HomeMy WebLinkAbout07-10-08COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 1 7 1 28-0601
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
STARLING NANCY JEAN
6335 CREEKVIEW ROAD
MECHANICSBURG, PA 17050
fold
ESTATE INFORMATION: ssN: 182-o5-sass
FILE NUMBER: 2108-0734
DECEDENT NAME: STETSON HELEN GOULD
DATE OF PAYMENT: 07/ 10/2008
POSTMARK DATE: 07/10/2008
couNTY: CUMBERLAND
DATE OF DEATH: 04/15/2008
REV-1162 EX(11-96)
NO. CD 009998
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
101 ~ S 7, 800.00
TOTAL AMOUNT PAID:
REMARKS: RECEIPT TO ATTORNEY
CHECK#1141
SEAL
INITIALS: AJW
RECEIVED BY:
$ 7, 800.00
GLENDA EARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
=ee for this certificate, S6.00
P 14~~~~.3'~
Certification Number
This is to certif~° that the information here given is
correctly copied from an original Certificate of Death
3uly filed with me as Local Registrar. The original
.ertificate will be forwarded to the State Vital
Etecords Office for permanent filing.
~. ~e,>,.i..~~l~~~~~AP~ Z 7~ 2008
Local Registrar Date Issued
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H19S143 REY 11f2o06 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
TYPE / PRIM IN
PEAMANENT CERTIFICATE OF DEATH n ~ ~~ U~
BLACK INN (See instructions and examples on reverse) STATE FILE NUMBER r•1. ~
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1. Name al [ecetlent (Fad, middle, red, suNZi 2. Sez 3, 3adel SeceMy Number 4. Date d OeeN (Monty, day, year)
182 -OS -6736 Aril 15 2008
6. Age (teal Birthday) Under 1 year lhMer 1 dry 6. Date d BiM (MOWN, M ,year) 7. Birttydece (City and stale w brdgn canlry) M. Place of DeaN (Check any one)
Mwwm a^Ya Hour MAMee MoePllab DNa:
9 5 vrs. A r i 1 1 0 1913 Phi 1 a Pa . ^ fnpelMre ^ ER / wmaliad ^ DOA wring Hama ^ Resitleaa ^oNa - sfrecdY
6b. Cauny d OwN &. Cry. Bom DeeN Bd. FedMy Name ltt nd NeUaAion, pve abed and mantel 9. Was Decedent d Hepenk OdgN? ~ No ^ Yes 10. Hate: Amaicerl hd'etl, BMd, While, do
N Yea, seedy C+man, lsuec+M
_
Cumberland Lower Allen Tw Bethan Villa e Ret. Center Me>xa",PaaMRHe",e~) White
11. DareMlls Usual Knd d wwk dare most d Ile. Do M slats retl 12. Was Decedent ever N ere 13 DecedalYs F_dKgdon lSpedfy w,y hfgMa 9~ canlPMred) 14. Mary 51apa: Marred, Never Mertred, 16. Surviwn9 (lf wife, give malMn rreme)
Widowed
oFartetl (Spedyl
IGid d Work Kex1 d Busarem / Indwuy .
U.S. Amred Forces? EbrnenrerY /Secondary (0121 Cdrege (1-4 a 5+)
Married Arthur Wilson Stets
Le al Secrete Law Fi m ^r.a "~
16. DxeMnYa Maing Addrm (Sued. dy/ knm, sm0s, alrcade) OecedenYs Did Decedem ~r
Decedentlivedm Lower Allen TwA, ,
ureN. ,7cL]Yes
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5225 Wilson Lane ,
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Cumberland T°'""a"0~ ,7e.^Na•oaaaaa^'u,aawlmi^
Mechanicsburg, Pa. 17055 ""~°w'y Actual lurired cAY/Baa
18. Feelers Name (First, ndMw, Md, su91x) 19. Modrer's Nana (Fht, mitlda, maiden aumeme)
William Gould Jeann~etta Ma rs
20e. IdartnanYS Name 1TYDe / Prnll _ 2W. InlormenYS IAei4q Addaes lSbea4 azY /lam, stare. rip mde)
Nancy J. Starlin 6335 Creekview Road Mechanicsburg, Pa. 17050
21a MBNod d DlsPOdeO^ ^ Cremeean ^ Daretlon 216. Date d DMDadMn (Maier, day, Y~ 21c. Pbce d OlspodAm (Nana d ce^idaY, werrlareq' w atlrer place) 21d. Lacaeon ICAy /lows, stare, rip cede)
~jBtrd ^ Remwd6wnsrere w.aclwNlbnwDwudonAUtlndzee
• A ril 19 200
p Mt.Holly Springs Cemetery t,Holly Springs,Pa.
^ Darer - Beatty M MMlcel F.ardrNrY comrNr7 ^ yes ^ No r
~ 27a. SlgMaue d Faisal service Idcwwee (w parson ectlng as sudQ 22b. litero. Nlnber 22a Name and r~daeas d Fedtty 5 0 1 N Ba 1 t ' m0 ~e Ave
. ~ rf~, Fn-011589-L Hollinger FH/Crematory Inc. Mt.$ollSprings, 1'a. 17065
cwnpMte ttems 23ecany terAyre9
at~add~~ro
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~ 23e. nre d my d re end P~• dared. (si9ridwe and Atla)
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c~ 23b. Uceme NumOar ~~ ~-
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loamy 2x26 mud he arrykted a' person
~ Ma Pmn>unces death 24. Tme d De1ad,'}
~ (, ~O ~'~'~ M. 25. Dee Piawunced Dead (6bnN, day, »>/a<`I~~
o i-~- - '~~ ~" LW ~J 26. way teas Rdarred ro Medcd Eaeminer! corona kr a Reasal Other Wren Cremedon w Darelion?
^ Yes ^ No
CAUSE OFD ATX (See Inetruotlona and earempba) r Approximefe nlenal:
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Fren in Part L
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dd 2B. Did Tobacco Use CaMraure ro Dedh?
^ Vey ^ PioMhly
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den 27. asrt I: ErMr ere c6aN d events - dseesas, inJuMS, w tmglceams- Nat drecdY caused ere Mere. DO NOT ems term
reepuatwy erred, a venlrtlaar AhrAadon wiNM showing dre abro9Y Lkl any Ore cause m wadi Ana. a
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^9 ~ No ^ Unknown
WMEDIATE CAUSE ffFmd daeaeea ~ I ~ ~
Ld r Q 'YO t(ttS [.<-+ a 7 A- C(_i c C-c+ yn
mrddon resdwg n dadh)
s 29.ttFemare:
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b~eaddrrqp to dw sate MUd m Ana e. r
Due b Iw as a wnse9uerlce o0: ^ Nd PraPre^L Ixn psgnent a+dvn 42 toys
EnMren WNERLYdYG CAUSE
NataMrered ere
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ewxas resul ^ Nd pre,owM, 0d pragnelA 43 MYs to 1 Year
Due to (a as a cOrlseg+rence erg:
d
befwa dseN
^ Unknown A pregnem w,tlvn Ne pest year
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36a. Wes an Auopsy 39b. Were Autopsy Arckgs 31. Mentor d DeaN 32a. Dab d Inlay (Marty, My, yar) 320. Desaibe Haw Irdury Ocarred 32c. Place d Iryury: lldne, Fem. SaeN, Pettey,
OMce Buikymg, dc. (Specify)
Peramed7 AveAade Pre b Campldlon
se d DeaN?
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yt~~^^a ^ Hanitide
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au ^ Aaidanl ^ Pendri9lmesageeon 32d. Timed Nµxy 32e. Injury d Wok? 32f. II TranspMaeon Injury (S~y) 329.4aatian of InWry (Drest, tdY /town, date)
^ Yes 1~7.No
`T' _ ^ Yss ^ No
^ Sukida ^ Cold Nd he flelemAned
^ Yea ^ No ^ DrNer I OpMalw ^ Pessager ^PedeaMn
M ~ may.
33a CeN6er Itnea ^^y one) 33b. signalua ad TNe d CerOfrer L
H'`~ ~' D
• Certlyirg phYdaZ^ IPhf~^ ceNtyin9 ralwe d MeN what anodler physkien has prawuraed Maih and cemNeted Nam 23i
d~lh attuned due to the ceuae(s)aM malrrer as areted_____________..___________________
To the beatdmy glowledge .~ s3L H.. N U l u ~
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r Pranouncirg ant cerdlying PMsblan (Physipen 6dh plaiartdng deaN andcerayi^9 re reuse of deaN)
^ 33c license NuNaer 330. Date Sigrred (Mwdh, MY. Year)
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to th besldnry knowledge, death aauma0 al the rime,dale, ant Mace, end duelo the ceusa(s)aM manner as stated_________________ ~~ 4 ZI ~ ~ ~. h) l6
q LOCp SS
AkNkd EaamMarYCwwaa
On tM 0asla d exemlrredon end / or Imasdgedon, N mY apinbn, MaN occurred at the rime, dale, and place, arts due to the csure(s) and menrrer as etated_ ^ _
d Cause d DeaN Ittem 2'7) Type I Print
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34. Name aMAddess of Person Who Co
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