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HomeMy WebLinkAbout01-08-10 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND Patricia D. Rockey, being duly sworn according to law, deposes and says that the facts contained in the foregoing Petition are true and correct to the best of her knowledge, information and belief. a Patricia D. Rockey Sworn and subscribed before me this =i ~ day of ~ (~ Q,~~, , 2010. ,.~ ,Notary Public COMMONWEALTH OF PENNSYLVAPIIA Notarial Seal ltaren S. Noel, Notary Public Cariiale E3oro, Cumb~iand County My Corn+mi~~i~n E~ires Dec. 8, 2011 Member, Pertr~syivarua Association of Notaries .805 REV I/OS This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as Laical Registrar. The ortgiral certificate will be forwarded to the State Vital Records Office for permanent filin . g WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $6.00 No. l~~ Local Registrar +`IH ~ ;G ~ LUI~~ Date i t43 Rev. 2/87 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH NAME OF DECEDENT (First, Middle, Last) STATE FILE NUMBER ~. Be lva Mile Dean SEX SOCIAL SECURITY NUMBER DATE OF DEATH (Month, Day, Year) AGE (Lest Birthday) R 1 AY DATE OF BIRTH BIRTHPLACE (City and P• femalAT h 207 07 - 9618 4 May 20, 2005 . Months Days Hours Minutes (Month, Day, Year) State or Fore' n Coun - t Ih r ~ ~/) HOSPITAL: OTHER: s. 85 Y'=• Aug~~~ 29, New Cumberland InpalieM (] ^ ^ ~w I ~ ER/OutpagsM DOA N 8. ~• PA 8a. H,,11e R.eid.no. ^ O1Ai ' COUNTY OF DEATH CITY, BORO, TWP OF DEATH FACILITY NAME (It not institution, give street and number (sP•uM ^ WAS DECEDENT OF HISPANIC ORK;IN? RACE -American Indian, Bladc, White, e ~, Cumberland 8c Middlesex Twp . No® Ye:^ Ir yea, apaciy Cuban, (Sp~+rY) ed. Claremont Nursing & Rehab Mex7-can,Puet~ORican,etc. ~ white ' DECEDENT'S USUAL OCCUPATION KIND OF BUSINESS /INDUSTRY AS DECEDENT EVER IN 10' (Gtve MIM o/ wodc done dartrq most DECEDENT'S EDUCATK)N of woANq Nir, do not uw ngreaj U.S. ARMED FORCES? (S onl stl ~pyyd) MARITAL STATUS -Monied, SURVIVING SPOUSE Ei.mant,ry;s Never Martkd, Widowed, tN wiH. aiw matd•n n,me) • ~+a• Secretor 11b. Healthcare 72 Yea^ "°~ t3 (a1z" 1 t%~itaye Oivorced(Specity) ('~'°`S'' 14, widowed DECEDENT'S MAILING ADDRESS (Street, CitylTown, State, Zip Code) DECEDENTS 17a. State Florida ~s • 2905 SE Ocean Blvd. AcruAL Did 'ITC. ^Yaa, decedent lived in RESIDENCE decedent tyre, 18. Stuart FL 3 4 9 9 6 (sea instructions live in a ~ No, de°edent ltved on other side) 17b. County Martin townahip7 ~ ~d, FATHER'S NAME (First, Middle, Last) within actual limits or Stuart cibboro 18. 1. Grimes Mi 1 e y MOTHER'S NAME (First, Middle, Malden Surname) INFORMANTS NAME (Type/Print) +g. Bertha Glendora Colm 2oa. Patricia D . Ro c ke INFORMANT'S MAILING ADDRESS (SUeet, City/Town, State, Zip Code) METHOD OF DISPOSITION 20b• 751 Cranes Ga Road, Carlisle, PA 17013 e DATE OF DISPOSITION PLACE OF DISPOSITION- Name of Cemetery, Crematory LOCATION - City/Town, State, Zip Code Donation ^ Burial ~ Cremation ^temoval horn State ^ _. ^ (Month, Day, Year) or Other Place e z~a. other(speciry) 2711, Ma 24, 2005 27c, Shoop's Cemetery 2~ower Paxton Twp. , PA 17109 • SIGNAT E FU L S LICENSEE OR PERSON ACTING AS SUCH LICENSE NUMBER 22a. FD 013 340 L NAME ANDADORESSOFFACIUTY P3rthemore FH & CS, Inc. 22b. z2t:. P.O. Box 4 1 New Cumberland PA 17070-0431 Complete it 23 -c only en ng To the best of my knowledge, death occurred at the time, date and place stated. physician is not avaltable at time of death to (Signatur nd Title) LICENSE NUMBER GATE SIGNED ' certiry cause ~ death. ~ ~ ~ . ~ J (~ (Month, Day, Year) 23a. [ ~ l q ~ ~ ~~J' ' Items 24-28 must t>e completed by TIME OF EAT ~ DATE RONOUNC EAD (Month, Day, Y r) WAS CASE REFERRED TO A MEDICAL EXAMINER ~ ER? • person who pronounces death. ~ ,/y~ ~) 24. M. 25. I r i dl ~ ~ a0 ~ Yes ^ No 27. PART 1: Enur the dbeaue, Iniurles or eomplleadone which cawed the death. Do not mbr tM mod' of dylna, such a, cardiac or nsplntory arre.t. shook or Mart failure. 28 Llet only om cause on eeeh Ilne. ; Approximate PART 11: Other significant conditions contributing b death, but IMMEDUITE CAUSE (Final ~ interval between not resulting in the underlying cause given in PART I. disease or condition .onset and death resulting in death) --- a. + I~JJa ~ )T 1 D rl DUE TO (ORASACONSEQUENCEOF): LOr2O{d,r,h AR•~-ytt' ~~j Sequentially list conditions b. ; ' If any, leading to immediate DUE TO (OR AS A CONSEQUENCE OF): r Tti'(P E ~ Q +"~ cause. Enter UNDERLYING CAUSE (Disease or injury °• r I-1 Y P that initialed events DUE TO (OR AS A CONSEQUENCE F): ' EYlT1z1 J S t O-~ resulting on death) LAST d, r WAS AN AUTOPSY WERE AUTOPSY FINDINGS MANNER OF DEATH , PERFORMED? AVAILABLE PRIOR TO DATE OF INJURY TIME OF INJURY INJURY AT WORK? DESCRIBE HOW INJURY OCCURRED. COMPLETION OF CAUSE Natural ® ^ (Mo^w. Day, rear) OF DEATH? Homicide Accident ^ Pending Investigation ^ Yes ^ No ^ Yes ^ No © Yes ^ No ® Suicide ^ Could not be determined 30a. 30b. M. 30c. gOd, ^ PLACE OF INJURY - At home, farm, sUeet, factory, office LOCATION (SUeet, Ciry/Town, State) 28a. 28b. 28. buUdiny, etc. (Specify) CERTIFIER (Check only one) 30e. 30f. 'CERTIFYING PHYSICIAN (Physician certifying cause of death when anolh r SIGNATURE AND LE OF CE IF To the bast of my knowledge, death occurred due to the causes(,) an~ manrti aas statef Odn. oun..ed death and completed item 23) ........................................... ® 37b. • ~ 'PRONOUNCING AND CERTIFYING PHYSICIAN (Physician lwth pronouncing death and certifying to cause o/death) LICENSE N To the best of my knowledge, death occurred at the time, date, and place, and due to the causee(s) and manner as stated ...................... DATE SIGNED (Month, Day, Year) '= ^ 31a:vIQ - O+~ ~.(•~~tl- 37d. -a3 "OS •MEDK:AL EXAMINERICORONER NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH On the basis of examination andlor Investigation, In my opinion, death occurred at the time, date, and place, and due to the cauws(e) and (Item 27) Type or Print manner as stated....... ......................R.......................... En.~vES`f tM, c~OSY~iwtq 31a. ............................................................ ...................................... REGIST SIGNATU'Ii;f~ID 32. )~3D GOOt? laGPt, Q~, EtJJt_,e. PA !703..5 //,~~ DATE FILED (Month, Oay, Year) Cumberland County Bureau of Elections • Voter Registration Commission 37 East High Street • Carlisle, PA 17013 (717) 240-6385 -Carlisle FAX (717) 240-7759 (717) 697-0371, Ext. 6385 -West Shore (717) 532-7286, Ext. 6385 - Shippensburg Dear Voter: Attached below is your Voter ID card. Please carefully detach, sign and keep for your reference. Please notify the Election Commission within 10 days from the date it was mailed if any information on the card is incorrect; otherwise, the information shall be deemed correct for voter registration purposes. Pennsylvania law requires that registered voters who appear in person to vote for the first time in an election district after December 9, 2003, must present a form of identification. If you are voting for the first time in your county, and intend to vote by absentee ballot, you will be required by federal law to include a copy of a form of identification with your absentee ballot. Cumberland County, Pennsylvania Certificate of Voter Registration DEAN, BELVA MILEY Voter ID: 020498121-21 751 CRANES GAP RD REPUBLICAN CARLISLE, PA 17013 Enrollment Date: 2/4/2005 Municipality: NORTH MIDDLETON TWP Ward: Precinct: NORTH MIDDLETON, 1 P YOU SHOULD KEEP THIS CARD ON YOUR PERSON. AFTER DECEMBER 9, 2003, IT IS IDENTIFIEATION OF YOUR RIGHT TO VOTE AT YOUR NEW ELECTION DISTRICT, DIVISION OR PRECINCT. Under the law you must present a form of identification to the election officials on Election Day the first time you vote in a new election district, division or precinct. This cans is an acceptable form of identification. Polling Place: N. MIDDLETON FIRE CO. #2 2061 SPRING RD CARLISLE, PA 17013 Signature or Mark of Elector Valid 10 days after: 1/25/2005 ~_ ___ BELVA MILEY DEAN 751 CRANES GAP RD CARLISLE, PA 17013 ~~• Prudential Patricia D. Rockey 751 Cranes Gap Road Carlisle, PA 17013 Dear Patricia D. Rockey: The Prudential Insurance Company of America Group Life Claim Division PO Box 8517, Philadelphia, PA 19176 Tel (800) 524-0542 Fax (888) 227-6764 December 28, 2009 Insured: George D Dean Control Number: G-35190 Claim Number: 11022930 We have received a Group Life Insurance claim for George D Dean. George D Dean designated Belva Dean as beneficiary of this life insurance policy, and Belva Dean survived George D Dean. However, before payment of this benefit was made to Belva Dean she passed away on May 20, 2005. Please accept our sincere condolences. At this time, the life insurance proceeds are payable to the estate of Belva Dean. In order for us to continue our claim handling at this time, we require additional information from you to proceed. We would like to make the processing of this Group Life Insurance Claim as prompt and convenient as possible. In order to do so, please provide us with a certified copy of a court order appointing an executor or administrator of Belva Dean's estate and the Tax Identification Number of the estate. If the estate papers have not yet been issued, please provide us with an estimated date that we can expect to receive this information. If the estate has not or will not be probated because it can be handled in accordance with the Florida small estate laws, we may be able to make payment. To do that, we will need you to file for a petition for summary administration. You must provide us with a copy of this court order of summary administration. Payment will be made in accordance with the terms of the order. Enclosed is a postage-paid envelope for your convenience. Please include the claim number noted above on all correspondence to ensure timely handling. We will give this claim our immediate attention upon receipt of all necessary documents. We apologize for any inconvenience this delay may cause you. We appreciate the opportunity to serve you. If you have any questions or would like more information, please contact Customer Service at (800) 524-0542. We are available Monday through Friday between 8:00 a.m, and 8:00 p.m. Eastern Time. Sincerely, Claims Coordinator