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H105.805 REV (2/21)
<br />LOCAL REGISTRAR'S CERTIFICATION OF DEATH
<br />WARNING: It is illegal to duplicate. this copy by photostat or photograph.
<br />Fee for his certificate: $20.00
<br />P 30297625
<br />Certification Number
<br />Type/Print In
<br />Permanent
<br />Bl.dk I
<br />Decedent's Legal Name (First, Middle, Last, Suffix)
<br />Mary E. Reinhardt
<br />2 0 2 5 0I Ill l l'"1
<br />This i$ toll certify that the into moil here given is
<br />corrOtly copied from an odlg'n X„Certificate of Death
<br />dulyll filed with me as Local 'tiegistrar. The original
<br />certificate will be forwarded to the State Vital
<br />I0tecq�ds Officj for, rmanent filing. I I
<br />COMMONWEALTH OF PENNSYLVANIA • DEPANTMENT OF HEALTH • VITAL RECORDS
<br />CERTIFICATE 11101, DEATH
<br />1.�2 1 3. Social Security Numb r
<br />* * 36732 n+ 024
<br />Sa. Age -Last Blrthda�, (Yr.) nL,y�, r!irnale 1 505-56-5730I !June 29, 2024
<br />ill
<br />84
<br />i°' Und.r 1 Year
<br />Months I Dees
<br />Sc.SUnd.r
<br />Morin.
<br />Day
<br />�'�. Minutes
<br />6. Date of 81rtb (Mtp/J$lY/Year) (Spell Month) 7a B
<br />Gr8hd
<br />I �1y 1�II
<br />I`e 4ixpli'OtV and State or Fanelgn X1 )
<br />I land. Nebraska �r1 1 k
<br />ILIII
<br />I il
<br />8.. Residence (Stage Or For.lgn Country)
<br />Pennsylvani i
<br />y
<br />8b. Residence (Street and Number
<br />Octl(ber 06. 1939
<br />- IIMdWde Apt No.) Sc. Did DecedentLI
<br />71tr Bl
<br />do a
<br />bpi (County) Hall �I
<br />�tp inshlp7
<br />'III
<br />Ih,
<br />gd. Residence (Cea,Pty)
<br />Cites, decedent
<br />160 Elephant Road a•
<br />1{+
<br />1
<br />r rp•
<br />Bucks
<br />9. Ever In U3 Armed
<br />8e. Residence (21p C0d.) 1891 7 0, decedent lived within limits of Dublin
<br />city/born.
<br />Forces? 10. Marital Status at Time of Gareth erried On Widowed 11. Surviving Spouse's Name (If wife. glue name prior to
<br />QYes ®No DUnknown I D DD lyor°.d Never Mani ClUnkn0wn JJI
<br />12. Father / Parent's Name
<br />first marriage)
<br />1 1
<br />(First, Middle, Le t Suffix)
<br />John'IEy Hayse
<br />14a. Inform f Name
<br />13. Mother / Parertrs"I
<br />Minnie Nab
<br />lam. Prior to First Marriage !lest, Middle,
<br />r 1, 1 " 1
<br />Last. Suffix)
<br />IIII
<br />114b. Relattorhsidp to. Decedent 14c. Informe'Irtt4
<br />William R. Reinhardt Son 5844 uih
<br />ng Address (Street and 1katutftbe
<br />Road Flpersville„ I-'f� 1y9}947
<br />d tV, State,
<br />Zip Code)
<br />Pal III III
<br />1
<br />f O**th �In NoutRa1: Inpatient
<br />a. glace o
<br />,....1t. a glace of D.atnZC
<br />file
<br />q�g
<br />)
<br />Emergency
<br />Emergenoy Room/Outpatient ri Dead on Arrival
<br />tin r. 0,n71��p]''
<br />Spmewh.r. OI)hof 'Fla . Nosp)t.i: (�d syWe^ 4ll tY (,J
<br />®Nursing Home/Long-Ter 'Facility I
<br />O.utledl
<br />i
<br />'J.6 Facility Name (1} not Inatltuticyt, give street and number)
<br />Brookdalo Dublin
<br />1 IViethod Disposition
<br />35e. City or Town, State, and'
<br />1] Othe1' (Spekily)
<br />Zip r' 13d. County of Death
<br />'llli 0917 Bucks
<br />"
<br />of
<br />gei Cmartltylt
<br />D Removal from State Bu joonationOro
<br />n Other (4 54iN) _..
<br />16d. Location
<br />te o} Disposition. n
<br />16b.DDate
<br />July 06, 2024
<br />id c8mabry, °rematch', or other
<br />refit Grove Cemetery
<br />place)
<br />III
<br />of Disposition (City or Town, State, and h P)
<br />Forest Grove. Pennsylvania 18922
<br />177aa.. 51
<br />Signature of Funeral Service Licensee or Person In Charge of interment
<br />nt
<br />BOvdStsm6aclt esrn>aKaRygsred]
<br />17b. License Number
<br />F0012740L
<br />.5
<br />17 Name and Complete Address of Funeral Facility Reed and Steinbach Funeral Ho Inc
<br />2�335 Lower State Ro8d DQvlaatown. Pennsvhrpnle.18901
<br />1 Decedent's Education
<br />"I
<br />1 II
<br />I
<br />02
<br />hi
<br />. - ('.hick the box that best describes the
<br />hest degree or level of school co np1.ted at the time of death.
<br />8th grade or less
<br />No diploma, 9th - 1,2th grpd
<br />High school graduate or GED completed
<br />Some college credit, but no degree
<br />Associate degree(e.g. AA. AS)
<br />hBach lor's degree(.g. BA. AB, B5)
<br />Master's tlegreir (e.g. Mh M5, MEng, MEd, MSW, MBA)
<br />Doctorate (e.g. Y'h0. Edo) or Professional degree
<br />19. Decedent of Hispanic 6 In - Check the
<br />box that best d.scnb.s ythet ter the decadent
<br />Is Sp.nish/HI penlc/Letlf6 C k the "No'
<br />box If decedent Is root lipanisl'i%Hispanle/Latino.
<br />No, not Spar)la I8pa Ic/Latino
<br />Yes, Mexican, M ticali American, Chicano
<br />Yes, Puerto Mown
<br />Yes, Cuban
<br />Yes, other Spanish/Hispanic/Latlno
<br />(Specify)
<br />20. D.cedenTegi
<br />the decedent
<br />White
<br />BI
<br />Arts •alarm
<br />eggs
<br />J.j00t$
<br />Other
<br />:e'
<br />d0n{I1111
<br />k tit 3ncandl Arn.rlcan
<br />Ind)lan
<br />t;�Irt'n
<br />goBi
<br />a.
<br />(Specify)
<br />Check ONE OR MORE
<br />d himself or herself
<br />or Alaska Native
<br />VK
<br />M
<br />race
<br />to be
<br />e1
<br />r
<br />}amiinlan
<br />repaeific
<br />fir
<br />In
<br />nIan
<br />I'IIj.
<br />o, C
<br />or Chamorro
<br />Islander
<br />What
<br />t
<br />21.
<br />(e.g. MD, DOS, DVM`LLB• ID)
<br />Decedent's Single Race
<br />Self -Designation
<br />Whit
<br />Slack or African American
<br />American Indian or Alaska Native
<br />Asia Indian
<br />- Check ONLY ONE to Indicate
<br />Jepa es.
<br />Ko een
<br />Vieer Asian tnamese me
<br />what the decedent considered himself or O t
<br />Samoan
<br />Other Pacific Islander
<br />Don t Know/Not Sure
<br />_
<br />*.n to be.
<br />22a. Decedent's
<br />done during
<br />u
<br />Registered
<br />Usual Occupation
<br />most
<br />rig Qf Working M..
<br />- Indicate
<br />DO
<br />NOT
<br />type
<br />USE
<br />RETIRED.'
<br />work
<br />II
<br />III
<br />Chinese
<br />Filipino
<br />N ti Hawaiian
<br />ied
<br />OLheSPadfy)
<br />22b Kind
<br />of dN}talnr.Wgddustry
<br />III
<br />III,
<br />Guamanian or Chemarro T
<br />He>� tkt
<br />�.
<br />1,.
<br />`iIllYTI PlSRSO. 24 I IUST 68 NO MPLE''ED
<br />cERTr FIEs DEATH
<br />23a. Date Pronounced peed (Mtii0.y/Yr)
<br />June 29. 2024
<br />9
<br />23b. Signat re of P9yon Pronouncing Deat (QM; 14h
<br />'.I
<br />W'.,,I 'p licabd.)
<br />e,., IItPD
<br />23c.
<br />UC.ns,I
<br />INtrrjMI,
<br />III �.
<br />2�d. Det. Signal (Mo/D.y/r"r) "
<br />June 29. 2024
<br />24. Time of Death
<br />Jennifer 5r(p8 dwell RN
<br />RN65758
<br />IIIj
<br />12:37
<br />25. Was Med Examiner or Coroner Co °MAI7
<br />Q Yes NI
<br />N0
<br />CAUSE OF DEATH
<br />26. Part I. Enter ther•haln M.v.nts-dis , Injuries• or complications -that directly caused the death. DO NOT enter terminal events such
<br />respiratory arrest or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add
<br />IMMEDIATE CAUSE --------> a. Failure to Thrive
<br />as cardiac arrest,
<br />additional lines if necessary
<br />Apwroxirrtete
<br />Onset
<br />03/2024
<br />Intermit
<br />to Death
<br />(Final disease or condition Due to (or as a < nsequenide !{
<br />• ulting In death) I.
<br />b. Advanced Dementia
<br />Sequentially
<br />f
<br />11
<br />'..
<br />list conditions, Duet (of a o s.quwlne. of):
<br />If any, leading to the came
<br />listed on line a. Enter the c.
<br />UNDERLYING
<br />CAUSE Due to (or as a rarisequence of):
<br />(disease or Injury the;
<br />Initiated the events resulting d.
<br />d.
<br />III
<br />II
<br />In death) MGM to (or op consequence of):
<br />26. Part tl. Enter
<br />III
<br />II
<br />other slenlfieant conditions rontri .ti t d .th but not resultingIn the underlying
<br />rlying cause n In Pa 1 ghr. Part
<br />Coroanry artery disease
<br />27. Win autopsy
<br />uY.s
<br />P�Np
<br />rmad7
<br />29. I}Femal
<br />28. Were autopsy
<br />to ro�g Int.
<br />the
<br />find
<br />cacti
<br />13
<br />. 0 available
<br />of
<br />death?
<br />11 d
<br />1
<br />'I
<br />.2
<br />Not pre g ant within Past year
<br />Pregnant t time of death
<br />Not pregnant, but pregnant within 42 days of death
<br />Not but
<br />.,
<br />30 1 D Tobecro Use Contribute tc �yath7
<br />I� 11..
<br />No Yes ® UnknownProbabiT 1
<br />31. Manner
<br />N furled
<br />jl}��aj{1 Suicideoccitio
<br />S l
<br />of
<br />1
<br />LIYOs
<br />Homicide
<br />Pending
<br />Could
<br />gl
<br />No
<br />III
<br />I
<br />4 1.1
<br />III
<br />pregnant, pregnant 43 deys;to 1 year before death
<br />Unknown 1f pregnant Within the past year
<br />y
<br />32. Date of Injury (Mo/Dayl/Yr) ,¢pelt Month)
<br />I
<br />LJ yldpll
<br />'I not
<br />t be
<br />be
<br />d 60rn
<br />deterlm�
<br />q
<br />`' �
<br />I.
<br />34. Place Injury
<br />33. T)rii4 tl sr,
<br />'I'41Y
<br />dil�Uyry
<br />11
<br />I'
<br />36.
<br />of (e.g home; Construction site; farm; school )
<br />Injury Work
<br />,I u��
<br />35. Location ONO (Street and Number. QM, to sir,
<br />',rap Code)
<br />at
<br />CI Yes
<br />ID No
<br />37.
<br />-
<br />If Transportation Injury, Specify:
<br />_
<br />n
<br />Passenger .tetor MI Other
<br />MIOththerr (Specify)
<br />38. Describe How Injury Occurred:
<br />39a.
<br />Certifier
<br />- physician, certified registered nurse practitioner. obviation assistant medical xamin
<br />Certifying only - To the best of my knowledge, death occurred plus to the cause(s) and a
<br />Pronouncing 8 C.rtlfying - To Fhe best of my know) rig , 5)sath t�eatrrMtl at the tint tl t)n
<br />® IN.d1ral Examine /Porch.[ - On She bash of .oral tkan, and/or nyestig.tion, Int my pl l n
<br />SIa of certlfle '.. Title or
<br />r iproner (Check only on.):
<br />d
<br />Ip) qT; antl due to the o(s) antlm'., iinii�
<br />death gtcurr.d at th. ti ., date• arhd i4a�$.
<br />s t d.
<br />rid du. to the causes)
<br />and
<br />'
<br />III
<br />''
<br />ni .d� Weld.
<br />I11
<br />39b.
<br />40.
<br />Name, Address and' 21p did rat Person Completing litre Oftba.th (Rem 26) Nita rii
<br />irrt)fi-gr_ikRNPpatin
<br />r t
<br />a VI,14loh
<br />1 1
<br />Numbs: 8PO18771�
<br />39u Date.
<br />Signed(Mdr/1
<br />July 01, 20
<br />pia
<br />�1
<br />43.
<br />NWmbler 1'4i,: Registrar's Signature 1
<br />09-101 LYnd4IP•Eegsn (Stgnatrua o,s
<br />Amendments,
<br />42. Registrar FI
<br />July 02.
<br />I'IIII1
<br />I. { f0.y/Yr)
<br />7ry.III
<br />Disposition Permit No. E765511
<br />H103-143
<br />REV 11/2017-E
<br />
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