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H105 11YtOOMREV 9-75
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IPEE FAR TH~S
II CERTIFSCATE i200)
FuU N
oE Dec
Addres
Place <
Dcath
Datc o
5~0969
w~-rtN~NG: ~t 1~ ill.p~ to ~wlicat. tlus coh h r~a.tbt o. rl~etea.~k.
COMMONWEALTH OF PENNSYLVANIA
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VITAL STATISTiCB
r s
N°_ 759632
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Alarital Status ---!`-~"_4~.. u_._d-4~QL1_.------ Se:._--•.~!k'1,~XLJ..---_Date of Birtl~~+~.~-!1,-S~•--- - -~- f-_1.LL /~
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Occupatiun -----~~--~~1'~ Q-G 1R~~rL l' L Sirthplace ..._._._------
--•-••-•- • - ta~ _.__..._----__
If Vetcran. v-hich War ..............._._.___
.._.Veteran's Serial No.
MEDICAL CERTIFICATE
Part L Death was cawed by:
[mmrdiate Caute (a)
Due To
Interval Betwcen
, Onset and Death
Due To (c)----•-------___-.__-.---~~_....__...,..--------------------•------------------------------.~~__.~______.---~-_..___.~__.-_____
Part 1[. OTHER SIGhIFICANT CONDITIONS: contr:buting to death but not related to the immcdiate cause givea in
Part I (a) ~ ~
` ~ ~
----------- •----- - --•-•--•-•---'~'-•-~ . _ _ ___..___ _-----
Accident, Suicide or Homicide ----------..~___-_•---.._._.__-----_--•--- ow did " lury occur -----------__---
Name and Tide oE Ptrson "~'~ ,- 1 ~
Who Certified Cause of Deat6 ( M.D., D.O.. Coroner) ._.--••-•-•--•• -.-----_--•--- .- --~/ ~ - -- - - -,(~ ~ ~
~/ -
Address.. ~ _.7.~_= :.._~ . ~ _~~ - ------------- ~ s .
This is to ccrtify that t6e intormation 6ere givea is mrtecUy copiod trom an original certificate of death duty 61ed with me as Locat
Regisuu. The criginal crnificate will be forw•udcd to the State Yital Statistics Otfice [or permanent filing.
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OoN of Ipw e( TA's Gwfif:cofio~
5~0969
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FILE[ LhC `: r~a^E'J
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fi ~~350 ~~~2~?
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LOCAL ftEGI3TRAA'S CTRTIFICATION OF DEATB