HomeMy WebLinkAbout10-2350IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
IN RE:
NAME CHANGE OF
SURVIVING SPOUSE
n.?
File No.p - 3 S Cc.?
NOTICE TO RESUME PRIOR SURNAME
(PLEASE PRINT OR TYPE)
Notice is hereby given that the above named
f
S
surviving spouse as of ra r PGAr i -
to resume and hereafter use the
J? ins k. jju'l
tiong
res4ng;
,being a
hereby intends
previous name of
and gives this
written notice avowing his / her intention pursuant to the provisions of 54 Pa.C.S. §
704.1. A Certifi copy of the Certificate of Death for the decedent is attached.
Date: 1)x'l A it
ignat of Petitioner P.4 4,, X3 /a / 69 y
Si ature of no/nebeinja resumed
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
On the day of _-AP r% , 2.0 , 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.
Notary Public
(Note: This notice must be accompanied by an original certificate of death for the
decedent)
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i/s'I 's 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.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $2.00
P 7714284
No.
H105 1
AI Rev.
eRINT
I
.NENT
SINK
Sean
32 Yn.
C"NTV OF DEATH
?I Cumberland
CARLISLE, PA 17013
Local Registrar
OCT 2 7 2001
Date
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
(Coroner)
P
Huber
Male w..w.•ae u 1te NUMBER DATEOF-H(Mph,Dry,v rl
ER I DAY
Mi
BIRTHPLACE (Ciry,rq
SIM
F ,•
,•
PLACE OF DEATH fCMgr oNy orre- aee lnatructune W. .0.) •. October 24, 2001
nutN e a
pMp, Cpmtry) HOSPRAL:
W YNESBURG, PA OTHER:
MPMNt ? ERtOtapovem 14 DO
A
on
7
h.
Re es
,idaOe ? Iswo,•
.EATM-CICLI
POF Y NAME(IIrgtinRiM1Agn, gYMrwmoer)
Carlisle arlisle Re
ional M
di
l
NNS DECEDENT OF HIS/ANIC ORIOIN7
"
Mden,
ea g
e
ca
Center
. Ctl,Wt. arC IMn.
w? ,PPtwwPR WHITE
KIND OF BUSINE83RNDUSTRY NU.S RMED U.S. . ARMED NT EEyVEERIN
FORCE87 DECEDEM'S EOUCAttON
Offt a MARITAL STATUS. Me-.. 10
SLIRVIVR?ILL gp?
nuCh P
CaZa
•? "°? ENtMMW/Soc
otMNy
ro,2,
Hevw ?MvNM, itty) e.
?.a(swP.cay)
(II WAa. Oive mlitlen Nmie)
zip cow .
Nr's ' 12 , Majotied Jenn R<ehwine
T7ES L
NCE 17,-SIM*pen?? Did 17a.QYN.weewnl Need M??,,`,?/
/?
M JJp
1n/Clion o,O,O,M
mTtC7T
?
?, :uLiTl?bYT?---h
"°e) .,. ,._.?. Cumberland ,own"? ,.. No. tlecodatawen
r t: aP uISPDSITION - N,ms a COMMON. Cnm,tory LOCH ON-COY40". Stan, ZIP Cow
SurIM Crettuuiert Removes lrorri 9late? (MOrh, aY•WM) Or Other Place 1YMfSoedv1 D2710/29/2001 1Big Rock Cemeten p
uNE 8E LICENSEE ORPE1130NACTING AS3UCH L 4ti-6te, PA 17013
_ ?'r ?9L Ctng 4T175 CREMATORYINCMT. HOLLY SPRINGS, PA
rtowMdge,,th occwno at On time, date and M Mated.
MNI,M1kMdda,nro To theoeatamylr w
(Sipnalwe and Tide) LICE
L NSE NUMBER OQE 9WNED
(MOnm, ay. Y%Mr)
0 CWVWed by TIME OF DEATH DATE PRO D AD (Moth, Day. Year) YMS ASE REFERRED TO IXCAL 5ZINER/CORONER?
„ON dram.
e• 2:01 A M. ,. October 24, 2001 y YMI NP?
(Or o.dwaM
,._ Probable Myocardial Infarction
WE TO IOR AS A CONSEQUENCE OFr
Occlusive Coronary Artery Disease
ewo
66"LW
COMPLETION OF CAUSE (Month. Day, Peer)
OFDEATH7 Natural Homidde ?
?. No ? p, ' NO ? ACdwnl ? P,Mhp InvaatyMlon ?
JJ"" El PLACE C cN(SP Y-M home, fern, Mnal
ta0. t S"kft L Ce ad not be wnrmew C3 bAldrq, Me (sPeGly)
9eTIFYa1B o^H
Wefeela?( death OemurgOWN 10 dNa,avenM nhera h,eed eompyMem 23)
my1•r••rt•dva. a•. wttfn occurred due to meavw•(el and m,nner,YNtl .................................................... ?
IOtl01BIC11/0 AND CEIITIF71N0 PNY8ICIAN (Phy.ciart Oah Pranourcirp dwm and c•rMPnO ro cauea d n,Mh)
iM bN10/Nylrn••ri•d0e.deetlt ooewrad M ? tI ..doI.,MlplNe, eves lhwft BN e•w•(h MMmenMrea. .......................... ?
t 10141 s of exate"Inardw for Investigation. In my oplMOn. Meth oceurnA,1 the Bme. deft. MM pl,e•. MM duo to the r+u«(q and
......................................................................
EO RAR'S SKLNATURE -7157":,
V% 9L.LaLucj)
Yee ? No ?
MI
Coroner
DATE SIDNE 14", Day. Year)
October 25, 2001
WINO COMPLETEOCAUSE OF OEQH
el L. Norris, Coroner
Basehore Road, Suite #1
nicsburg, Pa. 17050
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