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REV-346 EX (03-09) 3 4 6 0 0 0 712 0
ESTATE INFORMATION
SHEET
Pennsylvania FOR REGISTER'S OFFICE USE ONLY
DEPARTMENT OF REVENUE County Code Year File Number
DECEDENT INFORMATION' Enter data as it will appear on alpl 2 1 ~ ~ (, (~ / ~ `'~
documents submitted to the De artment.
Decedent's Social Security Number Date of Death Date of Birth
174 20 3225 12 02 2009 04.04 1926
Last Name Suffix First Name MI
DICKSON JAMES A
TYPE FILING: Enter mark (x) to indicate the nature of the return to be filed with the department.
Probate Return ~ Joint Assets Only QX Non-probate Assets Only ~ Litigation Purposes (No Other Assets)
LETTERS GRANTED: Enter mark (x) to indicate the nature of the proceedings at the register of wills office.
(Attach additional sheets if explanation is necessary.)
Testamentary ~ Administration ~ No Letters ~ Other (Please Explain)
ATTORNEY /CORRESPONDENT INFORMATION: Informat on and correspondence.rney or other inaiviaual to receive an ia;
Last Name Suffix First Name MI
MYERS EDMUND G
Supreme Court I.D.# Telephone Number
20558 (717) 761 4540
First line of address
301 MARKET STREET
Second line of address
PO BOX 109
City or Post Office State
LEMOYNE PA
PERSONAL REPRESENTATIVE INFORMATION:
Executor/Administrator
Social Security Number Telephone Number
(717) 233 4356
Last Name
DICKSON
First line of address
3602 N. THIRD STREET
Second line of address
City or Post Office
HARRISBURG
Attorney / Corrresponde~s a-mail addFe~,s:
egm~jdsw.com ~ C~ ; , :,
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ZIP Code -~ ~~ :: _-- ,.-r°:
17043 ~ ~-'~~~''
Enter all data concerning the personal representative(s) of the estate
authorized by the Register of Wills.
Suffix First Name
CARL
State ZIP Code
PA 17110
MI
A
OFFICIAL USE ONLY
TRANSAiCT10N COUNff
Complete general estate information questions, and indicate additional personal representatives on reverse side.
PLEASE USE ORIGINAL FORM ONLY
Side 1
3460007120 3460007120
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Deoeder>rs Name: JAMES A. D I C K S O N
Co-Executor/Administrator
Social Security Number Telephone Number
Last Name
First line of address
Second line of address
City or Post Office
Co-Executor/Administrator
Social Security Number Telephone Number
Last Name
First line of address
Second line of address
City or Post Office
General Instructions:
Suffix First Name
State ZIP Code
Suffix First Name
State ZIP Code
Decedent's Social Security Number
174 20 3225
This form should be filed with the Register of Wills of the county of which the decedent was a resident at death.
Please be aware the correspondent identified will receive all correspondence from the department. It is the responsibility of the
personal representative to notify the department if the correspondent contact information changes.
The department is authorized by law, 42 U.S.C. §405 (c)(2)(C)(i), to require disclosure of Social Security numbers in connection
with administering state tax laws. The department uses the Social Security number to identify the decedent and personal representatives
of the estate. The commonwealth may also use the information in exchange-of-tax-information agreements with federal
and local taxing authorities. State law prohibits commonwealth personnel from disclosing confidential tax information except
for official purposes.
3460007220
MI
MI
Side 2
3460007220 3460007220
105.HI15 NIiV 10007)
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.,
Fee for this certificate, $6.00 ,,lll~~~"""~~--- This is to certify that the information here given Is
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TYPE PRINT IN
PERMANENT
BLACK INK
, Name d Deceoag tFxp. madN. ~. sullul
James A. Dickson
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS ~
CERTIFICATE OF DEATH
(See instructior,fs arrd examples on reverse) STATE FILE NUMBER a ~~ tMaun aay years
2. Sex 3. Sony SeclaAy NumWr
Male 174 - 20 - 3225 December 2, 2009
5 Aqe tl.att Bud,day) llyder 1 yw _.
raorxns oars era..T kYwtaa PA ^ t ^ ER / Ou,pa,wM ^ DOA 18•-+t+r~9 Monty IJ RaWa,ee Uue,a • apr~r.
_ App i t 4 , 19 2 6 Pittsburgh , ,o. Rao.: Anwicrl atm. eladt, wtw. «~.
83 Yrs. 9 was DecetMn, d -ktWna prqu,? [1t No ~+ tso~ln
&. Gty, Bono, Twp. d Deem 8d. fanlaV Name la na insptAOn. qne stmt and nurroal QI ya, speuly CYoan. Whit e
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Mechanicsburg Bethany Village West ~ twt ~~ Mar~saNt: N.v«tuarr»a• ,s.stxwvxpSDa+atd~w.9l'wrn~^^amet
t Cumberland , ,2. was ~ecedentever n m, t3 pecedera's Educatan tSWury Dray Ngse 9~ Waowea. oworcad 1SVec0y1
' ,, . pece0enrs Usual t)oc 11(nd a work dorw moat d W _ Oo na sue aoradl ENrt,antary / SecortaaY ( Calege t,-1 « s.l
_ us. Amwd Force:? o-,zl Widowed
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t>ocaaents PA
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5225 Wilson Lane ,7o.cawgy Cumberland "a"''~""A'd
Mechanicsburg, PA 17055 t9,,,~,,.Ian,N,Fw,,.,n,oo,.,maiaenswnan»I
,9FanwsNarnetFint.maW.lest.wdlxt Charlotte Taeusch
Robert Dickson zoc Intomlarl(s sAaAin9 Aaaau (Slreel utY t w•^' ~°' ~ ooael
z0a. lniarnar,t': wme lTYa,P~tl 3602 N. Third Street, Harrisbur PA 17110
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~ L~NWOO" PA 17109
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