HomeMy WebLinkAbout10-05-07 (2)
CERTIFICATION OF NOTICE UNDER Pac O.C. Rule 5.6(a)
REGISTER OF WILLS
CUM'bQ.'("!a..rvL COUNTY, PENNSYLVANIA
Name of Decedent: An Y\L.... ~ l..\''r\c...h~r l6
Date of Death: 0 c-\-c be. y- J...llJ I ~a 10 File Number: ~L)~ 7 . DO Y30
Date Letters Granted: tV\. CiJ...J d .~ t'l7
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To the Register:
I certify that Notice of Estate Administration required by Pa. O.C. Rule 5.6(a) of the Orphans' Court
Rul,es was served on or mailed to the following beneficiaries of the above-captioned estate on
N{A
Name: Address:
\Ju..Yv1e~~g\.l\1.c-\ut;J( -~Oh '- )e.c..~ 2>-~I.t;"'do07
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1-: U i1:~ d.e.l\.~ tJrt 11iL<Lr& l~l ~()7)
(Ifmore space is needed, attach separate sheet.)
Notice has now been given to all persons entitled thereto under Pa. O.C. Rule 5.6(a) except:
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Capacity: ~al Representative 0 Counsel
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Name of Person Filing this Form '
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Form RW-08 rev. 10,13.06
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IMPORTANT NOTICE
NOTICE OF ESTATE ADMINISTRATION
PURSUANT TO Pa. O.C. Rule 5.6
THIS NOTICE DOES NOT MEAN THAT YOU WILL RECEIVE
ANY M01\TEY OR PROPERTY FROM THIS ESTATE OR OTHERWISE
Whether you will receive any money or property will be determined wholly or partly by
the decedent's will. If the decedent died without a will, whether you will receive any
money or property will be determined by the intestacy laws of Pennsylvania.
PEJ\1NSYL V ANrA
, Deceased
TO:
NO f5e.~1.f:;~t:.~ f{~~+--
=::s:h e Y' l.. "- .. \J... ~ I
\'Benefi ciary)
(Address)
The Decedent died: X testate (with a will) or _intestate (without a will).
You may have a beneficial interest in the estate as follows:
(If additional space is needed, use separate sheet)
The name(s), addressees) and telephone number(s) of all personal representatives appointed are:
~A\ffi. , ,ADDJ3.E~S - - TE~LP ONE w'\ '- L ~ (,)
:::u'l (. 'r-((,J t-t u.... n l...-tl.c... 't'-" \,. t:<... cl.~ ~ ka ~ 1"\ \Joe... \0 n Vl~~ U) h. \\' tL 15'iu/...
. (:rJ..Y~L-~~3S '-
If the Decedent died testate, the will has been filed with Office ofthe Register of Wills of ~M. n-e.\'""'~~
County .
If the Decedent died ~ Petition for the Grant of Letters of Administration was filed with the Office of the
Register of Wills of County.
The Register's address is
, and telephone number is
A copy of the Will or Petition may be obtained by contacting the egister of Wills and paying the charges for
duplication.
Date 10 - ~ J.-ICJa 7
Capacity:
~sona] Representative
o Counsel for Personal Representative
ignature of Person ilin this Fonn .
:She. .,. ~ "- t l~ \.l. Y\ c.-h ~.r-L K
Name of Person Filing this Form -
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Telephone
Form RH'-07 rev. 10.13.06
Ii. I~, i() ccrtifv that the information here given is correctly copied from an original certificate of death duly filed with me as
II Ii I, cgistraL The original certificate will be forwarded to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
No.
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Fce for this certificate. $6.00
Local Reg:istrar
P 13404.510
"MAR.1 9 ~r 1
Date
105-143 REV lli20JE
TYPE, PRINT IN
PERMANENT
BLACK INK
\"UMMUI'4lVVCI-\L.l n VI"" t"!:.I'r1I'4l;:)TL.YI-\I'IIIA. ut:t"I-\" IIVlt:I'I1 vr nCI-\LI n. Ylll"'.. nc.\."vnu.:l
CERTIFICATE OF DEATH
(See instructions and examples on reverse)
STATE FILE NUMBER
1, Name 01 Decedent (Flrs~, mlddie. las!. sutllx)
Jrfr>7Cf
/-1 V ,'?C /-( A /2 / /<;;
6 Date of 81rtr I,Mv'11h. daY.iear'1
4. Date of Death IMontl1, day, year]
...:,' -/.,' 2.,c 7
5'7'
Yrs
9-2-/'9'7'7
J 6/74~/-c;..'L.......
8a Place 01 Death I,Checlo. onlyonel
Hospital
/7// 0 Inpatient 0 EA 'Outpatient 0 DOA
9 Was Decedent at HispaniC Ongln?
L: ~ .- E ~ ~:x~;~:,~~i;rt~~~:n atci
Other
5 Age (last Birthday I
L"AP)3/?/,~
"V:'D";-I"t...-
L/l.... ,?C,:. 1'...",...',1
c:;.y M-
.g] Nursir.g HO'TIe 0 Residence DOmer, SpeClty
~ No 0 Yes 10, Race: Amencan Indian
lSPec1r,1
LA.//1'/ /'<:.3
Black Wr,;le,etc
6b Count., 01 Death
3d, Facility Name jll noll11stttutlon, give street and n\Jmb€r)
_./ C ~....t....... -; " l ... ,'II , / ':':-,.1
16 Father's Name (FIISt. middle. last suffiX)
-.I ;,t7/l)E ~
17b. County
/,/-1
C-,;<-j /?.J 6/Z ../,,-I'
Old Decedent
l'veina
Township?
17c.D Yes Deceaen\ lived In
17d,.&1 No Decedent uved wrthm
Actuallrmilsot
Twp
11. De-:eden1 s Usua: OeCIJ ati:Jr :Klne 01 wor1< doll-t ourlr mosl 01 wor~ln life Do not stale retired'
~;lrld 01 WOlk Kind o~ Business' Industry
G'<'-'.~T~' /'"__''' Cb"1 ~;:,,,--,i:' /?/I S';--,.:;, ;...E
. 16, Decedent's Mailing Address (S1reeL city,' lown stale, Zip code)
S--::;7 ,/",,,'~./.),-,;-I"'L,-,) '''It.....-A...~
12 Was Decedent eve~in the
US Armed Forces~
~y" DNo
13. Decedenfs EduCi:lllQn fSpecl!\,'onlv r"lgt'lest grade cO'Tlpleled',
Eiementary,' Secondary 10.12) COllege (1-4 or 5+1
/2.. 5 .;
1.1 Marital S:atJs. Married. Never Married
Widowed Divorced (Specilyl
/J--;;;/z-,z 1'.5 ,J
Decedent's
Actual Residence 17a. Slale
, ..s-jcZ
..~.",7'''I..~ 7(. ':""l..-
City flclItj
/;1 v / ) L. /7' /? /2 / .k
19. Mothers Name (First. middle malde[l surname I
./1/lu'-4 (' /l?t"- (/-{/7/i,. )
ry.:- /1- c /t ,-r..e / ~
20a Informant's Name \T ype .' Print)
-.S/'1 F/c ',1 L.
/-7"C-//I. C' /r /'7, Z / /0('
20b, Informant s Malllllg Aodress (Street City' tQwn. slat~, Zip code)
S5>7 /t/.;". 0< '7/-') /I~::
21c. Place 01 DIspOSition (NarT'e01 cemelery, cremalory or olher place I
LTZ-,'f./4"/~JV, ~~ t4- ///'1",...;/,: C. '-'/
--/ ':.//"i..~;: ~ t>. ..., /'/rJ /.>)- () ~
21d Localloo (City ;'town, state, zlpcodeJ
o
~
co
~
::i
22c. Name and Addr€ss 01 FaCility
4/',->",(:""i"( F..... ,/........-/,- /-/....... 1':'/
7'7 -7
-5';-
'"
J (;H/_ ~ T.. ...., /)/1 f.f,{ t-
23c Date Signed (Month, day. yeali
21 a Me\hod of DispoSition
D Burial 0 Removallrom Stale
Ze../
.J~'/t'.4j;~':'--:....,~",,; /.J)7'''-,),-"
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Completellems23a. whencertrfying
phYSICian IS nol available at 11me 01 oeatrl to
certify cause of dealh
23b License Number
Items 24.26 must be completed by person
who pronounces death
24, T,me of Death
25 Date Pronounced Dead {Monti'\, day year)
q.2c ^ M ~1(,nt. ;{H.. c2oo)
26 Was Case Rererred to Medical Examiner i Coroner 101 a Reason Othel than Cremallon or Donation?
Dyes ~NO
CAUSE OF DEATH (See instructions and examples)
Ilem 27, Part I: Enler the ~ - diseases, Inluries. or complicahons- that directly caused the death DO NOT enlert€'rmmal events such as cardiac arrest.
resplraloryarreslorventncularfibnllallon....llhoulshowinglheellology, List only one cause on e hllne
~~d7t~lt;e;al~n~~;d~~I~;ldlse.:;. 'XeJ ~/j\. -It') Gi rf
Due te (or as a consequenc of)
Approxlmale interval Part II: Enter other smrlf'cant condlllons corlributlnc to death 26 Did Tobacco Use Conlnbute 10 Death?
Onset 10 Death but not lesultlng in the under1ying cause given I~ Part I DYes 0 Probably
o No ~ Unknown
Dyes ONo
LJ Yes G No
31. Manner of Death
(a Nalural 0 HomiCide
DAwdent DPendlnglnveshgation 32dTimeoflnJury
o SUicide 0 COlild Not be Del€'rmlned
29. II Female:
o Not pregnar,l withlrl past year
D Pr€'gnant at time ot dealr,
o NotpregnanL but pregnant withlfl 4: days
of death
o NOlpre<;JrlanL but pregnant 43 days 10 1 year
betoredeath
o Unknown If pregnant y,..ithin the pasl year
Home. Farm. Street Factory
elc (SDecifYI
Sequenllallv list condlttQl1s,llany
~~l~~~~o ~NeDER~II~~~A~~~ a
(disease orin)ury lhal illllialed the
eyenlSreSL:llIng IIldealhj LAST.
Due to (or asa consequencE' of)
Due 10 lor as a consequence Of)
30a Was an Autopsy
Pertorrned?
ot Cause of Dealh?
11/1/12.-1'/1
32: H Transportallon InJur~' ,:Specily.i 32g Localion olln)ul)' IStreel city' town, state)
o Dnver.' Operator 0 Passenger DPedestrran
DOtner.Spen'"
33a Certifier (chad, onl\,' onel
Certifying physician IPhvs1Cian certifYing cause Jf death wher. another physiCian has pronounced dealr, and compleleo Iterr 23'1
To II'Ie besl of my knowledge, death occurred due to the cause(s) and manner as stated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0
Pronouncing and certifying physician {P~vsiclan bompronounclng death anc certlfYI;'Jg to cause o' deatn n
To the besl of my knOWledge, death occurred al the tIme. date. and place. and due 10 the cause(s) and manner as stalecL _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ U
~~~~:lb;:~Sm~~:~~;~~~t~: and i or investigation. in my opinion, dealh occurred at the time. date. and place, and due 10 the cause(si and manner as staled_ 0
IMontt'.Jd\-, year]
.,;'" /6"" 1('(,/
3.: NanH2 and AJc:~ess of Persor. WhP-'i'GlPlele~ Cai-H ot Death [llefT :~; Type
) I 'I?JI 'f II
(U1r f"~'IlIc;(fJ... j/"'", ~/r
'~ ,/+ """" ft ( J ,
DISPOSlllon P"rmll t~o. CJ J 7 I .~ -'j- S-