HomeMy WebLinkAbout08-27-09SNELBAKER ~ BRENNEMAN, P.C.
A PROFESSIONAL CORPORATION
ATTORNEYS AT LAW
44 WEST MAIN STREET
MECHANICSBURG. PENNSYLVANIA 17055
RICHARA C. SNELBAKER
KEITH O. BRENNEMAN
717-697-8528
P. O. BOX 318
FACSIMILE (717) 697-7681
Cumberland County Courthouse
Vb1St~l ~i1 YY 111.7
Room 102
One Courthouse Square
Carlisle, PA 17013
Re: Estate of Howard E. Smith
21-09-0774
Dear Madam:
August 26, 2009
Enclosed for your records is the corrected death certificate for the Estate of Howard E.
Smith.
Please contact the undersigned should you have any questions.
Enclosure
Sincerely,
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Sandra K. Showers
r,state Administrator
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OCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photag~ aph.
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wust43 REV n-2w5 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
TYPE 1 PRINT IN
PEF+YAaNENT CERTIFICATE OF DEATH
elacK wK (See instructions and examples on reverse) sraTE FILE NUMBER
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1. Name of Decedent (Fifsl, middd, last supix) 2. Snx 3. Social Security Nwnber 4. Dale d Death lMnnM, day. year)
Howard E. Smith Maie 183 - 23 _ 3001 August 7, 2009
5 Age 4asl Birthday) Undr t year UMer 1 da e. Dale d BirN (Monts, day, year) 7. Binhp4ce (' and s4te or are n countryl 8e. P4ce d Denth (Check orse)
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Other:
MonMS Days Hars Mnutes HOSpaal:
85 September 5, 1923 Monroe Township, 10
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yrs ^ Inpatient ^ ER / Oulpal4d ^ DOA ~ Nursing home ^ Residence ^Oaer ~ SpacAy.
W. County d Death Bc Cily, Boro, Twp. of Death !b. Factliry Name (K rid iraNugon, give Mreel and camber) 9. Was Decredeee of Hispanic Origin? ~ No ^ Yes 10. Race American ddlan. &aa, WMte. e¢.
Cumberland Camp Hill Manor Care Health and Rehabilitation (`~ k~ P`~'~~R~ `~`~M White
ale!
11. Decedents Usu& Occ Don IKIM d woh d one dun moll d wo tile. Oo na s44 retiree 12. Was Decedent ever Js Na t3. DeceOerst's Educafan (Specify only highest gratle comP 4led) 14. Mari4154tus: Married. Never Married. 15. Surviving Spo use Qf wee, give maiden name)
Kind o WorF rid of Bus ass / uduyry
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t U.S. Armed Faces? Elemen4ry 1 Secadary (012)
8 Capege (1-4 a 5+) Wltlowetl. Divorced (SPealy
Divorced
acturing
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Die S yB6 ^y~
16. DecedenYS Mailing Adtlress (S1ree1, city ~ town sole rip code) Decetlern's Dq Decedent
s44 PA Lweina n
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1700 Market Street ,
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PA 17011
Cam Hill
P ,7~ Nn DecedamLi6adwAnin Camp Hill
nD cnanry Cumberland
, Aclaal Lips d aly / Baa
1p Famee's Name (Firs( meddle- last sutlixl
Irvin G. Smith f 9. Mopler's Name (Fiml mldd4, n4itlen aanalre)
Alice Porter
20a Inlamam's Name (Type I Pmell 20D. InfamaM's MaAirg Address ISpeel, dry /Own, s4te. zip code)
Ken Smith 1624 Williams Grove Road Mechanicsburg, PA 17055
2ta. Method d Disposition I ^ CremaNOn ^ Dgnalwn 21 b. Date d Disposition (Month, daY. Year! 21c. P4ce of Disposedwl4Name d ceole4ry, uemdgry a ogles placal 21 d. Locatwrl ICAY 11own, s44, zq coda)
ppI anal RenwvaWanS41e wascbm.uanaroaneuonAalnaf=.a
I 2009
August 17 Mechanicsburg Cemetery Mechanicsburg, Pa. 17055
M EaaMnar / Coronart ^ Yes ^ No
^ Omer - S ,
22a. 5 e d Funeral Servic ensae e ' g as such) 22D. License Number 22c. Name and Address d FaciNry
! FD-012662-L Myers Funeral Home, inc. 37 East Main Street Mechanicsburg, PA 17055
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Complete Items 2 t when cerpying
pnYSkean is not evdlable al lone of death to 2 T best of m e, dean awned at the time, tla4 and s41ed. (Signature title) ~ /
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`~'`~ 23D License Number
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certdy cause d tlealh. ~ ^ ~ J S /
Hems 2426 must De cumplelW by person 24.7 a of Death .a
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S 25. Da4 P d Dead/(Morin, day, year) 26. Was Case Raferre to Medical Examiner /Coroner to a Reason OtneY roan Gemalan a Donation?
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who prorwuae5 deals. '
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d C~C+~/ST' aG ~) No
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H (Seri Instruettona An0 ~xampbe) , Approeallale WenaY.
CAUSE OF DEAT Pad II: Enter otlier 1WDtlIYA01S4m41a?Oal~llBgglYWl4flpAlB, 2a Dd Tooeao Use cwnalbute a Deals?
14m 27 Pan I. Enloe uw cLa10 ul ayxt115 aseases, wlurles. or wmplkations - and daecAry caused the deaN. DO N0T enter termaal evm4 such as wrd4c arrasL Onset 1o Dedlh hue not rewNing n pie aderrying cause 9wen m PM I ^ Yes ^ PeoDaay
respiratory anesf a vemricu4r IitxiNellon wilMut snowing the elioagy Lisl only one cause an eats 6ne. L No ~] Unerwwn
NIMEDIATE CAUSE Final diseuse or ~ x
carlddbn resudrq in l~eatlll ~~ R ~ ~~ / S ~r/llnf~i?n ' ~ 5 y~z~•(S
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Due to (or as a consequence °q:
SequemMH list taldAwns. A any, b. i
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ws year
^ PregnaN at Nmn d death
kaaNy w I~e ~ 6swd on caw a l
UNDEflIYING CAUSE Duo lu for es a consequencn oil: ,
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Due 1° (a as a con;aquerwe d): F (~ Na pieJnanl. DW yfeglw4 07 deye W 1 yeui
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d ^ Urdlnown d pegnaM wlppn IM {last year
30a Was an Autopsy 3gb Ware Autopsy Findings 31. Mannar d Deals 32a. Dale of Injury (MOnN, day, yeaf~ 32b. Describe Few Injury Occurred 32c P4ce d 4jury: Nome Farm. $aebl. Factory,
Pedcrn>ed? AvalWda Prar a Dompletiw
d Cause of Deals?
~Clalwal ^ Homicide Oplce Bolding, etc tSpadyy
^ Atcdenl ^ Pe,ding Invesngelwn 32d. Tune d Irqury 32e. Injury at Wa6? 321 II TranspoNlwn Injury (Sperily! 32g. Lowlvm of Uyury (Brea, coy I Own, s41eI
^Ye= ~~ ^Yn6 ^ Na
U Suecide ^ Could Not be Determined
^ Yes ^ No
^ Driver I ()peraar ^ Pazsanger ^Pedesbian
M oast ~ saw'M~
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33a Cemher jcneca udy one) 33b. a and Tde of Certifier r i s I ~ }•
• Candying physcian IPhysu:lan ceNrying cause d death when another physician has proreanwe0 deem and cexrlp4latl Item 23)
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mMn acurrod dw a the rouealq ant manner as abted
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• Prawuncinp end cedllying pnyalcian (Physician both peono,xwing dea4 and cenltyirg to cause d seam) ^
To pie beatdmy Nowbdge, deaN occurtea MMla time,date, end place,ant dwblM CauaMsl ant msnrler ae s4tad__________________ 33c jjj~A~~~rrrl~NSeee Number
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v, (~"1 A 730 Sigad (Haab, daY Yeae l
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On lbe wale d axe Inalion end / a avesligetion, to my op4bn, death acurred n Ula Ums, dab, and place, ant due la tln auwla) and numer as amen ^ e~led Cause d Deane Qom 27) Type I Prrlt
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~ Name ~ Atldress d Persm WM1
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