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IN RE:
NAME CHANGE OF .
SURVIVING SPOUSE .
OF 1N?PNARY
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA 2010 MAR 22 AM 9: 00
File No. 1b - AND UiviITam
NOTICE TO RESUME PRIOR SURNAME
(PLEASE PRINT OR TYPE)
Notice is hereby given that the above named
surviving spouse as of O )DR c'? r r1 ,
to resume and hereafter use the previous
???,cl',trn Ac,,r, She 11 v
Petitioner,
residing at,
Dine a
hereby intends
name 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: A\-\UZ 241 ?UK
Signature of Petitioner
%
SSigmture of n e bem res ed
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
a,oto .
On the °8r1d day of M=,b ,10ft before me, the Prothonotary or the
notary public, personally appeared the above affiant known to me to be the person whose
naive 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 seals
Notuy Public
(Note: This notice most be accompRnted by an- eriginal certificate of death for the
decedent)
49a•oo Pp w.iF
C'Aso
Q-- 00139aa.o
NMAL to
r? ii''
H105.805 REV 9/86
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 fAing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Pee for r-his certificate, $2.00
P 7234206
No.
TYPE/PRINT
IN
PERMANENT
SLACKINK
z
Local Registrar ?.
-?
ate
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH a VITAL RECORDS
CERTIFICATE OF DEATH
(Coroner)
R 105.144 Rev IN1
NAME OF DECEDENT (FNd, MidAe, Lam) STATE FILE NUMBER
SEX SOCIAL SECURITY NUMBER DATE OF DEATH IM..h, Day. *a,)
I. Robert A McGarvey 7. Male a. 1 _ _ 21 4.March 12, 2001
154
AGE{Lea BNmtlayl UNDER/YEAR UNDER/DM
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ityand PLACE OF OE/4 H ICMca only«u-
eoeimNUgior,san ter ode,
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Moshe Day. Hour Minutes . Year) 1'l?r-L-1Si7UL- ,rY) NOS -: THEN:
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COUNTY OF DEATH CD OF DEATH fACILITY NAME (a nainaitWion, gWe greet and number)
MFHd,'- COWfaN7 Amakan lndlan,BMCk, What, ac.
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Cumberland Mechanicsburg 223 East Locust Street
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,ON 10N0 aF SINES811NDUSTRY Vr DECEDENT EVEN tJ DECEOENT'SEDUCATMAIMfAL 871PU5-ManM
VryM+16 SPOUSE
U.S.ARMED F?RCEST Nawr ManNd
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Y.. El N. IX EM"'eslan/Sarorhaary CdaaW Diraad(Specty)
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er , Construction , .
n n-4«5t) Married Judith A. Skelly
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DENT
S MANJNO ADDRESS Istaa, CRYM-n. State, Zip Code) DECEDENT'S '
Pennsylvania
17c.?Wa,a.ceamNwb
NCE 'T•'?"•
223 East Locust Street
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See r
a
.ad.l
'See Imm?uctians aw in a
Mechanicsburg, PA 17055 ,m. 000MCumberland bnwap? 174. No.WCaMMOvW csppra
Watatna Md
WUa
cnAexo
S NAME (FNa, M1WN, 1a,0 MOTHER'S NAME (Fred, WWI., Malden
S"rarrp)
Robert M?e 1
e
INFORMANT'
NAME (TypaPrNq ORMANF' MA " ADDRESS Otea, CYylfown, Sue., Zip Code)
Mts. Judith A. McGarve
OF ION D/OE aF p3ON
PLACE OFq SPCGI •Namaa L WAHow •CaY7TOa
pPCaa
,
B«at? Cn.twwg Removal tom SWe? (Mona. DBK teal aOIMrPMa
enM°n? ona(s
.ct
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p
y
,n. March 14, 2001 st Harrisburg Crematory isburg, PA 17109
BIGNATUREDFFUNERALSER LK:E OR PERSON ACTING AS SUC
uCENSE NUMBER
NAME AND ADDRESS
OF MCILITY
n.
Mar
t
tees a7a
COnly rArrh IMaaa
47*&!Mtha twat. daaandpau Noted. L NSE.
mY
,
ptry root avaaaMaalkaa
lure
andT
dwwy'a-dl death. Signa
. Dat Yea)
t
aa.. tan.
74Qe mina con~ by TIME OFOEATH DATE PRONOUNCEDDEAD
,IM (MOnlh.Oay. Year) WAS CASE REFERREDro ME AL E,IMII R7
an vrho pronanua death.
5:50 March 12, 2001 Yea N.0
24
2
.
,.
26.
2T.PARTI: Emar a,a dhaeses,inylrb«rampacaione tthkh causadlM deaN. DO rplaMatMmndaadylrq, testa eacadiacorr
espNSlay arrest, Mock ahead IaWa.
PARTa: Other MpnBkart h
wnvi0utkp b eater
Loh oNyOa ahoaa0ach &w
W
,
.
e underlying
ikdarvelbalwean II°IresYllirlt In the Urhdadyal0 0- In P11HT 1.
ATE CAUSE (I - i aesl and desN
"`"wIr Gunshot to Head
rqwttle - ..
cai
DUE TO (OR AS A CONSEQUENCE OFD:--•,.
I
No condo" n
,
any.
WE TO (OR AS A CONSEQUENCE OFt
t
cauiO.E IRIOEPLYhq
CAUSE i.,.,
ina
g
d aw"s DUE ro IQR AS A CONSEQUENCE OF,:
.
'
reeWk
p ut d,aa) LAST
d
.
WAS AN AUlOP3Y IMERE AUTOPSY FINOM10S MANNER OF DEATH DATE OF M1JUflY TNAE OFINJURY .DESCRIBE HOW INJURY OCCURRED.
ORMED? gRSABLE PRIOR TO
(M M, Day. Year)
COMPLETION OF CAUSE
OF DEATH? NeI N ? "._I" ? Yea ? N. ?
Yea ? fb? Y.a ? N. ? ACWdard ? Penang lmeai0aion ? 30, M. 30c. add.
PLACE OF INJURY-At home, farm. areal, fee". off" LOCATION (SYM. Cir^-. Stab)
SuicMa Court not be determined ? Ihkkv
etc. ISI>e?yty)
'
1Mb. 2t. 700.
UNIT
'CERTPYIIIS MIp1'yYSIgAR IPh,--.yl Cause a deem what anWher physician has P-.-.W dealh -d c«nplWnd II «n 23)
SIGN
ATURE
Te,M aaarq'taaMap.,aanaewnddlra b,IN CaMNsl alt al0maeaM,W ..................................................... El Coroner
atb.
'/RONOUNGSIO A110l,YMRT,fY1NB PMY7aC1A/1 (Ptryslclan bdm paflaNlGtq death and catifyin0 b cause a duart) LM NBE NUMBER JDATE SIGNED OAaM. Day. Yawl
r Ma?aaawTnnom,dye,aaat aeeunwamaama,aMa,anaTtea,adamrtopreauaya)ama ramaaa.......................... ? t . , . March 13, 2001
NAME AND ADDRESSOF PERSON WHO COMPLETED CAUSE OF DEATH
.MEDICAL EIIAM04OLICORONER _
On the bates of eatealnleltan Gala Ine"Up drn
In my donjoh
death oocurtW to the thh
6
d (tan 27) Type or Prim Michael L. Norris, Coroner
637
,
,
O-
pace, mi
duo to the daua(a) ON
mMrn.treesed .............................................. 5 Basehore Road, Suite #1
....................................................
a,a. u. Mechanicsburga Pa. 17050
,?GIS 'S SIGNATURE AND NUMBER
33.
1 -U4 WEFUD(MUrtlh. Day Yaa)
IF 1