HomeMy WebLinkAbout12-21-07
IN RE: ESTATE OF
BRUCE L. GATES, Deceased
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
FILE NO.: 2007-01107
AFFIDA VIT
Amy M. Moya, Esquire, of the Law Offices of Susan E. Lederer, 4811 Jonestown
Road, Suite 226, Dauphin County, Harrisburg, Pennsylvania, being duly sworn according
to law, states as follows:
1. I- am the attorney for Frank K. Gates, Executor of the Estate of Bruce L.
Gates. Bruce L. Gates died on November 29, 2007.
2. On December 5, 2007, the Court admitted the will of Bruce L. Gates to
probate and issued Letters Testamentary to Frank K. Gates.
3. After the probate file was opened, I learned that the Social Security
Number on the death certificate and probate paperwork was incorrectly given as 196-18-
3642.
4. The correct Social Security Number for the decedent, Bruce L. Gates, is
196-18-3646.
5. An original corrected death certificate and a corrected Estate Information
Sheet are attached to this Affidavit.
A M. MOY A, ESQUIRE
Attorney J.D. No. 91402
Sworn to and subscribed
beft) me this \ qL day
of ~ ,2007.
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COMMONWEALTH OF PENNSVLVANIA
Notarial Seal
Jacqueline M. Mindeck, NolaIy Public
Lower Paxton Twp., Dauphin County
My Commission Expires Oct. 25, 2010
Member, Pennsylvania Association of Notaries
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LOCAL REGISTRAR'S CERTIFICATION OF DEA'TH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00
P 13989928
This is to certify that the information here given is
correctly copied from an original Certificate of Death
duly filed with me as Local Registrar. The original
certificate will be forwarded to the State Vital
Records Office for permanent filing.
Certification Number
~/J;~~.
Local Registrar ,
NOV 3;0 100/
Date Issued
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REV 11/2006
PRINT IN
VlNENT
:K INK
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
(See instructions and examples on reverse)
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6. Dale 01 Birth (Moo1l1, , III)
7. Bi ce(Cilyandstaleor
STATE FILE NUMBER
5. Age (lllst Birthday)
3. Social Security Number
196 - 18
3642
4. Date of Dealh (Month, day, Year)
November 29, 2007
mosiof fife. Donotstalere'
K"d 01 Busr.ssIlnduslly
Sales Holsum Bread
. 16. Oeoedent's Mailing Address (St....t, City I tOW1'1, slate, ~ code)
1000 West South Street
Carlisle, Pennsylvania 17013
12. Was Oecedenl ever In the
U.S. Armed Forces?
IXI V.. 0 No
Decedent's
ActuaIResidence 17a. Stale
13. Decedent's Education (Specily only highest grade completed)
Elementary I Secondary (0-12) College (1-1 or 5+)
12
ea. Place 01 Death Chock on~ one)
HOSpital. Other:
o InpaUenl 0 ER 10_nl OOOA IXI Nu"ing Home 0 Re_nce OOll1er . Specify:
9. Was Decedent of HIspanic Origin? IXI No 0 Yes 10. Race: American Indian, Black, While, elc.
(II yu, specify Ctban, (Specifyf
Mexican, PuMa Rican, etc.) Wh i t e
84 v".
Bb. Coon~ 01 Dealh
eptember 16, 1923 Fallen Timber, PA
ad. FaciIIy Neme (II not instllution, g;.e _, and ~
Cumberland
Sara A, Todd Memorial Home
14. Marital Status: Married, Never Married,
W_,Divorced(Specifyf
Widowed
17b. Coon~
Pennsylvania
Cumberland
Did Decedenl
Live ina
Township?
17c. 0 Yes, Decedent lived in
17d (1g ~~U~=oIL.Ned_n Carlisle
Twp.
18. Falher's Name (Firsl, middle, last, suffix)
City I Boro
19. Mother's Name (Arst, middle. maiden sumame)
Geraldine Wormer
2(b, Informan!'s Mailing Address (Street, city I town, state, zip code)
1809 Dogwood Road, Harrisburg, Pennsylvania 17110
21c. Place 01 DisposItion (Name 01 cemelery, crematory Of other place)
21d.locatiort (Cily' lown, stale, zip code)
3, 2007 Woodlawn Memorial Gardens Harrisburg, PA 17109
22c.NameandAddressoIFacIiIy Zimmerman-Auer Funeral Home, Inc.
4100 Jonestown Road, Harrisburg, Pennsylvania 17109
23b. Ucense Number
~-
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r. tJ A IV 'Cf.r. 0 ^-.1
Approximate Interval: Pan 11: Enter other simificant condlions conIribuIinn 10 dsllh 28. Did Tobacco Use Contribute 10 Death?
Onset to Death but not resulllng in the trder1ying cause given in Parll 0 Yes 0 Probably
Q-l'lO 0 Unknown
Sequent:t~~'~~a.
= UNDERLYIfG CAUSE
(dsease or i)jury lhal lritialedlha
ovenl, rISUlliig m deathl LAST.
Due to (or as a t;Ol'lS8quence of):
b. l)EMEkJT rA
Due 10 (or as a consequence of):
wEr<.iCS
it~
:29. If Female:
o NoIpregnantwithinpeslyear
D Pregnant altime 01 death
o No! pregnant, but pregnant within 42 days
01 death
o Not pregnant, but pregnant 43 days 10 1 year
beloredeath
o Unknown if pl'tglant within the pest year
:l2e. Place of Injury: Home, Farm, Street, Factory,
OIfrce Buiking, atc. (Specify)
c.
Due to (or as a consequence of):
:J:)a. Was an Autopsy
P-
d.
n. Were Autopsy FIndings
Available Prior 10 Completion
ol Cause of Death?
o v.. [9"No
OVes ONo
31. Manner of Death
~ra1 0 Homiclde
o Acddenl 0 Pendng In....igeUon
o S<ncIde 0 Could NoI be Det'rmined
32d. Tme of Injury
32g. location of lf1ury (Street, city I town, slale)
M
338. CeItifie< (ched< only one)
CertIfying phy.lclIn (Physician certifying cause of death when another physician has pronounced death and completed Item 23)
To the bHtof my knowledge. dealhocCtlrred due to the CIUse(S) and rnannet' II stated....................... _.... _................ _..........................
~=~a~ ~"::.h=:C~=::hu:.~:~~~:rt~ol:a=~:~~~ mannera. .tated........................................ 0
:c'::b;::n:::~~n= and / or Investigation, in my opinion, death occurred at the tfme, date, and place, and due to Ihe cause{s' and manner as stated- 0
33d. Dale Si!lned (Month, day, year)
IN\.b-.04-4-B'{G-L i11z/i/O'7
34. N'me and _.. pI p,,,,,,, Who Completed Cause."1 ~ (/JA!l1l 2l) TYJl! 111\i. 'nl
W 1(....-(- III-M .S KA (,1 r- y HI J-.l1V i )'VI)
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