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meer nao vo em Nat Fa a mr ree vegeta - = = ~, - ee er ren 20144 HEV. 4/60 7 t COMMONWEALTH OF PENNSYLVANIA . . ¢ ALAEGNO DEPARTMENT OF HEALTH ; . : VITAL STATISTICS MARY NO. CORONER’S CERTIFICATE OF OEATH , PEAT H 7 Coun a ‘City os-borewx — We. DECEASED'S " a. Sarees address, R.B., ‘gf Dox Number bccurnes {ny fe A. tr aT ess ht Levu aay; fj aie) tw ars u 7 fw" CC f ks or borough, give aa of towasbip {Do oat use R.D, vt Box Number) ‘oe fnstimeion’ (If got ia hospital, give scregt address) | b. Poar Office, Zone, and Sinte = st 3. VETERAN - Yes [?} No rt a, Which War. b. Serial No. (Moth) {Day} omit ! b9 HERE DID ’ f pECEAS| : : ; TUALLY a. State Cy Yeu, deceased lived ig towaship. . (VE? b. Country Fie, deceased lived within actual limics of id det 1k g wi city eet by iF 8. COLOR-OR RACE, (9. MARRIED (] NEVER MARRIED (77/10. BATE OF BIRTH 1. AGE (Io years Tf under 24 hours Lae bard i425 py Pew [er [ee bie Le Lit wicoweD [] vworcen RHA *# 75,19 ¥./ USUAL OCCUPATION {even if retir 13. SOCIAL SECURITY NO. 14. BIRTHPLACE (Stare ox Aqceiga eounry)+ 135. CITIZEN CF WHAT ‘COUNTRY? f oY a ia , hes ham vehi 4 : Le AAA al J 17. MOTHERS MAIDEN NAME ne a 19. INFORMANT’S NAME AND. BpORESS 2 AL 7 TG My AOL . be px] f H - USE Spear Enter only one cause per line PART L Death was caused by: IMMEDIATE CAUSE (a} ITED BETWEEN ONSEG-AND DEATH or DUE TO (b) oaditioas, if any, which 21. WAS AUTOPSY PERFORMED Yes No PETA . ACCIDENT [y | 22. b. DESCRISE HGW INJURY OCCURRED — A Y pave. time Hour Month Day Year suicine , yoy oF oe Mil! f b5 HOMICIDE [f-7 INJURY E.S.T. Aw , f. INJURY OCCURRED | 22. f. CITY, B : cqQuNyY 7}; pbile at 0 Nor while 4 Po 22, ¢. PLACE OF INJURY (e.g., bommc, farm, factory, street, etc.) 5 . , ork ar wotk LA i) tA Il bereby certify chat investigation of the death of the above named deceased resulted in the findiags bere scated, aod that time of dew bh is estimated as bt fm. me; date a i . sO f — . : . Signante of coreng: Eek pes er - b. Address A fowty P Cp? . > g. Dare sigaed A 14 1g bg . BURIAL cy 24. b. DATE 24. ¢. NAVE OF CEMETERY OR CREMATORY 24. d. LOCATION (City, Bogh., Twp/'& Cauaty) (Stace) CREMATION “ ; RemovaL [] DATE REC'D BY REG.| 26. REGISTRAR’S SIGNATURE 27. SIGNATURE AND ADDRESS OF FUNERAL DIRECTOR Lo. nM —_ J g 4