HomeMy WebLinkAbout06-26-09 10~.80~ REV (Ol/U?'.
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, 56.00
This i, t(~ certii~r that the informatiim here ~*iven
correctly cop.ec~ front an ori]inal Certificate of Dea
dull' filed t~~ith Ine as Local )Ze~,istrar. 'I'hc origin
certificate will be forwarded to the State Vit
Records ~3ffi~~e for ~;erm~tnent filing.
Certification Number
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plus-u3 Rev n:2aus COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
TYPE ~ PRINT IN
psucKwnT CERTIFICATE OF DEATH
(See Instructions and examples on reverse) ~r.r. ~„ ~ „ l 1 n ~1 ~'~ ((~ C? h
i. name a Veceeenl (rust. INOde. Iasi, wPox) - 2 Sax 3. Social Security Nwiber 4. D'dla d Deam (Manh.
y, year)
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90. County of Death &. City. Bwo, Twp. ul Death 9d. FazAay Name QI nd insauam, gwe greet arM nun0er)
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8. Was Decedent d Nispyib Orkyn7 No
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Amwiperi Nitlian,
pl yes, spedly Cuban, Brads WMe, eu
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11. DBCeoenl's Usual a Nmtl d work done dur d
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Ne. lb not 51ate reteetl 12. Was Decetlenl ever Ni the 13. Deceaenrb Educalbn ISpxlry ody hghest grade nomplete0) 14. Myilal Statue. klarried, NavN Married, 16. Survi
vkg Spouse III wee, give maitlen name)
Nab d Work Nadal Business / Indust U. S. Armed Forces? Witl
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owe
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lemyitary /Secondary (P12) Cdlega (I-4 or 5*) I~+M
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16. DB-CBfdenY6 M,a^1Mlg AdMasa ISDeet, city / bwn, stale,(zg~ code) /~ Decedent's Dtl-~_ agent ~-~LJ C~ , 1 "~'
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Actual LkdLs d Gny I Boro
13. fatliw's Name jFrsl. rnidAe, Wst. wpu)
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19. Moprer
s Name (First, nkdie, niaidari~°`~'~ )
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ZOa. Nlormanl's Name (Type / PruN) 2W. InlwnunPS Maprg Address (SU6e1, cRy / bwn, alal6, zip )
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21 a. Method d Disposi0
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^ Crematbn ^ Donation 216. Data W Disposi0on (Mash, day. Year) 21c. Place d Ospositiori (Name mrMl a Whw place) 21d. Locatron (City ! bwn, stale. zq code)
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&IIMI ^ Romuvy Irom Swe I
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Was Cremation or DwlaDOn Authorized (y (].
^ 'Dlt~r - Speciry: Dy Medkal Examirwr / Coroner9 ^Yes ^ No ~~ ~ (y ~ ~ -7
c~la,4`~tTYA~(~ q(~ Na~t~ ti~V
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22a Sgna d F rrerw Service lkensee (a pe azw ass 220. License Nwriber 22c. Name antl Adbass of Fazary
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y wMn ceNpkg 23a T e of mY krewbdge, meet occured pie lane, date and place staled ( tore and Mle) 230. licerue NurMer
physician is not ava0.aWe al lime d Oeapi Io
23c. Data $prk0 ( ,day, gay)
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camp cartsedaeam. _ ~L7''lJ /~ ,2A~1995p9L GtS-~S'U
Hems 24.26 nwsl w canpteied by p0lsai 24. imp of Oealh 25. Dale Pranacetl Dead (Monet, day. year 26. Was Case Rbbrred to Medical Exdrtaner I Coroner kx a Reason Omer dwn Rematbn a DWNhen?
rvna proriaaee, meet G1 ~ ~ C~ M
0 5 - a 5 - ~ o ~ ~
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^Yes ^No
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~ CAUSE OF DEATH (See Instruetlone and examples) r ApproxurMte imervaL Pan IL Eater amer
Ls-1 :_or ^^:":~14~CLN. 2p. Did Tdsaa:o Uze ConlnWt¢ b beam?
IMn 2]. Pan 1'. Enter dw GBdtllfd eve ds ds0ases, rcyurux, a Complicaeans - Inal tiredly caused In0 dOaN. DO NOT enter terminal events such as cardat arrest
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respiratory anesl, a vedrx:War kOr9Mkon wkhout stewing the etebgy. list ody one Uuse a1 ey:h lute. Onsw b beam DA not rasukap n me urxlenyky cause Yvan n Pan I. ^
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IiDOnMTE CAUSE IFUN daease a I y~7 ~ ^ Ur'Mbwri
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Sepw liaay Yw ron6Dons, A any. D - ~f. I {~ {C ~i 1 V"/ / 7(° L ((' [, j {.,) LJ r'regriarit aI Wne d deatll
lea6~q ro the cause Nuetl on Me a i
) Eobr 9w UNl1ERLYWG CAUSF Oue I~ (w as e..
ideuase a inpiry mdl ianalod th0 auWuanuo of)'. i t Ys
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averes rawang vi dealn)LA$L ~
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^ Ur'kmat d pepwn wd0n pie Pau Year
30a. Was an Adopsy 300. Were Aubgy Feidrgs 31 Maw % of Death 32a. Dale d I
Pencrtned? Aradaue P(xx to C uun r~ / Mury (Modh, day. Year) 320. Desaibe Now kpury Occurted r /C O / ~ 32c. PMce d Irptay. Ybre, Farm. Brea. Fadory,
01 Cause d Deam? k4a anal ^ Hununde Opbe Butlding. ek (Beatty)
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^ AaWant ~] Pendng Invewydlwn 32d. Tune d Iryury 320. Inpiry al Wak? 321 II Translwnaaun Iryury (Spepyy) 32 locybn f
^ Ye5 [L~Nu ^Yes
9 o ONurY (Strew. city / bwn, slate)
^ Swnde ^ Could Nd Oe DBbrrnrwd ^Yes ^ Nu ^ Dnver / Operate ^ Passenger ^Petlewian
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33a CBmhet Itliecu onry one)
<rap ng pnysicMn IPnysxan c
nirybg cause of deem rvnon another pnyseran has pronounced a0adi antl eanpbted Item 23) 3b. Sgnalae and Tae W CeNfau
alh ottyred due to IM Cause(s) aiM manrrer as shle~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ~ _ _
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cenirying ro cause d death)
To pie bail of my bwwle0ge, deaN a:curred as Ne Dme, dale, and place, aM due to Ine Causela) antl manner as slaled_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ 73c. License Number
33tl Date Signed IMann, day. Year)
. MedcyExamirwr/ceronw 7 %C
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~ On the basic W axaminatbn and / or imasligalion, in my opinion, death occurred al the Dnte
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and plan
and due ID the uuse(c) and malce
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3A. NamO aM Adpess of Person Who Carpbtetl Cause d Dean (He
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Dispcsnion Permn No. ~/ 3.~. O
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RENUNCIATION
REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA
Estate of Loretta .Young ,Deceased
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i. Betty J. Clausi, a.k.a. Betty J. Brown in my capacity/relatlo~s~ ,p`~s -~
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(Pent Name) ~ .~ -`*'
daughter of the above Decedent, hereby re+~ci~imce the I~ht to
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administer the Estate of the Decedent and respectfully request that Letters be issued to
Cathy J. Martsolf
(Dare) (Signatur B y J. Clausi, a.k.a. Betty J. Brown
678 Cumberland Point Circle
(Street Address)
Mechanicsburg, PA 17055
(City, State. Zip)
Executed in Register's Office Executed out of Register's Office
Sworn to or affirmed and subscribed Before the undersigned personally appeared the
party executing this renunciation and certlfled
before me this day that he or she executed the renunciation for the
purposes stated within on this ~b'F`'"day
of of ~-1't-~-- ~
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Deputy for Register of Wills u
Notary
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(Signature and seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's commission.)
G(3MMONWEALTH OF PENNSYLVANIA
Notarial Seal I
Tiffany L. Meeder, Nctary Public
Lower Allen Twp., Cumberland County
My Commissior, Expires April 25, 2G1'i
Form RW-06 Rev. to-t3-zoos Copyright (c~ zoos form sonware onry the Lackner Group, Inc. Member, Pennsylvania Association of !vctaries