HomeMy WebLinkAbout09-6938IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
IN RE:
NAME CHANGE OF File No, dQ- ?e438 L"cvi 1. /F?f?1
SURVIVING SPOUSE
NOTICE TO RESUME PRIOR SURNAME
(PLEASE PRINT OR TYPE)
Notice is hereby given that the above named Petitioner,
surviving spouse as of
, residing at,
being a
hereby intends
to //?J?reesu?me and hereafter use v the previous
J!: ?/L?/ -/./. XLA? f
10-1-10-IN
of
and gives this
written notice avowing his / her intention pursuant to the provisions of 54 Pa.C.S. §
704.1. A Certified copy of the Certificate of Death for the decedent is attached.
Date:. I t3
Signature of Petitioner
??_7J4?
Signature of name being resumed
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
On the day of 2009, before me, the Prothonotary or the
notary public, personally appeared the above affiant known to me to be the person whose
name is subscribed to the within document and acknowledged that he / she executed the
foregoing for the purpose therein contained.
In Witness Whereof, I have hereunto set my hand and official seal.
I 4K&
Notary Public
(Note: This notice must be accompanied by an original certificate of death for the
decedent)
NOTARIAL SEAL
PROTHONOTARY, NOTARY PUBLIC
CARLISLE CUMBERLAND COUNTY COURTHOUSE
MY COMMISSION EXPIRES JANUARY 4, 2010
2G09 OCT 14 Pik t *- 22
Lt.? v? dam? i L r ? ?-
?CL
? 23 te
T{I(15 kl>? RFV r(1! n"
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00
P 15000012
Certification Number
HIW1e3 REV 1112006
TYPE / PRW IN
PERMANENT
BLMX W
1
I
This is to certify that the information here given 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 Office for permanent filing.
o§C 2 / Foos
Local Registrar Date Issued
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH w VITAL RECORDS
CERTIFICATE OF DEATH
(See Instructions and examples on reverse) STATE FILE NUMBER
1. Ne-e of Decedwd (FM. MO, ecl mft) 2. Sex 3. SMW SM* Nmfer !. DO d Deee (Mo* dry, YW
N Richard Jones ale
186 -24 - 9450 November 26, 2008
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79
July 20,
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a. Nrw end,?mw d, Who Calpebd Can a Deeel (Be- M Type / P
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