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H105112500M REV 2-78 ~~~~C~
.(100 Csh pw booky COMMONWEALT~I OF PENNSYLVANIA
IFEE FORTHIS pEVARTMENTOF HEAITH-VITALSTATISTICS ~Q 905001
CERTIFICATE 52.00)
LOCAL KEGISTRAR'S CERTIFICATION OF DEATH Registered No.
Full hame
of Decease
First y~idl l
yr~
Residence
Number tro City or n Co Stst!
Place of
Death ennsyivania
County City, Borou r Tow~ship
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Sex Date of Deat ~ Race ~
Date of Birt ~fr Birthplacp~PW~~~~ _/4 biarital Statu I'
' Social Security No_ `J~~~~~~~~~A Occupatio /~~d~'l~' Veteran's Serial No.
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f NEDICAL CERTIFICATE Inlerval Between
~ Part I. Death was caused by: Onset aad Death
[mmediate Cause (a , ~
Due To (b
Due To (c
Part II. OTHER 31GNIFICAI3T CONDITIONS: contributin~ to death but not related to the immediate cause given in
Part I (a)
Accident, Suicide or Homicicie How did injury occur
Name and Title of Pereon
Who Certified Cause of Death (M. , D.O., Coroner~ M.E.
Addresa ~ ~ ~
Str~et
This is to certi[y that the inforrrwtion here iven is correctly copied from an o a! certiCcate of death duly filed with
me ar Local ReQictru. Tt?e ariginal certificate vri~i be forwarde~ to t $tate Yi S Listica ffice for permaneat flin~.
a
Louf RWiscn V t ht !es A D{sKict No.
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~ StrMt r y, Bo~ou'h. TownshiP
sr.
~ Data R~iwd by LotN Rspistr~r
/sr
Oats of Issu This Grti ~e~tion
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