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HomeMy WebLinkAbout03-13-09PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF WILLS OFD m ~~ L~r-~ COUNTY, PEIv':~1SYLVANIA Estate of ~ , > , , ~•-'' ( L~ (, J ~ } I ~ _ r ~ File Number r~' ~ V 1 - Q~"T t~ also known as Deceased Social Security Number ~ (-[ ~•~ ('' / ' / /(,~(i Petitioner(s), who is,/are 13 years of age or older, apply(ies) for: (COtYIPLETE 'A' or 'B' BELOW:) lad A. Probate and Grant of Letters.Testamentary and aver that Petitioner(s) is /are the i_` :~'~ ,_"• < ~-; j~ ; X named in the last Will of the Decedent dated ~^, ~(; ~ / ~ ~ and codicil(s) dated ,t:'(•,~r= w.~ ,~~, (State relevant circumstances, e.g., renunciation, dead: of executor, etc.) - ~ ,, ti~ _ , . ; '. C_ _.~ ~k. Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after executtoq-of~numett~s) offered ,. ; for probate, was not the victim of a killing and was never adjudicated an incapacitated person: `_' ;-, ~ = _ :- -', ~~ ~~~ CJJ -_ , - ^ B. Grant of Letters of Administration _ _' =l --- (Ifapplicable, enter: c. t. a.; d. b. n. c. t. a.; pendente life; dw-ante absentia; dur~i7ite7,~i:oritateJ .~ --~ Petitioner(s) after a proper search has /have ascertained that Decedent left no Will and was survived by the following spouse (if any) ~ heirs: (Jf Administratiat, c. t. a. ord. b. n. c. t. a., enter date of Will in Section A above and complete list of heirs.) Name Relationshi Residence (COMPLETE IN ALL CASES:J Attach additional sheets if necessary. Decedent was domiciled at death in (~ fi'ri't I)i K Ii~?1~-~ County, Pennsylvania with his /her last principal residence at _~ ~ f 't /~ '- 1S { ' L". lL -k~ l~ tom` v~'~t t 1 ~ I "~ 1 ~ ~~ Y~ A' I ~l C j (Lut ah eet nddrea•s, town/city, lownslup, county, state, zip code) Decedent, then _ years of age, died on ~~ - I I ` ('~-~ at Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property $ Z~ L~~ ("`, --; (If no[ domiciled in PA) Personal property in Pennsylvania $ (If not domiciled in PA) Personal property in County $ Value of real estate in Pennsylvania $ '~~ (;O ~~ i 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 i - .~ ~ ~7 ~'~ ct% ~ t "~ rn S ~9v P by ~ ~ 1 ~ ~iL3~(C Furst R6V-0? rev. !0.13.06 Page I Of 2 Oath of Personal Representative COMiVIONWEALTH OF PENNSYLVANIA SS COUNTY OF ~L( rYl ~Q~a h; ~ . The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are ttue and con~ect to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decedent, Petitioner(s) will well and truly administer the estate according to law. ~ ~~ /~ i Sworn to o. affirmed and subscribed ~~ ~~~'~~1%''/Y>7 ~G~C' / ~.~{.~ Signaka-eofPersona Representntive ~_a before me the ~ day of -, O --~ - ~~C-~ ,~~ Signature of PersonalRepresentalive -~ ~ -~ - ~ y ( .1 C.a.~ !___ ~ - -" -- For the Regtster Signature of Personal Representative ~ r .; _ ~+ -- ~~_~.~ File Number: ~I -OQ_ l7o"tt-~-l~ Estate of ~r-p,,r~ tC (~~ , ~ ~ u y~\~ ,//Deceased Social Security Number: '`"1~ - ['~~-~ ~~lp Date of Death: `~ - \ ~ - U~ AND NOW, ~GLr-[` ~ 13 ,~ OV ~ , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED t etters I~r~e~'TA fYlp ~-i-aY-{,t are hereby granted to~tC t O~_ ~ ~~ ~Ol~vY1[t ~n _ in the above estate and that the instrument(s) dated ~ -- ~ ° (j~~ described in the Petition be admitted to probate and filed of record as the last FEES Letters ............... $ .(~ Short Certificate(s) ........ $ r~0 - UO Renunciation(s) .......... $ Lim. St ~ ... $ ~S. C~ MCP !! ... ~ lid •o~ ... $ ... $ ... $ ... $ ' ' ' $ Telephone: ... $ TOTAL .............. $~t v •Sl_LL of Decedent. Register of Wills Attorney Signature: Attonley Name: Supreme Court I.D. No.: Address: F~,~~~~ Rw-oz rev. ro.l3.0~ Page 2 of 2 LOCAL REGISTRAR'S CERTIFICATION OF DEATH VNARNING: It is illegal to duplicate this copy by photostat or photograph. Foe for this certificate, $6.0O This is to certify that the information here gieren is correctly copied from an original Certificate of Death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records (~ti~ice for permanent filing. P 15216733 ~ x " % ~ o Certification h`umbel Local Registrar Date Issued _ t`J n ~ C_.- ~ - C7 .; ~.Cf -_ - _ _ ..i.l _~ (~ _ _ _ r ' '; T U~ _A ~ _) mJS hd Rev u¢oud COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS TYPE PRINT IN PeucKIErAKT CERTIFICATE OF DEATH fSee instructions and araeeae,lea es...e..e.°ea l~ \ LI 1 , Name of Decedem (first, mltlde. Wsl. wAixl ' hilt rllt NUMBER Frank G 2. Sex 3 Soaa Sec«iry Nimlber 4. Data a DeaN IMmm, Gay, year) 3uchle s A L Male 199 -07 - 7106 h ge I dsl BmhOay) IMOer 1 year Under 1 day 6. Dale a BiM (MOnN, ,year) 7. BAApbce (G antl stale «I« ' country) 8a. Place a OeaN (Cneck only «ie) MonNS he~5 Hours Mnulea ~ 8 9 yrs. 8/ 4 / 1919 h~~ yy~ HospIIW. WNI. [ ~i 11 i '1' ys, BD County of Death B Ci M~ L ~4 1 ! PA ^ InpalKm ^ EN r Oulpa4enl ^ DOA p~ Nursing Home ^ Reslderrc¢ ^olnar ~ specAy. . c. ty, Bono, Twp of DeaN Bd FaaYly Name (If ml Arsbulion, pve steel and number) 9. Was Decedent of H. spank OngN? No ^ Yes f 0. Races Amell[an Indari, Black WMIe e¢ ~, ~,~,s.~ ~ y,,., t-W1LLJCrland East PeI]n$LIJrO 1 • • . (11 yes, specify Cation, f ISpe~iy)7 M¢xkan P rt N \7 11 Dacea nf U l O Y ' _ , ue o lcan, ak.) ryl3ite . a s sua ccu on Klyd a work aorta dun most a worki NIB Do na slab cached 1T. Wes DaceMm aver N UN 13. DBCetleN'i Educeti0n (6TeeAY only niphasl p ode completed) 11. Maaal 9aluc: Manned, Nev« MarneO, Ib. Srarvlnnq Spouse III wde plva maden narnef Kind of Work Kind a B U S Armed Fwce57 I I tl . . usaess n usBy Ebme / $~ Wgpweq Divorced S INarY ery (0-12) Copega 11.q « Sv) I P~iM ' rrpp Sh' in P c 'n lpYes ^NO ' 12 W1dOWed IB D¢ce0erit s Marling AOdess (Blleet cdy / bwn, dale, tip Nde) Decederirs A Dd Decedent Pennsylvania ctual flealdence na 9ab 27 Far neon Road g Live lna ,7~ Fast Pe nafjp 0 A-~ Yae. Dnc¢dem Llved In Camp Hi11, PA 17011 nb cpanN Twy Townslry'+ Cumberland nG ^ No. Da<edem uved wlnN IB. Famer s Name (fhsl. middle. last, suhn) - Actual Lirrc6 d cny /Horn Otto E Buchle Sr 19. MoNei s Name (FAet, rivd0¢, maiden sumatrie) 20 I l Blanche E Palmer a n ormanYs Name ITypa t Pnnl) Patricia Ann Coffman 200. Inbrmanl's MaANg Address Israel cAy /sown, stab, xp code) z M 9744 Williams Ave. 131oomington, CA 92316 ta. emodaaspo:Non aemaucn Dpwebn ztb.Datea ^ Dispcsieon (Monty, daY. rear) 21c. Place d Disposilan (Name d cenwtery, «emalory «aner place) 21d. Localwn CI 1 ( N kwn, stile, :Ip codel ^ Hanel ^ Rerraval Irom Su ~ Waq Gemali0n or Donalmn Aulh«izad ^ oNer spec, a kMExarnharyc«arlerT 6d yea^Na 3 1 3 0 9 Fvans Cremation Service Leola PA 17540 zzas~gnatunyd wwral (dr~gas:ice) 220.Licens¢Narmer zzc.NameandAaaressaFadiN Nei EUnera Home, Inc ~ r ~ ~ FD 013239 L n0 ~t. T ~ r^ TT' n Compleb hems ~c only wnen caNlypg physiaen Is na avaAaae al lime of Oealh to d c N O 2Ba. To Ne bell a my Mowledge, deals occurre0 al Ale INN, dab acct place sb18d. (sgnature and INe) ~ 23b. LKYM14e Number 23.:. Dale Sgned (Monty, ay, year) c. ry ause eaN. G C v ~. `- tJ(.t, kJ -Z ~F -~ 2/ ~Q L ~/ ~~/Zv ~ r. hams 236 muss b¢ compleed by person wno prono«aes deain 24. Time of Death 25. Dale Pr«a«x:etl Dead IMonN, Oay. year) Z ~ 5 ~ l~. ~' ~ ~ 2 -. 26. Was Case Relarred to Medaal Examrwr / C««ier I« a Reason Omar than CramuNOn or D«1alan? M. `1~ ^ Ye5 CAUSE OF DEATH (Sae Inalruotldna and aaampleal nnm 27 Pan I Erller Ina GIdB19EHYBOLt - dseews, Iryunes, «mmplKahons -Nei drechy caused Ar¢ Oeath. DO NOT anlel Ierminal events I gppOximale atonal; Pan II: Eaer other - {IpAIB, TB Dd TWaae Use Canlrlbub to Deem? such es Crydl crest Dn l b D N respinabry arrest a venlraaer I Ion wglaa owag IAe alai list only one cause on each Im¢. ( , se ea but cal res N Ne rope given a ~°5 dl'u'g cause Pan I. ^ Y es ^ PrWably / 1 \ ~ IMMEDIATE CAUSE Final dsease or / - ` \ - 11 ~ 1 ~ LJ No ^ lMFnown } T \ C ~ ~ \I J~(y ,may, cOridlan resuNAg n l~aN) _~ \vi E s ~ r ~T, \ J /N.~ 29. II Female- Due to ( as a copse ry. ^ Nd pregnant wdNn pall ywr SeguernWly hsl cundhuns. d any. o leafing m Na cause Nsled on Mae a D e b E ^ Pre ar bnk a OeaN 9r'am u for as a cons u e op. mer tla UNDERLTING CAU6E Idseese « Iryury AI¢I N letl Yw ^ Nd gegrienl WI yragwrA wlNa d2 days evenly rewlhng nl d=..Ihj LAST 0 Due to for as a wnsequenca ot) d OeaN ~ I ^ Nol prequnt, WI pregnam IJ tloys io I year d r beWe deaN ^ Unknown A preynanl wlrhur IM past ye=n 30a Was ar~ Autopsy 300 Were Autopsy Findings 31. Manner of Deals 32a. Dale of Iryury IMOnN, Penurmed? Avadeae Prior Io Cwnpleh:,n - tlay, year) 02D Describe How Iryury Occvned 32c Plxe d Npury Mums Farm. $Ireal, Factory ~ y~~; of Gause ul DeaN? yJ rvarwel ^ Huni]e , OAice Buldirig. eK (S'pacJYl ~/ ^ Ves f ~( No f, Y¢s ~!o ^ '~'i"uem ^ PanJing Irnestiyalion 72d Time of InjuN 32e. Irqury al Work2 321. II Transporlaliun Ityu7 ISPs'u'M') 329 Locatwn of Iryury ISlreet, uN /Iowa, sWlul T ^ Suxde ^ Cwld Nat ue f~lelmineU ^ Ves ^ No ^ Driver I Op:ralon ^ Passenger ^Petleslrun M .,~Wior ~ SVeclly_ 33a Cedher Icn«k only oriel 33D Sgnal« rid T of G • Ced lyng phy ician lPl Ill y' I -II r "I p' a JdV d pelts hem 2ll y TON ben 1 y kno letlge 4 th O ed d 1 Ih () rm t IW _________ • Pr p rb eod N 9PKY ~ n1P y bTf J ed' Il ______________ _ y y r, y yl iJU ll To the bast OI my kn wledge, deem oc arced el Ise nn e, deb acct place en0 due lu the oase(s) and niar n bl tl _I [ _~.. nwN ¢ ]7J Dale Hxyu+l lM. nil Jvy ywlr , r nr as a e _ _ _ onn a Ysi ~ e.a n~ i _ _ _ _ _ _ _ _ _ _ _ _ _ _ . ~ ~ ` ~ / 2 ` . o m l on and I of mvnaivabon. in mr oplniun. aueN occurred nt Ne hm¢, aal¢. aria phc¢, elm due to Ina () an r:auw a d manner as abled_ ^ 34 Nano Mfdress of P rs«. Vlho Cortlplered Cause of DeaN Ih¢n • ~ 271 Type / Prml "Re ss,gn,wla,lm svf Nmnw` , aci F!-i•c T. ~ ~Q ~ ~ Lf l aleFledlMonln.dev.roarl ~ , , C / , l.Z.. ~0 IO Pc ~a.- Cis 4 rL~. lQx~. Ca .n A`~a~ ~q / ~ 1 A Dlsyuvbun Permll NU. ~._7/ ~~.,3~ WILL OF FRANK G. BUCHLE I, Frank G. Buchle, of 27 Fargreen Road, Camp Hill, East Pennsboro Township, Cumberland County, Pennsylvania, make this Will, hereby revoking all my former wills r.- ~ <~ and codicils. ~._o . __,Q. ~~ L) ri ~ 1. All legal debts, funeral expenses, costs of administration of my Estate, --- ~., ~~ c,,, _.. , ., estate taxes, inheritance taxes, transfer taxes and other taxes of a similar n~isi?pay,3ble ~'=- -,; _. _ a by reason of my death to any government or subdivision thereof upon or wiespec€~o ~. any property subject to any such tax, and any penalties thereon, shall be paid by them Executrix out of my residuary estate, and all interest with respect to any such taxes partly, out of the income and partly out of the principal of my Estate, in the absolute discretion of the Executrix; provided, however, that the Executrix shall not pay any such taxes, penalties or interest attributable to any property included in my Estate solely because of a power of appointment thereover which I possess, and such property shall bear its proportionate share of such taxes, penalties or interest. 2. I give, devise and bequeath all of my Estate, real, personal or mixed, tangible or intangible, of whatever kind and wheresoever situated, together with any property to which I have any power of disposition or appointment and whether acquired during or after my lifetime, to my beloved wife, Mary E. Buchle, provided she survives me for a period of thirty (30) days. 3. If my wife Mary predeceases me or dies on or before the thirtieth day after my death, then I give, devise and bequeath her share to our daughter, Patricia Ann Buchle Coffman of 9744 Williams Avenue, Bloomington, CA 92316. M 4. I appoint my wife Mary as Executrix of my Will. If my wife Mary is unable or unwilling to act or continue as Executrix, for any reason whatever and whether before or after my death, I appoint our daughter, Patricia Ann Buchle Coffman, as successor Executrix. .- 5 No fiduciary under this Will shall be required to give bond or other security for the faithful performance of the fiduciary's duties. IN WITNESS whereof, I have hereunto set my hand this day of May, 2003. L ~ / TESTATOR: '~~' _ ,- ,f/S_,-~?•-L ~J~- .~ Frank G. Buchle`~ Signed, sealed, published and declared by the above-named Frank G. Buchle, the TESTATOR as and for his Will, in the presence of us and each of us, who, at his request and in his presence and in the presence of each other, have subscribed our names as witnesses to this Will on the day and year last written above. WITNESS: WITNESS: `~~ ~, ~ ? ,~!-<<-. /~y~~~.-cam,-`.~ 2 COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN I, Frank G. Buchle, the TESTATOR, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Will, and that I signed it d voluntary act for the purposes therein expressed. Nota~a! S©6I Joyce A. Tambo!as, Notary Public -,~ Harrisburg, DauphIn County ~. -, My Comt~nisslon Expires Od. 5, x004 ~ ~_ , IAamoetiPe~nry~°~°®°aea°"otao~aA~ :. TESTATOR. ~ !'~~~ ~=L- ~ ~J,e-ec' ..-~ ~ ~'.C ~~ We, ~ Q u ~ l~ and /~r~`,, rti B~/d1 ~ ,the witnesses whose names are igned to the attached or foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw the TESTATOR sign and execute the instrument as his Will; that the TESTATOR, signed willingly and executed it as his free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the TESTATOR signed the Will as a witness; and that to the best of our knowledge the TESTATOR was at the time 18 or more years of age, of sound mind and under no constraint or undue influence. /~~ WITNESS: ~~ ~~ `" ~-~.~ALITNESS: <.~--- °~ ,. Sworn to or affirmed an acknowledged before me by i''-K~~ E ~3u ~ /L and ~(a.r.~ ~1 ~<-/~G~ the WITNESSES, this ~~ day of May, 2003. Q, `7~-,` r~ S~j L} NotariatSeal C~la}~~~3, Notary Publb q ftin County Niy co-mnlsstori Expires pct. 5, 2004 lY0hdt16® 3 If ?. I P II Ir(71 LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. I~ee for thi~~ certificate, `~6.U0 P 1500275_3 Certification Number REV 11/2W6 PRIM IN IANENT ;K INN t. Name of Decetlent (First, mitldle, lass, sudix) Mary E. Buchle Age ILaal Birthday) Under 1 year Untler 7 tlay 86 Mnalhe Dora Sara Minna Yra. COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH (See Instructions and examples on reverse) S7ATE FILE NUMBER 2. Sax 3. Social Security Numher 4. Dale „__.o._.,..__.~ . Female 192 - 12 ~ 4000 .Tar 8h. County of Death &. City, Boro. Twp, of Death Cumberlar-d E. Pennsboro Ttap. - K of W°M I o^^Kintl oj,~ysiu95s /Industry Clerical ulJllk (~j b lfi Decedent s Maemg Address (Street, city I town, stale, zip cotle) 27 Fairgreen Rd. Camp Hill, PA 17011 19. 2Da. Informant's Name (T / Print Frank G. ~uchle 227 21a. Method of Duposltion ^ Cremation ^ Donation 21 b. Dale of r~pp,, Burial DLSposdion (Month, tl/ayy, yyea~r) 21c. Place of L^J ^ Removal 6om State Wea Cremation or Donation Alrmodzed 26, 2009 ^ Omer ~ Speciy: by Medical Ezaminer /Coroner? ^ yes ^ No `Jan 22e. S'g Funeral Service L sae or rson acd h) 22b. License Number 22c. Name antl Address of Facility ~ 014819 L 1903 Market S o, Decedent Lived wthin Actual Limds of Cily I Boro t e, maiden sumama) ese Address (Street, city /town, stale, zip cotle) green Rd., Camp Hill, PA 17011 (Name of cemetery, crematory or other place) 21tl. Location (City /town, state, zip cotle) burg Cemetery Mechanicsburg, PA ', omplete Items 23ac oMy when cemfyng physidan is not aveeade al time of deem to ~elmy cave a deem. 23a. 7o me best of my knowledge, deem alt ~ time, data and place stated. (Signatua antl fide) ~a ' ~J l (~`(~ l lt~;l~ ~1Q~C,L ~~.1 Items 24-2fi mwt be cempleted W parson 24. Tme of Death 25 Date Prornuncetl Dead (Monet daY Yid who pronounces death. ~' ~ A M. , , JCI{'~UC)yy ~+ 1 ~l~-" 1 CAUSE OF DEATH (See Instructions end exampha) t Approximate inlerv dam 27. Pan I: Enter ma L'Dak10l events -diseases, injuries, or canpkadons - mat drectly WIKad me death. DO NOT solar lenninal ev t h resgretory ertast or ventricular en s suc as caMlac arrest, dbnll9lion without showing the elblagy. List only one cause on seen Ilre ~ onset ro Deam IMMEdATE CAUSE IFnel Nsease or condPoon resuklrg m death) . +~, t I/ r /,~ r1r y.; , ~K ~t ~ ~ r SequentiallNy lul tanditlons, d any, b Due t° (o as a consequence op. r t ` ~ ' lead to the cause dated on lice a. - ` ~ ~ ; ~.i.1.1'W10 t Fsler the UNDERLYNIG CAUSE Due to (o as a mnsequenca oQ. ~ (daease ar injury Ihat indieletl the 1 ~ 7 / events restating m death) LAST. 5 _ _ E ~ ~~ d D e t (or es a censequen a oq r I 30e. Was en ANOpsy 30b. Were Autopsy Findings 31. Manner of DBafh 32e. Date of Injury (Monet, day, year) 32b. Describe How Injury Occunetl Pedomied? Available Prior to Completion r1.~ of Cause of Deam? ~ L-CUVatural ^ Horrlirrde ^Ves ~ Na ^ Y C ^ Accident ^ peiMin I ( - 32d Tme I I ' ^ Na ^ Unknown 29. If Female: ^ N°I pregnant within past year ^ Pregnant al tune of deals ^ Not pregnant, but pregnant within 42 days of deals ^ N°I pregnam, Dut pregnant 43 tlays to 1 year before tlealn ^ Unknown 4 pregnant within the past year 32c. Place of Injury. Home, Fans, Street, Factory, OIACe Building, eta (SpeciyJ es ^ No g rives igabon o n(ury 32e. Iryury at Work? 321. II Tans lotion In' W WR' (SPec1Yl 32g. Laalbn of Injury (Street dry /town, stale) ^ Sukiee ^ Count Ncl be Determinetl ^ Yes ^ No ^ Driver I Opeator ^ Passenger ^ Pedestrian M. ^Omer-Sped 33a. Cenifier (check Doty one) N' • CMltying physlekn (Physiaan cenilyi~ cause of death when another physioan nos pronounced death and completed Item 23) 33b. Signature and 71de of CerMar 7 To the bast of my knowledge, tleath occured due to the auaels) and manner as slated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ,ey - r ~ ~: -7 ,-t,1~~ • Pronouncing antl certdying phyaiclen (Physician both prorwuncing death and cenitying to cause of tleam) - IN To the beat of my knowledge, tleath occurred et the time, date, and place, and due to the ceu 33c. Ucnnse Number 33tl. Date Signed (Month, day, year) • Medcal Ezeminer 1 Coroner se(a) end manner ea stated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _. ^ r/1 ~ "~ On the bests of ezamination and / or Invesdgallon, In my opinion, death Dreamed al the time, date, end place, and due to Ise cause(s) and manner as slated. ^ ~ 1 2" 1 ~ ~~-'" 34. Name anlId`` Atltlress of Person Who Completed Cause of Deam Iltem 27) Type I Print 35. Register's Signet Num / 36. Dat dedl .day, Year) ~ Y~::-~ ~~Y '7 Disposition Permit No. 0' 2 `3 (Month, day, year) ~ 21, 2009 6, 1922 Bell, PA ",g°°,apire` other ~y Inpatient ^ ER / Outpatient ^ DOA ^ Nursing Home ^ Residence 8tl. Fadlity Name (II tall institution, give street and number) ^Olner ~ Speciy: 9. Was Decedent of Hispanic Odgin? No ^Ves 10. Race: American Intlian, Black, Whrte. etc. Holy Spirit Hospital (If yes, specity Cuban, ISpeciM Mexican, Puerto Rlcen, etc.) Wl1y to 72. Was Decedent ever in me 13. Decedent's Etlucalion (Specify only highest grade cempleletl) 14. Marital Status. Marrie4 Never MarrieQ 15. Surviving Spouse (II wile, give maiden name) U. S. Armed Forces? Elements,ry /Secondary (0-12) College (1-4 or 5+) WidoweQ Divorced ISpecir}+I ^Yea ~Go lL Married Frank G. Buchle Decedent's Did Decedent xn Actual Residence 17a. State _ PA Live in a 17c. ~ yes, Decedent Lived in E. Pe><msbor0 176. County ~aaWJCf-L~ township? rwp. 17d^N 236. Lkanse Number 23c. Dale Signetl (Month, tlay, year) i fvi ~~cl (is (q Jcinu(1/y ~i t ~C~.~C~~i 26. Was Case Refaned to Medical Examiner 1 Cororrer far a Reason Other than Cremation or Donation ^Ves ~Nc Pad II: Enter Omer SIgD~dt condifo s coot' ' o to deem 28. Did Tobacco Use Contribute to Deem? but not resulting m the underlying cause gWen in Pad I. ^ Yes ^ Probably This is to certify that the information here given is corL-ectly copied lrom an ori~*inal Certil-irate of Death duly filed with me as Locai Registrar. The original certiticate will be fon~arded to the State Vital Records Office for permanent 1-fling. ,*~st )r =Date Issued c~ ~:~ ~= o - ~, ~, ~ ~ ~' . -- - :, ~ L _; y~ r _ =:~f C ~ r, 1~ ---i '- q -, Q'1