HomeMy WebLinkAbout05-11-09 t1~+-, >r^ Rile nl ::
LOCAL REG{STRAR'S CEF~TIFICATION OF DEATH
WARN{NG: It is illegal to duplicate this copy by photostat or photoga~aph.
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Certification \umbcx
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xRINT IN
ANENT
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This i~ tU Cc~riii~x that tic itd~)rn).Uion here ~~iven i~
correctly ro;~ii~d ii<,;n an t>ri~*inai ~'Lrtili~ate of U`ea[?
duly t~ileLl L°: ith )ne a~ l_or~Ll l~e~ri~trrr._ The <,rivainrl
certi[icate t4i4i ~_~ f~yrtisarded )o the State Virr
Records f)f; icc t)r perm,.uT nt tili)~~~*.
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Local Rey*I~:rar ~~~ ~7ate {sued
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
iSee instructions and examples on reverse) STATE FILE NUMBER
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1. Name of Decedent (First miG11e, last suffix) 2. Sex 3. Sodal Secunty Number 4. Date of Death (Month, day, year)
male 194 - 28' 9938 March 4 2009
5. Age (Last Binliday) Under t year l)nder 1 day 8. Date of BiM (MOnlh, day, year) 7. Birthplace (City and state a fa ' country) Ba. Place of Death (Check only are)
8 4 etaww o-ars Hwrs 1,5nNea
Aug . 8 , 19 2 4
Lithuania Hospital:
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Bb. County of Deam Bc. CNy, Bono, Twp. of Death 8d. Faa'I'ay Name pi not instiMion, gh'e street end mtmber) 9. Was Decedent of Hispanic Origin? ~ No ^Yes 1 D. Race: American Indian, Black, White, ek.
Cumberland
S.Middleton Tw
Carlisle Reg.Medieal Ctr. (N yes, spedty Cuban,
MexicagPuenoRican,etc.) (Si1eL'lM
white
11. Decedent's Usual Occu lion Kiiq of work done tlu ~ most M work' INe. Do not sUte relit 12. Was Deceeient aver in the 13. Decedent's Education (Speclly only highest grade crompleted) 14. Marital Status: Monied, Never Marrietl, 15. Surirving Spouse (Ii wife, give maktan name)
Kind of Work Kind of Business l Industry U.S. Awned Forces? Elementary /Secondary (0-12)
7 College (14 or 8.) Widowed, Divorced I Spaciy>?
widowed
dock worker trucking ^vea )gNd
16. Decedent's MaiNng Atlaess (Sheet, dry /town, stale, ziD code)
523 Herman Ave Decedent's Did Decedent
Adual Residence 17a. State Pennsylvania Live in a 17c. ^Yes, Decedent Lived in Twp.
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Cumberland nd~]•No,DsretlentLNedwithm
lemoyne, PA 17043 ,7b.Cwnty
Aduel omits or T,r~moyna ciryrBOm
18. Falherb Name (First middle, last, suNra)
Stesys Brazinskas 19. Molhar's Name (First, middle, maiden surname)
Katerina Masalkate
20a. IMormant's Name (Type /Print)
Heidi H. Garber 20b. Informant's MaNing Address (Street. city I tam, state, zm wtle)
5403 Oak Ave.,Harrisburg,PA 17112
21a. Medrod d Deposition ^ Cremation ^ Daatian 21b. Date d Dispostion (Monty. day Year) 21c. Race o1 Disposition (Name d cemetery, crematory or other place) 2f d. Locetion (City !town, state, zip code)
~Bixial ^Rerrmval born State ;Was CremallonaDateNon Atnaorized March 12
2009 St. Casimir's Cemetery hicago, IL60457
,
• ^ Other - Sped'ty: i ~' Medkal Examirtx I Coroner? ^Yes ^ No
22 q(Funeral Lkensee (a person acting as such) 22b. License Nartber
FD-013163-L 22c. Name and Arldess d Fadliry
Musselman FH&CS,324 Hummel Ave.,Lemoyne,PA 17043
hems 23ac oNy when caNlykrg 2 Nte d knowledge, deem and place SN]letl. (Signature antl Nile) 23b. License NwMer 23c. Date Signed (Month, daY. year)
. phYSkAan re npl available al time or Beam to )
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oer6ly cause of deaM. - om-
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th 2 . Date Pmriowmed Dead (Month, y, Year) ZS. Was Case Relerted to Medical Examiner /Coroner for a Reason Other than Cematlon or Oonatron?
hems 24 26 must he canPleted by person
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;~ ^Yes ^ No
wM pronounces deem. M (
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CAUSE OF DEATN (See Instruetlons and examples) r Approximate interval: Pad II: Eller other 5iaid~at ~,NO„a contrib.= __ to Ma+h. 28. D~M Tobacco Use Conidbute to Death?
Item 27. Pan I: Emer the chain of events - dseases, mjunes, a corrtplications - mat drecty caused Ifre death. W NOT erns terminal every such as cardiac artesi, r Onset to Death
' bN not resWtmg in Ute ualarlyhg cause ghan in Pad I. ^Yes ^ Pmbedy
respifabry artest, a wmincWar fbMlaeon wAMut stwwing the elbbgy. Ust only ate cause on each Ikte.
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t ^ No ^ Unknown
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IMMEgATE CAUSE Final drsease or ~J
y~~L~.Q Win i )'/' 'i G~ i ~ (,Yi! G-(1-
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wMilan resulting m death) 29. tt Ferttale:
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Due to or as a con op:
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year
ot Pregnan
^ Pregnant at time of death
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SequerAlatly fist condtbrw, d airy, p
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lead m the cause ksled on tine a. f t
rig Due to (or as a consequence oQ: r ~ '
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UNDERLYING CAUSE
Ih ^ Not pregnant, but pregnant within d2 days
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(dsease or'mjury that kNtiated the c
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events resuNkg in Mam) LAST. ^ Not pregnant, but pregnant 43 days to t year
Due to (or as a consequence oft:
before dash
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d ^ Unknown it precyant within the past year
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30a. Was an Autopsy 3W. Were Autopsy Rndrcgs 31. Manner of Death 32a. Date M Injury (hbMh, day, year• 32b. Describe How Injury Occurred 32c. Race of Injury: Home, Farm, Seet. Faaory,
ONice Building, etc. (SpecityY
Penamed? Avaiable Pna to Cortipleibn
of CaJSe of Death? ^ Natural ^ Homicide
^ AatiMM ^ Pendng InvesNgaNon 32d. Time of Irryury 32e. Injury et Work? 321. U Transportation liqury (SpedyyY 32g. Location of Injury (Street, dry /town, state)
^ Yes ^ No ^Yes ^ No
^ Suicide ^ Could Not ba Determnad ^ ~
^Yes ^ DmerlOpe2la ^ Passenger ^PeMstnan
M ~r ~,rry.
33a. Cenifier Ids ^^N one) 33b. 5gnatae Ale of ~ mr
• CMNying physklen (Physidan cenitying cause of deem when aroma physk:ian has praiaaxad deaM and comPietad hem 23)
death occurred due to the ceusa(s)and manner as smted.____________ ____________ ________ ^
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ProneUtlcing and cenKyMg physkian (Physcian both pronotxxing death antl cenilying to cause of deem)
• To the best of my knowledge, Math occurred et the tMre, date, and place, and due to the cause(s) ant manner es stated- _ .. _ _ - _ ., - _ - - _ - - - - - ^ 33c. License Number
yy, ~1 ~ `~ ~~ 3 -./
/ " '~ v ~ J ~ v J 33tl. Date S netl (Month, daY. yearl
-"' 1 (,'
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• Medkel Examiner /Coroner
On the beats of examtnadan amt / or Imestigetlon, in my opinion, deem occured at the time, date, std place, and due to the reuse(s) and manner as staterL ^ 34 ~ Address of parsyon-Wtro Canpietad Cause of Deam Iltem 27) Type / Pnnl
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38. Registrar's B' ore and Distric
O"~ lt,Z~ /I r''I ~I 'I 36. Dais F~d ( day, year
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Disposhion PertnN No. ~ ..J
LAW OFFICES OF
LESLIE DAVID JACOBSON
LESLIE DAVID JACOBSON
8i5o DERRY STREET
SUITE A
HARRISBURG, PA i~lii-526o
CHAD J. JULIUS
SCOTT McPARTLAND
Phone: (~i~) 909-5858
Facsimile: (~i~) 909-~~88
May 8, 2009
Ms. Angie Weber
Register of Wills Office, Cumberland County
1 Courthouse Square Rm. 102
Carlisle, PA 17013
Re: Estate of Stanley Brazinskas
Dear Ms. Weber:
Thank you very much for your phone call today. Enclosed please find a corrected check in the
amount $395.00 payable to Cumberland County Register of Wills along with an original death certificate
for Stanley Brazinskas.
This letter will also serve to confirm our request for five (5) short certificates.
Thank you for your assistance in this matter.
Sincerely,
Elizabeth Rhoades
Legal Assistant
Enclosures
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