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HomeMy WebLinkAbout10-16-08PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF WILLS OF C v w~ ~~ aM.d COUNTY. PENNSYLVANIA Estate of ~ LV ~ l-a L- S'S C1 ~,~,< Sl.r t~-C-~ ~ ~ File Number ~~/D~ also known as Petitioner(s), who is/are 18 years of age or older, apply(ies) for: (COiYIPLETE 'A' ar 'B' BELOW:) °~ A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is /,are the ~~ ~..~I \ 1`~ ~- STbC~~na'~med in the last Will of the Decedent dated IQ Sv'~, Iq~~j' and codicil(s) dated (State relevant circumstances, e.g., renunciation, death of executor, etc.; Except as follows, Decedent did not marry, was not divorced, and did not have a child born ot• adopted after execution of the instrument(s) offered for probate, was not the victim of a killing and was never adjudicated an incapacitated person: ^ B. Grant of Letters of Administration (If applicable, enter.• c. t. n.; d.b.n.c.t.a.; pendeitte lire; dw-ante absentia; durmue minoritnte) Petitioner(s) after a proper search has /have ascertained that Decedent left no Will and was survived by tht; following spnu e~if any) arteirs: (!f Administration, c. t. a. ord. b. n. c. t. a., enter date of Will in Section A above and complete list of heirs.) - -~; :,:T7 ~= C: - = ~~ ..__ Name Relationshi Residence;--;?' -- y~ _ _-f, -~© Q (COMPLETE IN ALL CASES:) Attadt additional sheets if necessary. ~ Decedent was domiciled at death in Syw~.b(A~ County, Penns ]vania with his /her last principal residence at f y l I 7 Ac~r~.¢~cs't1y ct- ra-r,,P '\~•«-~- ~~ 1~ ® 11 (Lrst street address, town/city, township, county, s ate, zip code) \ \ Decedent, then 9 V years of age, died on MO,y ZsJ?'Ga~t~ ~-} ~\y S- c„r~'~ CTVS~~ Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property $ ~~1 S ~~ (If not domiciled in PA) Personal property in Pennsylvania $ (If not domiciled in PA) Personal property in County $ Value of real estate in Pennsylvania $ Cj situated as follows: Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant of Letters in the appropriate form to the undersigned: Signature Ty ed or rioted name and residence ~``--`~ p~LV..~i S~ocks~.t~~ (2 l ~ , 1 l7Aa27•"MO ~;Tt{ S r CX~-N~l1-" l-f f L~- ~ j •701 Fm~m RVV-0? re». 10.13.06 PagO I Of 2 Oath of Personal Representative COMiV10NWEALTH OF PENNSYLVANIA SS COUNTY OF Cvw.~.e~~cu~,lG~ The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true and con'ect to the best of the knowledge and belief of Petitioner(s) and that, as persona] representative(s) of the Decedent, Petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed and subscribed befot'e me the~~ day of C-~I~er_ ~~z~ _ Irv Fort Register Signature oJPersonnl Representative --~ ~:; Signature of Personal Representative -y U f"~ -<<IJ -_- ~~ -? Signatzu~e ojPersona/ Representative ` - °- C; , - - ~, `~ = -~ frt. UL I _ O(~_ I VJ I ~J'-s File Number: Estate of i'~ ~--~ t1 H 1-~esY~ ~ e~S~Ca~ ,Deceased Social Security Number: 19 Cn ~ ~ ©Q ,~'r/~ Date of Death: L t ~/ / ~ f 4 ( 7 AND NOW, 1 ~~? ~ (~,~ ~ ~-F G ~jV~ ,, Q ~, in consideration of the foregoing Petition, satisfactory proof having been presented before e, IT IS DECREED that Letters _ __ _T'es~- o.. taw are hereby granted to fa ~-~ ~ P1 ~. S''C'o~~S i~r ~ s (Z and that the instrument(s) dated t ~ ~~\ Y (~ '? ~S' in the above estate described iu the Petition be admitted to probate acid filed of record a/s~ th1e/last Will (and rCyoydlicil(hs)) of Decedent. FEES `__~ ~X I(l.~ ~(I (D/[ ! ,C Letters $ ~, ~ Regis[erojWills ' ~' ~. Short Certificate(s) ~.5~... $ ~ •D~ Attorney Signature: Renunciation(s) .......... $ . $----~ ... $ ... $ ... $ ... $ ... $ ... $. TOTAL .............. $ 1 ~' . V~ Attorney Name: Supreme Court I.D. No.: Address: Telephone: F~~„. RW-oa ,~~ 10.13.or Page 2 of 2 LGCAL REGISTRAR'S CERTIFICATIGN tJF DEA'1•I-I ~NARNING: It is illegal to duplicate this copy by photostat or photograph.. ~ f~:e t~~!~ this rertifica[e. X6.00 ~ ~448~9~~3 Certification Numher 1~his i~ to certify that _te inf~irmation here ~i~~en is correctly copied 1~rom an ori~,inal Cerlifiar,c of Death duly filed with me as Local 3egistrar. Tht original certificate will he irrvarded to the State Vital ' RecurL?s C'~Pficc for u~rt-anent filing. ~~1~.~~~ ~~> Local Registrar ~-~ - Date Issued n <.~ :>> r' C~ _ _ ~ ._,A . H706.113 REV 1112003 ~EPFMIANDlT at.Aac r3c !I n COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS \ .=j7 _. CERTIFICATE OF DEATH -'+ :":" (Sss Inatructlons and e9LSmDlws en revwrewl ~i /.rwtlao~ua.+IFt.L maa.. w6 ~U _. _...`...-.._., ~ Alvah L. Stocicslager male a 196 14 _ 0996 4.DerMay 20, 8 aIW~Sr3tlM uw~ ultler~ aDmdetm 7. wtlawa e.PradDrm a,wr aw ~ rwmt oti• Hre r.e. Haprt O3rr: 90 Yn. Nov. 11, 1917 Greene T'wp.,PA. ^e10i~,,z ~~„ ~~~ ^ ^~, N. Coudy d Deam 9F Cly, Bao, Twp. d Dinh 3d Faa~y Namt (M nol betlhrai, ONe ehttl and nniMd B.1VU Dacadri d HrpWe OaprT ®Tb ^ Yr f0. Rea: AmMan bdart BrdL YMt, eb. Cumberland Camp Hill Holy Spirit Hospital ~'''~'D'~''`~°'"~ ( wtl~, Paab R~rq eb.) white 11. Deotarfe Ueutl d aadedar mar d N. Do rq wr 12 NM Deeadwt ewr b Yw to DeeedeKs 6lbtlbn (SpwBy ary hldwr Bradt oemp4Yd) 14..FW W Sh41c dnNq Netlr MmMO, 15..9uvMYg Spdw~(N MN, qM nWtlr ro'r) a Amwd F V O ~0 r7 gMdWak ~ ~ . E~grY/seaandery lo•tz) cob2e (tor s«) nn WbOWti ~°!Tj(~1 ) r++ r LabOre ManU~aCturi~" ng ^Yr LUNO __ _ ~j' dVWCII w ,ao.tle.nw.,°~m.r(s~.tl'`y'a~""~`'~,°°°~) 1911 Dartmouth Street °idd"'~' Pennsylvania °"°•ra"" Aar~R.tldrw 1hStr u»ra 17e ^Ya paaraLNedh Camp Hill, PA. 17011 . , T•a ,70.COaay Cumberland T°"'""PT ,7a.~ ~ lMdw3hh Camp Hill d ~,~~ 1a FYWt Namt (Ftµ niddt, rtL wM 13. tw3w. Nemt (FyaL mHdt, mebr eunamt) Lester Stocksl er Susie Wingert za teamra's Namt (ryPt /Pnq zee. teanirri wrq Adler (sbatl, dylban, err, bP ooaq Alvin L. Stoclcsl er 1911 Dartmouth St., Camp Hill, PA. 17011 z~.. wmaa a ^ ciwrean ^ Daw3an zth. Dw d Mao M. TrA ^ "°"""'1tran~'t' z~a Prot d DlAOrbn Mwr a orawy arrvdr arahr qer) zia leeatlon Ipy/ben ertt, aP otdt> ^ ,,'a ~'°~;,,,r ^Yr^~ May 24, 2008 Mt. Pleasant Cemetery Chambersburg, PA. 1720 Uewrr « r each) 22b. Urnt tAenher -013391-L Tae. Nanw andAdl Thomas w d fatly L. Geisel Funeral Home, Falling Spring Rd., Chambersburg, P 29ee eM' whn pyrdn r nd awrew r sat a erm b 23a. U M beq d my bcwledOA drm oauM tl b tlnw, aW and Pro ffira (SgwM end ar) 230. Lbww Numher 23e. DeOt ~ 1, d•r, Ted atAy our tl deeOL _ bnr x423 mutl M aonpNtr by peram alt pmeue.+es atrr< 24.7tr d DssN ,~/ / ~ ~ M 23. ore Pnx/nym} d Dead (~+h dry, YrA ~ 2A Vhe Cw Rtlwna b wabtl Enniwr/ Comn.r br a Reeean Oaw mr CwrWbn or DarweonT • • 7 . / / ~A ~ d OL ~ yj . ^Y•• eun 27. Pr t ErwM OAUSE OF DEIn7i (sea IMVUetloM arwl ) r Applalntt trrvY: S~ehdmdl-dYtwe. Y~ubr, a caiplratlpr -tlwt dYedy eeurd b dtttt DD N0T crier rmriW ttab aril r nrlee amrL 1 Dnrt b Drm a Y tl ol a mkd s ~d eh L P„ LL FnMr omM hd M muetp b W undedyYp uw plwnb Pwl L 2a Dld Tdamo Ur CawGr b DrmT Yr ~ Pmbedi ^ ^ me aw r , on w aa thtwep 3rJ.Wloy,.Lm eny one au.8n. a cfi iw. r ~E Wy ~MTEC~ 6 i m ~ ^ No ^ UNmm . / W°°°" IwYFIp I7 ~1 ~ a M~;,l~ S ~j,~ ~..~ ~I •C C .,~/ .w. ~ '"r; /C 2A MFanWt: •• ,7 NZC Drb(or a ~ ~ M aonedaaLlry, r. G)7`rC~/O~~I~~th7w//}!~•1 T~'~~~ ~ ~~~ ^ Nd DwpwtwMb Drr Y•w ^ Pn> ratltmeddtMh b etrltelwdmir t. p Elev UN06aYNG CA116! Dr b (ar r a aantepwriea d): r ~-tdi •ttiro.f f #M ~ ~" e r; - ^ ~Dr•OrL hd DAPWewWn42 deya . _ ~ D ,A. ,E ~.t., d dttln r b (a r a aawao/rlaa d): ~ ^ ~ ~ bl prepud 436ytbtyw . 6 ; w ^ UNO w w n ~ prepwt wlrin IM PW year 3h. Wr r Aubpy Perbnned7 900. WweAurpty Fr3p AvaAthN Pdab Canpletlon 31. wmer d Deem 3Ta Dar d iMly 1~4 dn: Y•tl) 32h. Drab Haw ~~~ ~~ Y a y Stier, facbry, ~ d CaurdDrmT ~RJ~ -"° ^~''b~ OEp sidn0. ) ^ Yr [$ No ^ Yr ^ No ^ AaUOMe ^ Pwq~p gad. Trr d Way 32t. Y~ey tl Wak1 921. tlTrrpartlon WaY 32p. Laatlm d WuY (Slur, tlylbwi, Wlt) ^ Sublat ^ Caub Nd M Delrntwa ^ Yr ^ No ^ Dawrl Operatic ^ ^ U OMr • ~Y• 93a Carrtrl~aYy tew) 930. SIpWr a • ~rMi PhY•wr (PhyYdn pNrYq otr. d arm rhr endhtr prythin lw pmpuced dsdi aM adnPltrd Ysm 23) J rem.wtdwybw.w,.,armaewr.aarbm.rr.(.,rd.rm.rr.Wil-------------------------------- h ebra (Pl yd h m t d ' -M ~ ~ 'e . -a1-.. - , q O ~ r o Pwwne n f rm aM aedtlyYp b uin d arm) Te ar Mtldnry bwrWpt,dnm eeeumatlmt tlma,dW,endPwAtnd drrme cwwye)and awnwrr errd ^ 39c. Urre N umher 93a pr (yapldry, ytar) _________~~.~_____ • wrier eaalwrlearaaw d ~ p ~ V 2 d 0 ~ t} 0 to O j/ On lb hrr dearnYurm ntl/r hratlpatlar,bnry opYYa4 drm eeeloreatlmt ant,aar, end pNr,yq drbtlr rwa(a)aM mrawraWtd_ ^ >!. Nenr eMAd/er d Pwaan Who Camgerd Cwr d Drm (IYm 27) lyq / z. Rt¢Vaft SlyWUe aM Draw Numbtr - I d I ~ I aZ I ~ 19 I 3e. Dab Fid (MagL aeY. Y••A J- w{ ~tAti}r1l~l Nrtb l6j I N•t+Ca' l r fy ~ o , rr ltJ 2 ^ ~t~t DYPrVan Pwm3 No. ~ f Q3,~Oa2 l ~ WILL ~_~' =- ~• ~=~ ..• ; .__. - - ~..~~ ALVAH L. STOCKSLAGER _ _'~ - :- I, ALVAH L. STOCKSLAGER, of R. D. 1, Fayetteville; ''Pennsylvania, r.., declare this to be my last will and I revoke all codicils which I made here- tofore. First: My wife, HAZEL M. STOCKSLAGER, and I own as tenants by the entirety all the furniture, rugs and other household effects situate in our home. Second: I give all of my estate, real ar~d personal, to my wife if she survives me by thirty (30) days. Third: If my wife does not survive me or if my wife and I should die simultaneously or within thirty (30) days of each other, I give all of my ~i estate, real and personal, equally to my two children, SHIRLEY MIXELL, Fayette- ~~,~~ ville, Pennsylvania; and ALVIN L. STOCKSLAGER, Camp Hill, Pennsylvania, per ..t. ~' stirpes. ^= Fourth: My executor, for any purpose of administration or distribu- ~-,. tion, may sell all or any of my property, real or personal, at public or pri- vate sale, for cash or credit, and may execute deeds or bills of sale. No purchaser is obliged to see to the application of t:he purchase money. Fifth: All transfer, inheritance, estate', succession or other taxes payable by reason of my death shall be paid out of my estate as a general administration expense. Sixth: I direct the payment of my debts and medical, funeral and administration expenses from my estate as soon after my death as conveniently may be done. Seventh: I appoint my two children, SHIRLEY MIXELL and ALVIN L. STOCKSLAGER, co-executors of this will. Eighth: No fiduciary appointed in this will, and no duly appointed -1- successor, shall be required to give or enter into any bond or security in any; jurisdiction. ~4- IN WITNE have hereunto set my hand and seal this1~ day of July in the year 1978. ~~C'Ez,:~.~ ~f/.rt,~'~""~~.~~-z._ (SEALI Alvah L. Stocks ger Signed, sealed, published and declared by the above as and for a last will in the presence of us, who have hereunto subscribed our names as witnesses at the request and in the presence of they above and in the presence of each other. l ? ~ -2- COMMONWEALTH OF PENNSYLVANIA ) SS: COUNTY OF FRANKLIN ) We, Alvah L. Stockslager, Hazel M. Stockslager, Martha B. Walker and Bonita R. McNew, the testator and the witnesses respectively, whose names are signed to the attached or foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the testator signed and executed the instrument as his last will and that he had signed willingly (or willingly directed another to sign for him), and that he executed it as his free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the testator, signed the will as witnesses and that to the best of their knowledge the testator was at that time eighteen years of age or older, of sound mind and under no constraint or undue influence. .~ ~/ / / , Testato Witness Witness ~~ Witness Subscribed, sworn to and acknow- ledged before me by Alvah L. Stockslager, the testator, and subscribed and sworn to before me by Hazel M. Stockslager, Martha B. Walker and Bonita R. McNew, witnesses, this /y~ day of July, 1978. Notary Pub is E0N1TA R. McNEW, Notary Public Cfienabersburg, Franklin Co., Pa. My Cammission Expires October 2, 1978 -3- 705905 REV.(07/041 /711 ° ~') l~ f ~~ r' / ~/1 _ ~il~ Prr_`_ This is to certify chat 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. WARNING: It is illegal to duplicate this copy by photostat or photograph. Calvin B. Johnson, M.D., M.P.H. Secretary of Health ,_ ~.. _ .~_~ f ~ ._ I No. Charles 1-iardes:er State Registrar 0 CT O ]: ~Q,05 c~ . - I,.. , i:.: - C;: i -• . ..!-.) `i7 .. F' ~+ ;~R,,,, ~,~ COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH ~~ V f i1~Ofr NAME OF DECEDENT IF rtR. M:,ab. LdRI SE% SGCIAL SECVRITY NUMBER DATE OF I7EQN,MwM. Des. A&J ,. Shirley Ann Mixell :female ]. 186 - 28 - 4487 .- July ZI, 2005 AOE ILaR B+obaY) UNDERtYEM UNDERI DAY DQE OF BIRTH BIRTHPLACE IC+y and PLACE OF gEQHtChtts orW nne-,ee,nslruc6prs nr~orMr aoe) ___ MornM r ~„ „atr,a s M;,,A,a !MOnM. Day 'Alnl wredFCregn COUntrvl HOSPITAL: OTHER: PA 3-3-1936 Greene Ttap. 69 Yn Inpaline ^ ERIOIApatiaN ^ DDA ^ ,' ~'° ^ Ra.b.nw ~ ~., ^ , . ~ s. s. ~. Ito. _ CEDENt' OF HISPANIC ORIGINS RACE - Amaaean IMan. Bndt When. atc. D E COUNTY OF DEATH CIT`y, DORO. TINP OF DEATH FACILfTV NAME pt nm ing9utron, give stren orb rw,rnoer~ VMS ~ L~ 7J No AJL Yw^Nyao. apaNyCWan. lSCOrM Franklin Greene Twp. 5759 Lincoln Way East Mnawlt.HNMMRIwn,nc white DECEDENT'S USUAL OCCUPQION MIND OF BUSINESSANDUSTRY VMS DECEDENT EVER IN DECEDENT'S EDUCQION MARITAL 5iQUS-MNriaa SURVIVNiG SPOUSE (GAra end d work Dona d%atg rrbR U. S. ARMED FORCES7 ea NMr~ ~ WiCOMO. IX wr•. gn• nisMn wnel e) EMnranury/SacalGry Coaaga ki W m a d rro, uaa ra re op ng ; ,,. Pro ram Anal st ,,.. Gove ent ,:. ~^ ~~ ,]. j6'~' 12 "aai5" ,.. married ,,, St~~ldon Mixell OECEDENr'S MAILRIG ADORESSISaaR.CM~.SMIa. Zp Codel DECEDENT'S ~~yy L'eene 17C eawd.ra IIwM in Oa LJ'Na 5759 Lincoln Way East . . . D. ACTUAL 11a. Sala Dla ~~'~ ~«~• PA. 17222 Fayetteville ~~•'~" Franklin ? , ^ ~.~; ; , ~~ , ~~ ,, - , , - ~,,, FQ,IER'S NAME (First MitlaM. LaRI MOTHER'S NAME IF.R. Moak. Maa1M SW namel Alvah Stocksla er Hazel Fanner , „- _ ,- INFORMIWT'S NAME RYpo'~nt1 I ,,, Sheldon L. Mixell NFORMANT'S MMLINO ADDRESS ISaeR, Cilyiroam, Stns, Ip Cadal ,,,-5759 Lincoln Way East, Fayetteville, PA: 3.7222 MET1gD OF OISPOSRION DQE OF DISPOSITION PLACE OF DISPOSRION • Name W Cemetery. Cramuay LOCATION -Cily/TwrL sun. LoCaoa BurW® Crwrwlon^ Ramaaal Yam Swa^ IManM. DaX MRI or Oerar Platy °""'~I~M ^ l 27 2005 J Mt Pleasant Cstleter 17201 Chamberstxir PA ,,,- u „a, . . :,.. OF SE E OR PERSON ACTING AS SUCH LICENSE NUMBER NAME AND ADDRESS OF FACNRV ~,,, FD-013391-L ~-'Thomas L. Geisel Funeral Home, Chambersbur PA Aama 13oc Dray wMn weMeq dta Dan d my trnowka,s. oath occurrW al Manna, ate ono pew Rhea. LICENSE NUMBER DQE 5N3NE0 r PMantan ~ rros ovosabN n lima d daaM a re sna TaN IMmM, DaY. ~ Catuy calrao W aM1h. ]!o. ]A. ]]e. Mama 2F1B rMW W wrrupnla0 aY MAE OF DEQH DQE PRONOUNCED DEAD IMmM. Dey. Yen) VMS CASE REFERRED TO MEDN.u EXAMINERICORONERS param Nn pmrnrarca aaodr. 5:30 Jul 21 2005 "'^ "° ~. ].. M. n. 27. M11T L EMn dM aisouas, in(uNS a cMpkatbrrt which wlrsaa IM aaa[h. Do np amor IM nbaa al eyin,, such as cardiac er reapralory arrest, sMCe a MN taiWn. I AppNaiman PMT N: OUrr sgnifkua corlOaorrwrsrAtAYr, n aaatlt Out l e nPART1 s nd d l, CatlN pswr . g ta la n y Lin ay aM CatleaMaafJr and. ~aaalYn aalwaan r10, raaMl ann ~ tYMED1ATE CAUSE IFwI ~ ~ i ~ f aaaara mrWion .rq--{1 ~ e~~f 7 1 t l O rwlrrgndoaMl-- a. 9 Ma -~. W TOR AS A COHSE NCE OF): SaplrarttloaylM aondilona D. I Nngt MaWrg NtamMdWa DUEWIOR ASACONSEOUENCE OFT: I olM. Enlor UNDERLYNq ~ CAt1EE ID+waa ayuv c, - thn aW,ad evens DIIE IOIOR AS A CONSEQUENCE OF): - I roaJarlg n oooMl L,ABT l 0. YIYLS AN AUTOPSY WERE AUTOPSY FINDINGS MANNER OF DEAN DQE OF INJURY TIME OF INJURY INJURY Q NlORKT DESCRIBE NOW INJURY OCCURRED. PERFORMED'1 AMULABLE PRIOR TO / IMOnm. Dry. sbar) CO~ETNxI OF CAUSE r--, Nn l l 1M wo ^ y rn s un sY. ^ No^ Amon ^ wrrdaq kvwlgnkn D Y« ^ No r~ ^ Na ^ sawia. ^ caaM la a an.m,lnad ^ PLACE OF INJURY . At hortla, nrm, RrM, lac,ary, ax. M - LOCQNXI IStreR. CAYFTOwn. Sdill) Is Wldn9. Mc. ISpeuN1 1.a. 210. H. 7M. >01. _ fJFMIFIHlIChatoNy arrM 'CEIITIFYMD PNVSIpAN (Physcw+ceruMng wse tl oeam when dodos pnyscan hes pronwnceo seam orb comgeeo Iles 131 S QURE MDTITLE OF CERTIFIER To Bra Dan el my Yrawna0a, a.am oecurraa aoa b un caueNsl and manna. n aa,M ................................... . ........... .. .... 7t0. ' DQE SNLN IMean, Day Yanl LICEN U R 'PRONOUNCIND MDCERTIFYINO PHYSICIAN IPrryscan ~Om pryquncrtg seam and cMAyvg to cause of tleaml Te Na Dan M my arrosana,rr, OaaM eeeuead al IM IYna, Mte. end Place, and duo 1• tM eaawlq one mannaua aMlea .......................... ^ ~ ,'l v L//~ ]IC. - V - ]ia. NAME AN ADDRESS OF PERSONWIOC PLETED CAU Olem 27) Typo a Prim ~r At ~ ~ - 'MEDICAL EXAMINER/CORONER , Y f~ d C A , f ~ ~~ , •1 fl' 'F/- On N,o Daah of o%aminatlon ond/or Investlgatirsn, in myopinion, death occunad at tIn time, dm, and place, and due Lo the cauaela) and m.RR...oat.,ad ................................................................... ... .................. ..... ..... ^ ],.. /~~j'~f ,ry ~ ~/ ! ' Y~ (' GV. 1 l~ ]:. REGISTRAR'S SIGNQURE AND NUMBER ~?~g,~ 6, YJ DATE FILED IMOnm. DaY~ Wart ' - ]] ].. ,,~ ~ ~ GDJ