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.JlIN1l 5 2007
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REV 11/2006
PRINT IN
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:K INK
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
(See instructions and examples on reverse)
:',- '~
11. Decedent's Usual Oceu tioo Kind of work done durin most of workin me. Do not state relired
Kind 01 Work Kind 01 Business I Induslry
Clerk State Government
12. Was Decedent ever in the
U.S, Armed Forces?
[]lives ONO
Decedent's
Actual Residence 17a, Stale
13. Decedenl's Education (Specify only highest grade completed)
Elementary I Secondary (0-12) College (1-4 or 5+)
12
14. Marital Status: Married, Never Married.
Widowed, Divorced (Specify)
widowed
Other
- Hospice
m?lthm Sp"ci~ House
10. Race: American Indian, Black, White, etc
(Specilyj
85
February 12,1922 Marysville, PA ONU~i"gHome
ad. Facility Name (1f not institution, give street and number) 9. Was Decedent of Hispanic Origin? Qg No D Ves
Twp. Carolyn Croxton Slane Hospice Residenc ~:'~;~:;~~rt~~~:~; ele)
3, Social Security Number
1'iS- - Ib -4$'''3
I. Name of Decedent (First, middle, last, suffix)
_h~I'\.J, C.r'ossl~
5 Age (Last Birthday)
v"
6. Date of Birth (Month, day, year)
Dauphin
white
. 16. Decedenfs Mailing Address (Street. city.. town, state, zip code)
8 Dewberry Court
Mechanicsburg, PA 17055
18. Falt1er's Name (First, middle, last. suffix)
Russel James Crossley
17b, County
Pennsylvania
Cumberland
Did Decedent
Liveina
Township?
17c. ~ Yes, Decedent Lived in
17d. 0 No, Decedent Lived within
Actual Umitsot
Dpper Allen
Twp
Cityi Boro
19. Mother's Name (First, middle, maiden surname)
Floa Elizabeth Keller
20a. Informant's Name (Type I Print)
Gary J.
2Gb. Informanfs Mailing Address (Street, city !town, slate, zip code)
556 Allenview Drive, Mechanicsburg, PA 17055
21b, Date of Disposition (Month, day, year) 21c. Place of Disposition (Name ot cemetery, crematory or other place) 21d. Locafion (City flown, state. zip code)
Evans Crematory
22c. Name and Address of Facility
Parthemore FH & CS, Inc., P.O. Box 431, New
Schaefferstown, PA 17088
23b Licef1se Number
MO - oc. 220(., - L.
Cumberland, PA 17070
23c. Date Signed (Month, day, year)
f:)(,[-zsfo+
26, Was Case Referred to Medical Examiner I COlDner for a Reason Other than Cremation or Donallon?
OV" [)<;INc
CAUSE OF DEATH (See instructions and examples)
Item 27, Parll: Enter the ~ diseases, infuries, or complications that direcl1y caused the death. DO NOT entel terminal events such as cardiac arrest
respilatory arresl. or ventricular fibrillation without showing the etiology . List only one cause on each line
Approximate interval
Onset to Death
Panl!: EnlerOlhersianifJCantconditionscanlribulino to death,
but not resulting inlhe underlying cause given in Part I
~~~d~~;e;atn~~; d~~~\ dise:;
Q~S"'I.Y'Jo.--~ {'~~
b, DUlt~~queocet'~L
Due to (or as a consequence of)'
to hf'~.
?-. mo!..
6""",...-'1. h-b, Di~
~et\l.V'osc.{tKo\i.1
28, Did Tobacco Use Contribute to Death~
DYes DProbably
IgJ No 0 Unknown
29. If Female
D Not pregnanl within pasl year
o Pregnanlattimeoldealh
o NOlpregnanl. but pregnant within 42 days
of death
D NOlpregnanl,butpregnanl43daystQ 1 year
belore death
o Unknown i! pregnant within the past year
SeQuenlialty list conditions, if any,
~~!~~~~o J~D~Rt~II~~~iu~ee a
(disease or injUry thai initiated the
events resulting In death) LAST.
Due 10 {or as a consequence of)
Ov" ONc
31. Manner of Death
jgl Natural 0 Homicide
o Accident 0 Pending Investigation 32d, Time 01 Injury
o Suicide 0 Could Not be Determined
32C. Place of InJUry: Home. Farm. Slreet, Factory,
Office Building, etc, (Specdy)
30a. Was an Autopsy
Performed?
JOb Were Autopsy Findings
Available Pnor 10 Completion
of Cause of Death?
o Yes 5ZI No
32g. Location of Inlury(Street. citY/lawn. state)
33a Certilier (check onfy one}
Certifying physician (Physician certitying cause of death when another physician has pronounced death and completed Item 23)
To the best of my knowledge, death occurred due to the cDuse(s) and manner as stated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0
Pronouncing and certtfylng physician (Physician both pronouncing death and certifying to cause ot death)
To the besl of my knoWledge, death occurred al the lime, dale, and place, and due to the CBUSe(S) and manner as stated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0
Medical Examiner { Coroner
On Ihe basis of examination and I or invesligation, In my opinion, death occurred althe time, dale, and place, and due to the cause(s) and manner as stated_ 0
0+
35, Registrar's Sign~, f and Distnct Nu~ ff,'/' ','
~ ,,"7 rY' r-, 7T/ /.-. A"" /> .a:L<;7.R_
I~ I / I dl / I / I
'~O"fJ
34. Name and Address of pei"iTIl=IeSd;~U~i OS~t~:;~7r:~ I Print
1 Kac~y Ct. S:l!~.0 j~S-:'~,--
Mecha:m.cr:ooburg, JP;:-1 'I.... ~ J
Disposition Permit No
WJ2SS
23-29330'15
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 2B0601
HARRISBURG. PA 1712B-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
CROSSLEY GARY J
556 ALLENVIEW DRIVE
MECHANICSBURG, PA 17055
-------~ fold
ESTATE INFORMATION: SSN: 195-16-4563
FILE NUMBER: 2107-0866
DECEDENT NAME: CROSSLEY JOHN J
DATE OF PAYMENT: 09/21/2007
POSTMARK DATE: 09/21/2007
COUNTY: CUMBERLAND
DATE OF DEATH: 06/23/2007
NO. CD 008721
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $14,250.00
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
$14,250.00
REMARKS:
CHECK#1547
SEAL
INITIALS: JA
RECEIVED BY:
REGISTER OF WILLS
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS