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20144FV.4/60 COMMONweaLTh OF PEnnSyLVanIA CALREG.NO. DEpARTMEnt OF hEALTH VITAL STATISTICS MARY r.NO. CORONeR's CERTIficate Of DEATH DEATH Box Nunbe OCCURRED MAorle MAILING ADDRESS N: or borougbgive ae of towasbip Do oot use R.D.Boz Numbe Full Name .VETERAN Ye No of Hospica .thich Var b.Serial No AME OF (First) b.(Midde ALLen 5.DATE DECEASED OF Type print DEATH HERE DID ECEASED CTUALLY a.State owaship. b.Coury Y No, deceased lived within acinaJ Jimits of IVEZ city orborougb 8.COLOROR RACE 9. mARriED NEVER MARRIED 10ATE OF BIRTH 1.AGEla yc funder I y< funde 2aour o3m0CIm DIVORCED s.brbdy Moachs Mia. USUAOCCUPATION ( if sed 13. SOcial Security no. 14.SRHPLAESe toesg country 15.CITIZEN CFWAT COUNTRY FULL NAME OF SPOUSE 17.MOTHE MAIDEN NAME FATHER'S NAME AME AND APORES e MEDICAL CERTIFICATION INTERVAL BETWEEN {a.bc PART L Death was caused by: MEDIATE CAUSE totlerl- trllet, ro Coaditioos, if any, which DUE TO(b ave risc to above causc fa) staiog cbe uadcdying DUE TOc cause last. PART II OTHER SIGNFICANT CONDITIONS: coqributing to death b a relaced disguse given in Part id. 21.WAS AUTOPSY si PERFORMED Yes ACCIDENT 22.b.DESCRISE HW INJURY OCCURRED 22.c.TIME Hour Month Day SUICIDE OF B. INJURY E.S.T. 1/. HOMICIDE 14 .INJURY OCCURRED 22.c.PLACE OF INJURY e.g.,bowc, farm WNSHTP Nor while factoy,scet,ctc.) rork arwok I bgreby certify h at investigation of che dcatb of the abovc aamei deceased resulted in the f .E.S.T. e.date statedabos 72196) Sitoa . b.Address c.Dae signed BURIAL 24.b.DATE 24.C.NAVE OF CEMETERY OR CREMATORY 24.d.LOCATONCicyBo.Twp&Couaty (Stase CREMATION REMOVAL DATE REC'D SY REG.26.REGISTRAR'S SIGNATURE 27.SIGNATURE AND ADDRESS OF FUNERAL DIRECTOR