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RENUNCIATION
REGISTER OF WILLS
CUMBERLAND COUNTY, PENNSYLVANIA
Estate of MARY JANE L. SETZER ,Deceased
I, CAROLYN S. DIERCKSEN , in my capacity/relationship as
(Print Name)
P~ughter of the above Deceden~r, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
SUZANNE S. WELLS , Daughter
9/IZIU~
(Date)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this day
of ,
Deputy for Register of Wills
Form RW-06 rev. 10.13.06
~~_
(Signature) n `,(.
C ,~I-~
7311 Chy~-ch ~v~
(Street Address)
L,
PITTSBURGH, PA / $,~
(City, State, Zip)
Executed out of Register's Office
Before the undersigned personally appeared the
party executing this renunciation and certified
that he or she executed the renunciation for the
purposes stated within on this / 2 r~+ day
o S~ Pry 8E,~/ .100 9
a~~tcc,~.a) ~"
Notary Public
My Commission E~:pires:
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's Commission.)
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i ~'1 Ceshrrsssicn Fti~r~s Jura 5, 293
his is to certify that this is a true copy of the record which is on file in the Pennsylvania Department of Health, in accordance with
the Virtl Statistics Law of 1953, as amended.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
5191553
No.
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1112006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
IT IN
K CERTIFICATE OF DEATH
(See instructions and exam les on reverse)
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1. Name of Decedent (Frsl, middle, last, suffix) 2. Sex 3. Social Security Number 4. Dale of Death (MOnlh, day, year)
Mary Jane Setzer Female 201 - 18 - 4937 Au¢ust 28,2009
5. Age (Last Binhday) Under 1 year Under 1 day 6. Date of Bidh (Month, day, year) 7. Bidhplace (City and stale a laeign country) 8a. Place of Deadl (Check only one)
klontln Days Hours MnuRS Hospital: Other.
84 Yrs. Jul 14 1925 Columbia Pa In orient
^ p ^ ER / Outpatient [] DOA ^ Nursing Home (~Pesidence ^Other ~ Specify:
' 8h. Canty of Death Bc. City, Boro, Twp, of Death Bd. Facility Name (d not institution, give slreel and numher) 9. Was Decedent of Hispanic Origin? No ^ Yes 10. Race: American Indian, Black, While, etc.
Cumberland Ham en
3600 Lo an Ct 1A (II yes, spealy Cuban,
Mexipn,PuennRipn,etC.) (SpeciM
White
11. Decedent's Uwal Occu tbn Kind of work done dodo most of world life. Do not slate refired 12. Was Decedent ever in the 13. Decedents Etluption (Specity only highest grade comp leted) 14
Marital Slalus~
Married
Never Married 15
Survwin
S
o use (If wife
ive maiden nam
)
Ki fWork
School r`~eacher KkMd Inesllndustry
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~
'I U.S.ArmedForces? ElementarylSecondary10~12) College (1-4 or 54) .
.
,
Wdowed.l3ivacetl(SpeciM .
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usque
ianna,
tap ^Yea Nc 4 Widowed
• 16. Decedent's Mailing Address (slreel city 1 town, slate, zip code) Decedent's D Did Decedent
r a
3600 Logan Ct Apt lA Actual Residence 17a. Slate
live in a 17c ~ Yes, Decedent Lived in 211 Twp.
Townahro?
Hill Pa 17011 ,7d ^ No, Decedent Uved wkhin
,7b County Cumberland
AdualUmitsol CirylBao
18. Fatlcels Name (Frst middle, last wffix) 19. Mother's Name (First, middle, maiden wmame)
Harry Lindenberger Florence Albri ht
20a. InlonnanYs Name (Type / Pdm) 20b. InfamaM's Marling Address (Street, ury /town, shale, zp code)
Marianne Bartlett 3109 Fairbluff Ct Sunmerfield h
21a. Method of D'rspositbn ~ Cremation ^ Donatbn 21b. Date of Disposilicn (MOnN, day, year) 21c. Place d Dispositbn (Name of cemetery, crematay or other dace) 21d. Location (City I town, shale, zip code)
^ Burial ^ Removal Iran State i Was Crematbn a Damllon Authorized rtrtnn
^Dther-Specify: ; byMMkalExaminerlCoroner? I~IYes^Nc
Set 1.09
Hollin er Cremato
Mt Holl S vin s Pa
e d F rat Service Licensee as slxdr) 22b. License Number 22c. Name and Address of Foolery
• - 011654-L ers-Horner Funeral Home Inc 19(13 Market St Cam Hill Pa 17011
Complete Items 23ac Doty when cer6lyirg 3a. To the best of my knowledge, deadt occurred at dre time, date aM dace slated. (SignaNre and title) 23b. License NumGm 23c. Dale Si
9~ IMonm
day
Year)
physician a Trot available at time of death to ,
,
cerdty cause of death.
8~ P4.~ oval be candeled ~, person 24. l ime of Death 26. Date Praounced Dead (Monty, day, year) 2fi. Was Case Referred to Medical Examiner I Coroner for a Reason Other than Cremation or Donation?
who pronounces deaM. ~~ / M. .-. ~f ~.~ ^Yes []'I~o
CAUSE OF DEATH (See InsUuctlons and examples) A radmale interval:
hem 27. Part I: Enter the cfan aevents -dseases, i uries, a cam ' r PP
r7 drratims- Ural dredty posed tlce deaN. DO NOT enter terminal evmk such as pNiac arrest, r Onsd to DeaM Pad II: Enta otlcer
Ill ca~6tions canNtulno to death,
bM nd rewhing in the undertying cause given in Pad L
28. Did Tobago Use Cantdbute to Deatll?
^ Yes ~robahty
resdrebry arrest, a ventricular lbrillaUm witlgN showing the etidogy. tut Doty one pose on each &ce. r
^ ~ ^ ~~
IMMFJkATE CAUSE IFinal disease a
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Ly""
cendfian rewNiog m ) _~ a. /r E f ~f /7}T~L ~scJN(>•- ~}'1~~/~ i 29. If Fenale:
(~
Duero (a as a consequence off: i Na pregnant wiUin past year
SequerrtiaMy k5 oondltiau, U ant, b. ~ ^ Pregnant at 6me d d~N
~ ~ pose ~~ an ~ a
Dice to a as a cans Q
Enter UNDERLYING CAUSE ( equence o : ^ Not pregnant, but pregnam wiUrin 42 days
(dsease a injury drat IniOaled Me c. r
events resulting m deaM) LAST. r of death
Due to (a as a consequence oQ: r ^ Na pregnant, but pregnam 43 days b 1 ypr
• d r
r
belae deaM
^ Unknown U pregnant wdNn Ure past Year
38a Was an AMapsy
Performed? 386. Were Ardapsy Fmdmgs
Available Prbr ro Comdetion 31. Manner of Death 32a. Dale al Irqury (Monty. day, year) 32b. Descnbe flew Injury Occurred 32c. Place of Irlryry: Hama, Farm, Street, Faday,
d Cause d D~Ih? Q ~wml ^ Hanidde ~ ~ ~ (~uhl
^ Yes L
1^w' ^ Yes ra'HO
LJ ^ Aaident ^ Pendng InvesBgation 32d. Tnce d Injury 32e. Injury al Work? 321. II Tmnsponation Injury (SpealY) 32g. Laplbn d Injury (Street city I loran, shale)
. ^ Surctide ^ Cardd Nd be Determined ^ Yes ^ No ^ Dmer I Operata ^ Passenger ^Pedestdarl
M od,ar ~ speu'ry
33a. Cerhker (check Doty one) 33b. SignaNre and Ttle of Cenifcer
• Certiryprg physician (Physiciarl certitying pose of death when anaha physician has pronounced death and camdeted Item 23)
To tlce hest
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led
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my
now
ge, death occurred due to the eausels)and manner as stated---------------------------------
• Pronoun
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ng physician (Physidan hour prawundng deattr and ceniryirlg to pose of deadly
To tlce best of my knowledge, death occurred at Me Ume, date, and place, and due to the pusHs) and manner as sated
^ 33c. License Number 33d. Date Signed (Month, day, year)
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
• Medical EzamirarlCoroner ~S Q~S~~ S(,.~ [r ,,, /r ,_ p~
On the basis of examination and 1 or mvesbgahon
in mY oplnbn
death occurred at the lime date and
lace and d
t
th
d
^ / T
,
,
p
ue
o
e wusefs) an
manner as slated_
~ 34. Name and Address let y
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35
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