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WAR1ZtNG: It u illcgal to dupliutc tF,u copy by photosat or p::oc~grapk.
.-..~:-~ ~~ j= ~~~ ~ ~ • ~1973 ~ / o ~-~ ~ ~ -
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~TK"is ~.~~ ccrtify ~ t}tat "~k a true copy of thc record which is on filc in thc Pcnnsylw.r.i~
~~~e '' ` nt of Health,~ ucordance with Act 66, P. i,. 304, approved by the Genual
~'~ b~r, june 24, 24 ' . ,
i~ - ~ ~~. ~ ~:~ ~ _• t ~- , ~~
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(~ .;,f~it'tf~is cer~ti~}c~.S~~ J, Fincon Spcl!er, M.D.
' ~,~!:~ . = ~~' ~ _~ ~•:. . ~ Sea~tary of Hea;th
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' , ~~:w:~.-y=`?F ~ ~ ` ~ - Harrcisburg, Ycnnsylvania
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Ht06 ta3 REV. 3•~2 CpMMpNyyEqLTH OF PENNSYLV/WU1
LC~:.L F:EG. NO. BEFARTMf3VT CF H~ALTH
PRIMARY ~~
~~' y
~ r'!'~C V1TAL STATISTICS
DIST_ NO.
~ CERTiFICATE OF OEATH
1. OEATH •. County b. Cit~t or borouyh 2. DECEIiSED'S a. StrNt addresa, R~., o- 8ox Numb~r
O~CCURREO Nuntin~don ~~~~~'
AooAESS •
R.D. i~ 1
c. if doath did not ocCUr in CitY
L`S
or borou
h
ive name oi town
hi b. Post Off~, Stab and ?~p (',od~
SS 'j1(p
g
, ~
p
s
(~
t
I}
Ai
A
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o [tc7
u5ft _
. Or
k
wr
~er! Kapleton D6 t ~• Z'~Sz
d. Full Name 3• VETERAN Yes ^ No
of F+~sp~tai
or i~c~:lulios! (it nat :•ts tsGSN:iai, giw Sireet atiare55) i~ i- Whittt Wsr b. Serisl NO_
4 NAMt F ~. (First)
DECEASEO b_ (M~ddle) c. (Lsst) S. DATE (Month) (Day) (Year)
yeT~
(TYpe or int) I~OC~ei13 ~,1@~
~
~pEATM NB,rCYI l8~ 1~3
6. WHERE UID peR~~ c- O~d deceased I~ve ~n s tow~stip?~
DECEASEU a. State
~ Yes, deceased 1~ved ~n s
townsh;p.
ACTUALLY Hunti OA
UVET b. Cou~ty ~
^ No. deceased lived w,thin sctu~l lim~ts of nty or borouaR
)
7. cEX 8. RAC•~ .MARRIED~NEVER MARRIE~ 10. DATE OF BtRTH 11_ AGE(inyexs ~~~ 1 If~2a-wu.s
fQi4a1. I~h~t@ WIOOWEOD DIVORCED j~CC.22 1~2 lastb+rthdsr) ths Oars Hours M~n.
C ci ~o~~ AoounrrRr~
~2.usu~-~.~u~exife '~f`~•ed~ '~
~ 0 ^1OtaSR~
~`Aie
d «~
un Y
-
i
l
H
t
iG. FUII NA~Jii OF SPOUSE ~: ~RQ,TFiER'S! .AIt7EN WAME
~
Jack Kendal Flesi ,sster
arlin
18. FATHER'SNAME (`,e0 9~I
~ u~ 19. ~t1FORMANT'SlUAME.AUDRESSAtvDZ IPCO~E
Y Jac~s Flemin Ka le n t R D 1--Pa
MEDICAL CERTIFICATE ~i~ems 20 cnro~,gh 23 mus~ be ow~.~eced ~ pny~~ o~r) INTERVAL 8E7WEEW
20. CAUSE OF DEATH: Enter o~ly one causs per ~;ns for {a~ (b) 6(c). ONSET AN~ OEATH
PART 1. Daalh was caused by: ~ ' _' ~
IMMEOIATECAUSE(a~_ ~ ~: ~_ .y~:'- - - - G'~ ~"7'1~1-~~j'
Conditio~~s
if an u
~~'~ c ! -
.
y,
which g.~ve rise to v
a1K~ve cause (a) stat- DUETO(b;_
~ng tFw underlying
,;:~~„~ ~~5~ ouETO~~~
PART 11 OTFIER SIGNiFiCJWT OONq7'lpf11$: opntribut~ng b tleath bu~ rwt te~d p t~ ~r~~ ~ Q~ n pn 1(~~ 21 _ WAS AUTOPSY
PcRFORME~
- Yes ^ No Q
22. a. ALCIDENT 22. b. OESGRIBE iiOW ACCIDENT OCCURR~D 22_ c_ TIME lia r IiAw~th Dsr Year
Yos ~ ~.a ~ OF m_
ACCIDENT E T
22. d. ACCIDENTOCCURRE
22. e. PLACE OF ACCI~ENT(e.9., home, _
22_ f_ GTY~ BpqpUGH Tpyy~{S-Ap .
CpUNTY STATE
4Yhile at Not while fum, atrest, etc. )
•w,rk ^ at work ^
za. ~ r.rwry wn,ty uiat - attorxfod the at~ow ~rrarl deoasK,d and t-~ death oaarred bom ehe cs~~es and m ehs d~ ~ta~sd aboN at n-, E~ T.
/ i M.p_
a. S~~~n.~ture J ~: ; . 7 . , ~ ~ ! ' ~ '1 D.6- b. Address ~ ~~: ~~! ~' l <- c_ Dste signed ~ ~~/ ~ 3
?4. :~ RUHIAL 2~ b UATE 1. c. NAMEOF CEt~AEi'ERYpRCREIrAATpq 21. d LOCJ1TfONiGty Bo.o•. Twp• Cov~ty (Stats)
R[MOVAION O ~l'.21 ~1~3 CO=f1@IlUB C~p@1 C@~t,g }~i •t.OA IIe ~~t• ~O~
2b: DATE REC'O BY REG 26. REGISTRAR~ $IGNATURE 2T,,61GNAl'URE ANp J-qpR OF FUNERAL DIRE R
~ il~,r. 21, 1973 " -
S.S. No _r'~ ;,,~ L ~;/~~_-i. /~~"''"f" ~. ~- ~4rblsoais~Pa. 17243
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f991 l~AR 19 P~! i2= 12
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