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F:IDOCS\PD\NTC\Yetter.Sandra-Notice of Name Change.wpd
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY
PENNSYLVANIA
IN RE: SANDRA Y. HAFFLY
NAME CHANGE OF File No. D 9 ? 7
SURVIVING SPOUSE
NOTICE TO RESUME PRIOR SURNAME
Notice is hereby given that the Plaintiff in the above named Petitioner, SANDRA Y. HAFFLY,
residing at 1479 Maplewood Drive, New Cumberland, Cumberland County, Pennsylvania, being a surviving
spouse of ALBERT S. HAFFLY, JR., decedent, who died on October 5, 2008, hereby intends to resume and
hereafter use the previous name of SANDRA N. YETTER, and gives this written notice avowing 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 &/n
Signature of Petition ,
SANDRA Y. HAFFLY
Signature of name being res ed,
SANDRA N. YETTER
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 she executed the foregoing for the purpose therein contained.
In Witness Whereof, I have hereunto set my hand and official seal.
COMMONWEALTH OF PENNSYLVANIA
ROTARIAL SEAL -W
JENNIFER A. MEARKLE, Notary Public Notary Public
New Cumberland Boro. Cumberland Co.
My Commission Expires July 7, 2012
(Note: This notice must be accompanied by an original certificate of death for the decedent)
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00
I P 14828711
Certification Number
S
H108.1M REV 11/2008
TYPE I PW IN
PERMANENT
elACKM #31-364
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.
(9 ' / o( 7 of
'A" Local egistrar Date Issued
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH a VITAL RECORDS
CORONER'S CERTIFICATE OF DEATH
(See Instructions and examples on reverse) STATE FILE NUMBER
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Disposirm Pemul No. o.2-4,3? q s ,,e
FILE D -':,)FFICE
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rfr, ) TARY
OF THE
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