2~P CODE r ~~ . o IIitEOtGL CER IfICATE (~~ems 10 tA~ouqA 23 must be cumpletW Dy PA~s~e~ae~ onlr) tN7ERVAl BETWEEN ONSET AfJO OEATH 20. CAUSE OF OEATH- Enter only one csuse pe~ ~~oe to~ (al. (p) s(el. PART t. DutA waa uuscd by- IMME0IATE CAUSE t~l L ; v e -~ /= G . /6( ~- '~ - _ Co~+6.hons. ~} ~ny. wA.t1- ~1 p~v~ r:a~ 1o abow caus• GUE 70 (b) ~~r L~ h o.r e o~ /-'.iia t.~' -e' ~ J (a) suan9 tM une~~- .. , ~~~. . , ~. . 5~~~ No. PS-4061 ~ ~~ ~i :t~te, topy of the rccord which is on fik in the Pennsylvania .s~c.~o~isttice wich Act 66~ P. L, 30~/, a~proved by tht Gerural nss~moir.~~•;fy~~ ~cr"e• .p. n • `'~ .• ` - ~~i. .!~* '' , ~~:3" ~'~~, : . ~~ ~ ~. ,~ • . (Fee far this cectificate, f2.00) Leonard Bacb,n~. M~. , ~ Secreury- of Healch - Huri:burg. Peaarylwnis ~. . . -~ . ~ . - - ---~---._--_.. - ~ -• -- - - --- -._~ __ Nt05~t~! Rw. sa~ ~~~ ~ COMMONWEALTN OF PENNSYLVANIA ~OCAL REO. NO DEPAR7ti1ENT OF HEALTH PRIMARY VITAL STATISTICS D~ST. NO. O~~G~ CERTIFICATE OF DEATH Irnq c~us~ ~~st. OUE TO (cl PART 11. OTNER S~GNtf~CANT CONOIT~ONS contr.0ut~~+q ~o d~aln Ou1 no~ rels~~d to Ihe ~mmedule uuse g.ven .n Pa.~ 1 t-~1 2~ WAS AUIOPSY PER-ORMEO Yes, Hp•~ 22 • ACC~OENT 22 O DESCh~BE HOW ACCIOENT OCCCF.~t~~ ~? c TIA~L` ~k.ur ~~ Man:n O.~y Year Y~s^ t~o^ pf m _ ACC~OENT < < 12- d. ACC~DENT OCCURREO 22 e PIACE OF ACC~DENT (~ y. nome. ~Z 1 CIT V. BOROUGIf. TUWNS~~~P ~CO:lM)Y^ STATE WMI~ at f~ot wn.le .- (a.m, st.eet. ete 1 work ~~ at wo~k - . 23 1 Mr~by ec.vl~ tnet 1 anrnd~o ine aWi~e ~amed Clceascr and ~rY CNth octar~ed I~um t)he e+~u~es a~J uo u~e A~~e .!..tr.~ ..~ .~a at -~~ M. E: ! t,~,'-J~.~' 4 / / ~~ ~~ /~~~ -~ ~ ~ /~/r ••' '' ~ ~ ~•~ - J~+/ ~N-. ~...~~_.z~i~ or /~s , •- ~~ r ,-_ ~" .;~natu.e ij" O O p AdOress ~cj ~ / " ~~ ~ ~ ^'~~ ~ c 'J.N~ a.qnerf~// `~ y/7~ ~ / 2~ ~ OURIAI /. I~ b UATE 24. c. AAR1E Of CEMETER 24 d LOCA1~Oti l(-~~r u~ ~~~, twP b C~u~~~r~ tStsle~ NEMUVAL / CREMA?!ON I : /V fI v,~~' 'rj77~~ !~/ Q/` ~ ~~.~'~SP~I .~// ~P./Y ,~• 2S OA7E REC'O BY REG 26 REG~STRAR S S~G[vATUHE ~ 27. +f NATURE ANO ADDRESS Uf iL•NI R~U~IIkI ~t ~ ~ ~ - ..~. 4' ~ ~__' --. ~{~'~``"' ~if • %`jL' ~ ,w-t~~ el~~"'"`j'~~~~~:tZaS~t~-~~ ~I /s'~/(~ " ~ o. ------ t ~f fE° -4 ~;~; ;~ 16 5~~~~` s~ ~ C F CGUN YiE ~ RO~f.R Pp~ iftr.S f 1 8~34`7 P~~E2747 ~~EFx ~~~~t:~r ~~~Fr ~ 3 ~ . ~:~. ~. ~ ~ ~~ _ ._. ~~~_.~ ~ -- _ _ ~ - :~ -~~~~~ ~ /