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~ WAFZNIJN(3:M:_1~''•is;i~legal to dupiicatc this copy by photostat or photograph. ~ i
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. . . 0 1974
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`:Date No.
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~ -°.~'~,is :is~3to certif~; 't}ia ~this is a true copy of the record which is on file in the Pennsylvania
~~,~~rartment ~ o~ F3e~~~~,, in accordance with ~ Act 66, P. L. 30•Y, approved by ~he General
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Fee foi ~his certificate Y2.00 REC~R~ ~E~~~~~p ~"""e""~
( ~ ) ~ - ~ J. Finton Speller, M.D.
~ ~ 3 ~,5 . Secretary of Heatth
, ~~~~~r Harrisburg, Pennsylvania -
i Hios-~~3 a:~. s-1 - COMMONWEAITH OF PENNSYLVANIA ~ ?
~OCAL REG. NO. DEPARTMENT OF HEALTFi i
~ • PRIMARIi~ /y~ ~ VlTAL STATISTICS ~ ~ O ~ ~ , ~ ` ;
DIST. NO. 7 ~_~l CERTIFICATE OF DEAT'ri - t~~
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t. GEATH s: County b. City or bo?ouflh 2. DECEASEU'S Y- Street ~ddr~ss, A.D., or Box Numb~r ~
' OCCUARED . - ' MAILIt~(i
~ IN: v@ r~Q.f~ O SUC~arCrG@IC ADORE3S ~ S~ ~o v~. A ~~.n u e
; c. It d~ath did not oceur in Gty b. Post Otfcs. State end 2,p Cod~
. or poroug~, yive nams of township
i (Of? not use R.D. or Box Number) d~ ~ C~~ ~ C,L, • ~ b 3~ !
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d. Fuil N~me 3. VETERAN Y~~ ~ No. ~
oi Flospiql ~ra. n 1~ 1 i h ~ OS i~~0.J~
or institut~on (if not in Twspital, 9ire street addresa) YVhieh War b. Serial Np,
NAME OF a. (First) b. (Middl~) a(l.ast] 5. OATE (Month) (D~y) (Yeu) j
OECEASED
ITYP~ o~ Print) o h n i l 1~ o...~,~, W Q.~~~ DEA7H ~ 3 - 7~ ij
6. WH~i~E t`3ii3 ~ c. Oid dsceased tive in a township7 ' t
~ DECEASEO a. State Q-- ~ Yas, deceased livsd in townsni k
ACTUALLY O i 1 C~ t_ p ~
UVE? ' b. C`o~.~ty ~~l ~ No, deceased lived within actwf limits ot ycity or borov9h_ . `
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7. SEX 8. RACE 9. NIARRIED ~ NEVER MARRIED? 10• DATE OF BIRTH t f. AGE (+n Ye+?s tf undtr.f yea~ !i und~r 24 h~vrs J
' r I~st binhday) Months L~ys Min_
M = - W - WIDUWEDO _ DIVORCEO ? ~ ~ " (p ~ -
12_ USUAi O£CUP T ( s~ ' etired) 13. SO 1 l U Y . 14. BIRTHPLACE (Stata or for~i n count ) 16. C~T12 N OF WHA'f COU?1:
FiY E
u ervisor-~~.~ ~e~~nery Z'~'1 Coal Glen P~ ~ ry - U~A ~
!B. FUII NAME OF SPOUSE - 17. M07HER'S MAIDEN NAME
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Cs rQ.e e S _ W~~, _ ~IariS~R Hinds - ,
18. FATHEE}'S NAtiIE - t F T' AM ESS N 21P ODE . ?
Richard Ward ~ s~' ~~i~ City, Pa .16301 ,
MEDlC.qL CERTIF~CATE (Itema 20 through 23 muat be compteted by physician only) INTERVAI BETNEEl+I ~
" O?~SET ANO QEATH i
20. CAUSE OF OEATH: Ente~ only one cause per line tor (s), (b) 8(c~ - . _ t
' PART 1. Death was uused bp: / " ~
IMMEOIATE CAUSE (a1 • ~~-G~//'ui~'?~. C /~Ys~f ( I Z/ ~~s . - . i
~ ConditiOnf. it anr, which . ^ - i
yav~ ryp [o above uuse ~ i !{r..,Ln s... i'L l;~ ~
(s) sbtin9 th~ undar- DUETU(b) ~N+s1c~~_f ~
- lyiny es~sa last. OUE TO (c) ' -
PART ~~=-~NlFl~rNT C~D!'IONS: contributing to death but not related to the imm~dhte uuse 9even in Part 1(a) 21_ Y~S AUTOPSY ~
~ oERWRMED
~ hSo
_ 2?. a. ACC~DENT 22. b. DEFiCRIBE HOW ACCIDENT OCCURRED 22. c. 7l1NE Hour Morth u~y TeK ~
Y~s? NoQ . ~ QF m- ~
ACC~DENT ~ T.
22_ d. ACC~~ENT OCCURHED 22. e_ PLACE OF ACC+DEMT (s.Q., homt, pp. i. (;ITY, 80AOUGH, TOWNSHIP COUNTY STATE '
Whil~ ~t ~ Not whils Q tarm, street, etc) f
wwk at work . . - - - i
29. 1 hereby eertify thai t tnd the abo,n named deceasee n~ t death occurr~d from ths cauaea snd on ~F,a date sbtetl sbov~ st 1. ~ Z. ~
~ M.O • •
, a- SiQnature ~ ~~"'t- -D:O. b. Add~ess yG~!'~p~ ~(,(l~;,CVj• f" c. Dsta aignrd I
2~• BURIAL ' - b_ ~ATE 21. a NAINE OF CEMETERY OR CREMATOR 2~. d. IOCATION (Gq. Boro. Twp, 6 Countyj ( ts~)
a Movi1ON ~ ~-2~-197~4 - unset Hill Mem Garden Cranberr Venan o Co~ Pa. .
o y~ g
_ 2b. OATE REC'D BY REG. 26• REGISTRAR'S SIGNATURE 27. IGIIATURE AND A'J ESS OF FUNERAL DIAEC7DR
~ ~_5 ~ . ~~IZ ! 'S~ 7i/ ~~:1~~ r ` ~~A ~ v j~~1 ~l~ ~~1 City, Pa
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