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Pa. O.C. Rule 6.12 STATUS REPORT
REGISTER OF WILLS OF ~
COUNTY, PENNSYL VANIA
Name of Decedent:
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Date of Death: r' :3 J ') :l. 00 f,
File Number:
00 3 70 I
~lA - \ 60
Pursuant to Pa. O.C. Rule 6.12, I report the following with respect to completion of the administration of
the above-captioned estate:
1. State whether administration of the estate is complete: . . . . . . . . . . . . . . . . . . .. [i(Yes D No
2. If the answer is No, state when the personal representative
reasonably believes that the administration will be complete:
3. If the answer to No.1 is YES, state the following:
a. Did the personal representative file a final account with the Court? . . . . . .. DYes I:i1No
b. The separate Orphans' Court No. (if any) for the personal
representative's account is:
c. Did the personal representative state an account
informally to the parties in interest? ............................... fitYes DNo
d. Copies of receipts, releases, joinders and approvals of formal or informal accounts may be
filed with the Clerk of the Orphans' Court and may be attached to this report.
Date
J<:UYV# 4- 7 2. 00 p.
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Signature of Person Filing this Form
Capacity: rnPersonal Representative 0 Counsel
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Name of Person Filing this F1:}n .
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Form RW.IO rev. 10.13.06
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H105.905MS REV.i5-05)
This is to certify that this is a true copy of the record which is on file in the Pennsylvania Division of Vital Records In accordance
with Act 66, P.L. 304, approved by the General Assembly, June 29, 1953.
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WARNING: It is illegal to duplicate this copy by photostat or photograph.
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Cilvin B. Johnson, M.D., M.P.H.
Secretary of Health
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Charles Hardester
State Registrar
0762276
MAR 1 5 2006
No.
2 Date
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H105.143 ReY. 01~
TfPf/PHINT IN
PERMANENT
SLACK INK
1 Name of Decedenl (First, middle. Iasl)
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COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH' VITAL RECORDS .-'::; ~
STATE FIJ:PUMBtR
4. Dale of Death m,day,year)
January 31, 2006
o Residence 0 Other.
10. Race: American Indian, Black. WMe. tic
(SpecifyI
White
hi hast rade co Ieled 14. Marital Status: Married, Never married, 15. Surviving Spouse (If wife. give maiden name)
College (1-4 or 5+) Widowed. Divorced ($pecif)1
arried Lo Greene
Did Decedent
liveina 17c.X1 Yes, Decedenl liYecI in LnWP..T A112n Twp
Townsh~?
Janet W. Greene
3. Social Security Nurmer
5. hJe (Last birthday)
83 v"
; Bb. County of Dealh
7. Dale 01 Birth Month.da .
Cumberland
Lower Allen
mosl of workin life; do not stale retired
Kind of Busmessllndust'Y
Secretar Law Firm
16 Decedent's Mading Address (Street. cityl1own, slate, zip code)
325 Wesley Drive, Apt 123
Mec~anicsburg, PA 17055
12.
13. Decedent's Education ec
Elementary/Secondary(Q-12)
12 2
PA
17a. Slale
17b. County
Cumberland
17d 0 No, Deceden1 Lived within
Actual Lirrilsof
18. Father's Name (FirsI,rriddle,last)
19. Mother's Name (First, middle, maiden surname)
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Arthur Wagner
Fannie Beard
lOb. lnlorrrenfs Mdng Address (Street, cityllown, state, zip code)
325 Wesley Drive, Apt 123 Mechanicsburg, PA 17055
Harrisbur
P
17109
23c. Dale Signed (Month, day, year)
:r~rwtNr 31/L.000
26. Was Case Referred 10 a Medical ExanlnerlCorol'lM?
~Y85 DNa
Part II: Enter other sianificant condilions conlmulinalo death, 28. D~' Toba UseContrbute to Death?
but not resulting in tile underlying cause given in Part leD Probably
o 0 Unknown
208. In!orman!'s Name (Typelprinf)
Mr. Loy Greene
21b. Date of Disposition (Month, day, year)
I : 50 A/'Y) .TCV11/lt1i1..li
CAUSE OF DEATH {See Instnlctlons and eumplesl
Item 27. Part I: Enler the ~ - diseases, injuries, or eorf'4)licalions - that directly caused the death. 00 NOT enter terminal events such as cardiac arrest,
resptalOfy arrest. or ventricular flbrilafion without showing the etiology. DO NOT abbreviale. Entet only I" cau!';e on a line
IllUEIlIATE CAUSE (F".,""...." lt~fi:A' h "'<J.~ ~ d vr<..
condition tesulllOQ II cleath) ~ a. ~ _ _ __
Due 10 (or as 8 consequence of): A.
Sequentia'Y"'condiOn"Wany, b. r/lc.... __D-'7;-
_ =~:o:~~:~~a Due 10 (or as a eonsequenceof):
. (diseaseoriljurythalllilialedthe
ev9nIs resulling in death) LAST
Approximate interval:
onset 10 death
Due 10 (or as a consequence of)'
308. Was an Autopsy
f'arlonned'
.
3(1). Were Autopsy Findings
AveilablePrior~to ion
of Cause ofD .
o Yes No
32d, Time of Injury
31. Mann
32a. Date of Injury (Month, day, year)
32b, Describe how Injury Occurred
Ih
o Homicide
o Pendinglnvestigalion
C Could Not Be Determined
alUtal
o /lceidenl
o Suicide
o Vas
No
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33a. Cerltfier (check only one)
Certlfyfng physician (Physician certifylng cause 01 death when al'lOther physician has pronounced death and COl1llleted Item 23)
To the best of my knowledge, duth occurred due to the eause(s) and manner as stated
Pronouncing and certifying physician (Physician both pronouncing death and certifying 10 cause of dealh)
To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner as stated.
lledleai .umlnet'!eoroner
On the basis of examlnatlon and/or investigation, in my opinion, death occurred at the time, date, and place, and due to the cause(s)and manner IS stated
Dale File<l (Month, day, year)
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00:1'01
Cilyl13tlro
21d, Location (Cilyl1own, state, ~ code)
Inc
29. ifF
pregnant within past year
o Pregnanl allir.le of death
o Not pregnant, but pregnant within 42 days
01 death
C Not pregnant, but pregnant 43 days to 1 year
before death
C Unknown if pregnant within the past yea,
32c. Place of Injury: Home, Farm, Street. Factory, OIIk:e
BuildiFIQ, etc.(SpecifyI
32g, location (Street. cltyl1own, state)
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33d. Date Signed (Month, day. year)
'2.. - ( ~.,;)1.
a:~'s~nalu,,~u~,
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(See instructions and examples on reverse)
34, Name and Address of Person \Nho ConlJleled Cause of Death (Item 27) TypelPrinl
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