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HomeMy WebLinkAbout05-19-10PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA Estate of DONALD E • EDMONDSON File Number a l -'~ ~ - ~~ ~oZ also known as Deceased Social Security Number 17 3 3 8 7 4 4 8 Petitioner(s), who is/are 18 years of age or older, apply(ies) for: (COMPLETE 'A' OR 'B' BELOW.) A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is /are the Executrix named in the last Will of the Decedent dated 3 / 15 / 2 0 0 7 and codicil(s) dated (State relevant circumstances, e.g., renunciation, death of executor, etc.) Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the instrument(s) offered for probate, was not the victim of a killing and was never adjudicated an incapacitated person: B. Grant of Letters of Administration (If applicable, enter: c.t.a.; d.b.n.c.t.a.; pendente life; durante absentia; durante mtnoritate) Petitioner(s) after a proper search has /have ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs: (If Administration, c. t. a. or d.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.) Decedent, then b2 years of age, died on 5/12/2010 at HOLY SPRIRIT HOSPITAL CAMP HILL PENNSYLVANIA Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property $ 10 , 0 0 0.0 0 (If not domiciled in PA) Personal property in Pennsylvania $ (If not domiciled in PA) Personal property in County $ Value of real estate in Pennsylvania $ 19 5 , 9 0 4.8 0 3825 SULLIVAN STREET, MECHANCISBURG, PENNSYLVANIA situated as follows: Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant of Letters in the appropriate form to the undersigned: Signature Typed or printed name and residence _.-~~ % ~.~ n % LAURA M • FOULKROD 2264 FORSTER STREET t Page 1 of 2 Form RW-02 rev. 10.13.06 (COMPLETE INALL CASES:) Attach additional sheets if necessary. ~ ,-~ f-~ N ._%~ Decedent was domiciled at death in CUMBERLAND County, Pennsylvania, with his /her last principal residence at ~8 2 5 .SULLIVAN STREET MECHANICSBURG PA 17050 HAMPDEN TOWNSHIP (List street address, towrr/ctty, township, county, state, zip code) Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF CUMBERLAND The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true and correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decedent, Petitioner(s) will well and truly administer the estate according to law. Sworn to or affr-ned at~~ subscribed Y before me the _,~.______ day of __ , r ~ ~~ J , ire of Personal Representative Signature of Personal Representative na e~ 1.0./ w.-~...... ., .. ~..~ _. For the R i ter Signature of Personal Representative - -~ ~ Y.... r-+`: Y~ ~ ! ~ ,r ~/ ~ T - + r ~... } File Number: ~ 1 - - ~oZ ---~ C ~$ - : ~-` ~~ Estate of DONALD E . EDMONDSON ,Deceased ~ '~" Social Security Number: X 7 3 3 8 7 4 4 8 Date of Death: 5/ 12 / 2 010 '~ AND NOW, , 2 010 , in consideration of the foregoing Petition, satisfactory proof having been presented be a me, IT IS DECREED that Letters T E S T A M E N T A R Y are hereby granted to LAURA M• F O U L K R O D in the above estate and that the instrument(s) dated 1] 3 / 15 / 2 0 0 7 described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent FEES Letters ............................. $ Short Certificate(s) ............ $ U Renunciation(s) ...•............ $ ~ A-cs m~~.-tirnn .... $ 6• crU TOTAL ......................... .... $ .... $ .... $ .... $ .... $ .... $ .... $ ~g~. ~ v Attorney Signature: Address: 2331 MARKET STREET Telephone: 717 - 7 6 3 -13 8 3 Form RW-02 rev. 10.13.06 Page 2 of 2 Attorney Name: LINUS E • FENICLE Supreme Court LD. No.: i? 0 9 4 4 K:\Edmondson.D.Will.doc ' March 14, 2007 r.a C`1 `.a __.. LAST WILL AND TESTAMENT ~ o ~' .,. -~., E J ~^~ OF -~' =~~. r-- ^' ~~~~ ;,~; .~ ~.. .. l. ~ ~.../ '4J M ~. ~' DONALD E. EDMONDSON ~~~ =~= , ... ~~..} -=~ :. -y na I, DONALD E. EDMONDSON, of Mechanicsburg, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this my Last Will and Testament, hereby revoking any and all prior Wills and Codicils thereto by me at anytime heretofore made. 1. IDENTIFICATION OF FAMILY. I declare that I am a widower and have one (1) child, whose name is LAURA M. FOULKROD. As used in this Will, the term "my child/children" refers to all my natural children and adopted children. As used in this Will, the term "issue" refers to all lineal descendants of the indicated person of all generations, with the relationship of parent and child at each generation determined by the definition of "child/children" set forth in this paragraph. 2. PAYMENT OF BURIAL EXPENSES AND DEBTS. I authorize my executor to pay all the expenses of (1) a funeral or memorial service; (2) the interment of my remains, including the costs of a gravesite, if necessary; and (3) the installation and inscription of a suitable marker at, and perpetual care of, the gravesite. I further direct my executor to pay all of my debts that my executor in his or her sole discretion may allow as claims against my estate. 3. SPECIFIC BEQUESTS. 3.1 I give and bequeath the sum of Ten Thousand ($10,000.00) Dollars to my granddaughter, DEVIN MARIE FOULKROD. 3.2 I give and bequeath the sum of Ten Thousand ($10,000.00) Dollars to my step granddaughter, THERESA MARIE BERRY. 4. DISPOSITION OF TANGIBLE PERSONAL PROPERTY. I give all of my tangible personal property of every kind and description, including, but not limited to, books, pictures, clothing, articles of household or personal use or adornment, household furnishings and effects, and automotive vehicles and their accessories, but excluding any money, evidences of indebtedness, documents of title, and securities and property used in connection with the operation of any trade or business to LAURA M. FOULKROD. ~. Donald E. dmondson -z-z _~_~ , -, `:., ~ ~ 'w,. ~. t i~ .. .. ._.-> ,. . . +~-~ .. ~~ > .-~ K:~Edmondson.D.Will.doc March 14, 2007 5. DISPOSITION OF RESIDUARY ESTATE. 5.1 Disposition. All of the rest, residue and remainder of the property that I own at the time of my death, both real and personal, and of every kind and description, wherever situated, to which I may be legally or equitably entitled at the time of my death (my "residuary estate"), I give outright and absolutely to LAURA M. FOULKROD. 5.2. In the event my LAURA M. FOULKROD is not living on the sixtieth (60) day after the date of my death, I leave all the rest, residue and remainder of the property that I own at the time of my death, both real and personal, and of every kind and description, wherever situate, to which I may be legally or equitably entitled at the time of my death (my "residuary estate") to her issue, per stirpes. 6. POWERS OF ADMINISTRATION. 6.1 Grant of Powers. My executor, in the administration of my estate, (lny "fiduciaries") shall have the powers and authorities set forth in this Article 6. These powers and authorities may be exercised by my executor and trustee in their sole and absolute discretion, without the permission or order of any court. These powers shall be supplementary to those conferred by law, including, but not limited to, those set forth in Title 20, Chapter 33, of the Pennsylvania Consolidated Statutes. 6.2 Retention of Assets. My fiduciaries shall have the power to retain any or all property of my estate, however received and acquired, for so long as they deem appropriate. This power may be exercised even though the property may not be of the type authorized by law for investment, and even though the retention may leave a disproportionately large amount of the value of my estate invested in one type of property. 6.3 Transfer of Assets. My fiduciaries shall have the power to sell, transfer, and convey any property, of whatever nature, including real property, and wherever situated, that I may own at the time of my death, or that may come into my estate or after my death. The sale, transfer, or conveyance maybe by public or private sale, at such time, on such terms and conditions, including selling price and credit, in such manner, and for any reason that my fiduciaries deem appropriate, including, but not limited to, the purpose of obtaining net proceeds to be distributed to my residuary beneficiaries. 6.4 Investment. My fiduciaries shall have the power to invest and reinvest any property in my estate in preferred and common stocks, bonds, notes, common trust funds (including any managed by any corporate fiduciary), interests in investments, trusts, mutual funds, leases, mortgages on property wherever located, and, generally, in any property and in proportions of property as my fiduciaries deem ~ dvisable, even though the investments 2 Donald E. Edmondson K:\Edmondson.D. Will.doc March 14, 2007 are not of the character or proportions authorized by applicable law for the investment of the funds. 6.5 Power to Borrow. My fiduciaries shall have the power to borrow money for any purpose, for any periods of time, and on any terms and conditions as they deem advisable (including the power to borrow from any corporate fiduciary), and to pledge, mortgage, or otherwise encumber any property in my estate to secure repayment of any loan, as well as the power to renew existing loans either as maker or endorser. 6.6 Power to Hold Property in Nominee Form. My fiduciaries shall have the power to hold any property in the name of a nominee or in bearer form. 6.7 Distribution in Cash or in Kind. My fiduciaries shall have the power to make distributions in cash or in kind, or partly in cash, in divided or undivided interests, as amended, or other applicable law, and to determine which assets shall be sold and which shall be distributed in kind, without notice to or consent by any beneficiary. 6.8 Distribution to Minors and Persons Under Disability. My fiduciaries shall have the power to make distributions or payments to or for the benefit of any beneficiary who is a minor, an incompetent, or who in the fiduciaries' judgment is incapacitated. The distributions or payments shall be made in any one or more of the following ways: (1) directly to the beneficiary; (2) directly to the creditor in payment of the debts or expenses of the beneficiary; (3) to the guardian of the person or estate of the beneficiary; (4) to any custodial parent of a minor beneficiary; (5) to a custodian for the benei=iciary under any law related to gifts to minors, including to my fiduciaries in that capacity; or (6) to any other person who shall have the care and custody of the person of the beneficiary. There shall be no duty to see to the application of funds so paid, provided due care was exercised in the selection of the person to whom the funds were paid, and the receipt of the person shall be full acquittance of the fiduciaries. 6.9 Continuation or Liquidation of Business. My fiduciaries shall have the power to continue or to permit the continuation of any business, incorporated or unincorporated, in which I may have any interest at the time of my death for any period of time, or to liquidate the business on any terms as they deem appropriate. This power includes, but is not limited to (1) the power to invest additional sums in any business, even to the extent that my estate maybe invested largely or entirely in the business, without liability for any loss resulting from lack of diversification; (2) the power to act as or to select other persons to act as directors, officers, or employees of any business, to be compensated without regard to being a fiduciary under this Will; and (3) the power to make any other arrangements in regard to any business as my fiduciaries shall deem proper. 6.10 Employment of Agents. My fiduciaries shall ave the power to employ and pay the compensation of any and all attorneys, agent custodians, attorneys-in-fact, experts, 3 onald E. Edmondson K: ~Edmondson.D. Will.doc March 14, 2007 ' investment counsel, accountants, bookkeepers, or other agents or providers of services as my fiduciaries deem advisable in the administration of my estate. 6.11 Commissions. My fiduciaries shall have the power to take reasonable commissions on account at any time during the administration of my estate without the approval of any beneficiary or of the court, but subject to allowance or disallowance on the settlement of the final accounts of my fiduciaries. 6.12 Third Party Reliance. No person or corporation dealing with my executor shall be required to see to the application of any property paid or delivered to my executor, or to inquire into either the authority of my executor to enter into any transaction or the expediency or propriety of any transaction entered into by my executor. 6.13 Charitable Donations. In the event that any of my tangible personal property is donated to a charitable organization(s) then my fiduciary is instructed to use the value of said donation(s) as an inheritance tax deduction for any inheritance tax return which may be required to be filed as a consequence of my death. 7. PAYMENT OF DEATH TAXES. 7.1 Payment of Estate Taxes. I direct that all federal and Pennsylvania estate taxes payable as a result of taxes assessed on property passing under this Will shall be paid from my residuary estate as a part of the expenses of the administration of the estate. 7.2. Inheritance Tax. I direct that the Pennsylvania inheritance taxes payable as a result of my death, limited to taxes assessed on property passing under this Will, shall be paid out of my residuary estate and shall not be deducted or collected from any beneficiary under this Will or other transferee. 8. EXECUTOR. 8.1 Appointment. I name, constitute, and appoint LAURA M. FOULKROD as executor of my estate. 8.2 Bond Not Required. None of the individuals named in Section 8.1 shall be required to furnish a bond for the faithful performance of his duties as executor. 9. PRESUMPTION IN CASE OF SIMULTANEOUS DEATH. For the purposes of this Will, in determining whether a person has survived me or another person, a person shall not be deemed to have survived me or another person if he or she dies within sixty (60) days of my death or of the death of the other person. 4 . Donald E. Edmondson 10. LIABILITY OF EXECUTOR. My executor shall not at any time be liable for mistake of law or of fact, or both law and fact, or errors of judgment, nor for any loss coming to any beneficiary under this Will, or to any other persons, except through actual fraud or willful misconduct on the part of the executor or trustee. My executor may, from time to time, consult with counsel with respect to the meaning, construction, and operation of this Will, particularly with respect to the appointments, allocations, and disbursements, and may act on the advice of counsel in all matters without incumng liability on account of his or her actions. 11. INTERPRETATION. 11.1 Successors of Fiduciaries. All pronouns referring to an executor and the term "executor" shall be construed to mean any person acting as my executor, co-executor, personal representative, or administrator, as the case maybe. 11.2 Number and Gender. If required by the context of this Will, singular language shall be construed as plural, plural language shall be construed as singular, and the gender of personal pronouns shall be construed as either masculine, feminine, or neuter. 11.3 Headings. All headings used in this Will to describe the contents of each article, paragraph, or other division are provided for convenience only and shall not be construed to be a part of this Will. 11.4 Governing Law. This Will shall be construed in conformity with the law of the Commonwealth of Pennsylvania. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and Testament, consisting of six (6) typewritten pages, the first e (5) f which bear my signature in the margin for the purpose of identification, this ~,,,~/~day o , 2007. DONALD . EDMONDSON, Testator Signed, sealed, published and declared by the above-named Testator, DONALD E. EDMONDSON, as and for his Last Will and Testament, in the sight and presence of us, who, at his request, in his sight and presence and in th ~ ht and pres ce o each her, have hereunto subscribed our names as witnesses. Witness Address ~~ ~ W tness L'9~`!~ ~'~~c ,~'~~ivr~ af~ess l ~ ~~~ Q / ~0 // 5 K:\Edmondson.D.Will.doc " March 14, 2007 ~ ' COMMONWEALTH OF PENNSYLVANIA ) SS. COUNTY OF CUMBERLAND ) I, DONALD E. EDMONDSON, THE TESTATOR, WHOSE NAME IS SIGNED TO THE FOREGOING INSTRUMENT, HAVING BEEN DULY QUALIFIED ACCORDING TO LAW, DO HEREBY ACKNOWLEDGE THAT I SIGNED AND EXECUTED THE INSTRUMENT AS MY LAST WILL AND TESTAMENT; THAT I SIGNED IT WILLINGLY; AND THAT I SIGNED IT AS MY FREE AND VOLUNTARY ACT FOR THE PURPOSES THEREIN EXPRESSED. SWORN OR AFFIRMED TO AND CKNOWLEDG BEF RE ME BY DONALD E. EDMONDSON, THE TESTATOR, THIS ~AY OF 2007. ~- DON D E. EDMONDSON ~_~~ OTARY PUBLIC COMNO~ qtr cr~~ ~ t-€ OF PENNSYLVANIA Notarial deal Deborah L EsrennA!r.~.-~. N©tary Pt~lic COMMONWEALTH OF PENNSYLVANIA ) Camp Hill Boro, ~.s?~~?Qrland COt,~y MyComrnission to ~ June 18, 2010 SS. COUNTY OF CUMBERLAND ) ~~~ Penns""~~ ~ .,.t,+^tion of Notaries WE, ln~l ~~~ ~/' ~~1~`t~ AND ~~t..° r~ l°_ ~ ~ /1 I C~/~ THE WITNESSES WHOSE NAMES ARE SIGNED TO THE FOREGOING INSTRUMEN'T', BEING DULY QUALIFIED ACCORDING TO LAW, DEPOSE AND SAY THAT WE WERE PRESENT AND SAW THE AFORESAID TESTATOR SIGN AND EXECUTE THE INSTRUMENT AS HIS LAST WILL AND TESTAMENT; THAT HE SIGNED WILLINGLY AND THAT HE EXECUTED IT AS HIS FREE AND VOLUNTARY ACT FOR THE PURPOSES THEREIN EXPRESSED; THAT EACH OF US IN THE HEARING AND SIGHT OF THE TESTATOR SIGNED THE WILL AS WITNESSES; ANL> THAT TO THE BEST OF OUR KNOWLEDGE THE TESTATOR WAS AT THE TIME EIGHTEEN (18) OIZ MORE YEARS OF AGE, OF SOUND MIND AND UNDER NO CONSTRAINT OR UNDUE INFLUENCE. ORN OR AFFIIZMED TO AND SUBSCRIBED TO BEFORE ME, THIS ~S D Y OF Q,/~ , 2007. S I`~OT a ~~~,~~+~ ~ H Oh' PENNSYLVANIA =~1~i~.:~, :,' Baal Deborah L. fir:; ,,~ n~n~y p Camp HiH Boro ?.~ +r -gland MyCommissron ~.,,. . June i ~p 6 Member, Pen.nsb<~:<-~~~~ -,,, ,~_~~~tion of Notailes nS v/~c ... /n.. - LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. ~ Fee for this certificate, $6.00 P 16177890 Certification Number This is to certify that the information here given is correctly copied from an original Certificate of Death duly filed with me a~> Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent ding. L~~ ~~~ ~ AY 4 201C~ - ~ Local Registrar Date Issued rya ~ _.___________ __ __ _.___ _ ___________.._.___ ~ _ _._r./ --mr ~ .~, , .., ( ~ `) .....,_ -.._._...,_. ..__~ .,._ ....__,... ~......_._,.,._.._._,.. ___, ._____ ,_. __._._. ,_ ......._...,_-_ ___.._~ ,,:---- ~~~ ~ -'1 ~ y._ t ; • '+J ~y' 1 om ,.- _, nW,._,.._,-..._ _.. ._..,-_._ ._......_.____. _......_.,....._..~~... ~ •• _ y,~ ry I REV 11/2008 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS / PRINT IN -~ CERTIFICATE OF DEATH (S@@ (flStt'UCtlOfls end @X@mples OA r@V@ESe) STATE FILE NUMBER 1. Name d Decedent (Fhel, middle, bat suffix) Donald E. Edmondson 2. Sex Male 3. Sold Security Number 4. Date d Death (Month, day, Year) 5. Age (teat Bkthdey) lJndr 1 r Urder 1 8. Dated &rlh de , 7. and state or 17 - - Ma 12, 2010 Ba. Piece d Deelh Check on ane 62 vrs, ~~ Sys Hour Asnuta September 11, 194 Harrisburg, PA Ho Ital: ~ pgyr Bb. Cotmty d Death &. Ci ty, Boro, Twp . d Deelh 8d. Faapty Name (N not irattlt ution glue street and number) ,~~ ^ER/ OutpatleM ^ DOA ^ Nureing Home ^ Reaklence ^ Other • Specify: Cumberland E. Pennsboro Twp. , Holy Spirit Hos ital P 9. Was Decedent d Hkpenic Origin4 ®No (tl Ya, sPedty Cumin, ^ Yes M i P 10. Race: Amedan Indian, Black, White, etc. ( 11.Oecedr>Ce Uwd KkW d work do ne du ' moat d Nfe. Do nd ebb 12. Wae Decedent ever b the 13 Deoedent'e Edu ti S d ex can , uerto Rken, etca whit e KkrddWork IO U S A d F . c on ( pe ry Doty highest grede completed) 14. S ~M~ e Martled, 15. Surviving Spouse (11 wMe gkre maiden name) nddBuskx3as/Indueby Engineer Public Utility . . ma orces? ^y„ ®M EMrnerdary~SecorWary (a12) College (1-4 or 5+) D J , 1B.o.~eaeM~eMalengaeereae(s><.eet,`~ty/'a„n'$rate'~p~ode) , °a~eaanr Widowed a Penns lyania y ~ nt 3 82 5 Sullivan Street Actual Reskiena ne. ebb Ll ve in 1 ~c, ®Vea Hampden Decedent IJved in Mechanicsburg, PA 17050 , _ Twp 17b.County Cumberland T°""~"p? 17d.^No,DecedentLlvedwlthin 18. Fethefs Name (Fkat, ntldde, lest, su1Pot) Edward Edmondson Actud Limits d City I Boro 19. Modbr's Name (FlraL rtrklde, maiden armreme) Stella Hoch 20a. Infomrent's Name (Type /Print) 20b. Infortrbrit's Melling Address (Street, city /town, state, zip code) Laura M. Foulkrod 21 Mdf d d D 2264 Forster Street Harrisbur PA 17103 a. a lsPaltlon r ^ Crernatlon ^ Donation ® Budd ^ Renavel hen Stat 21b. Date d Dleposltlon (Month, day, Year) 21c. Place d Dfaposltlon (Name of came ry d ) tery, raemato w other ace 21 d. Locatlon (City /town, state, zip code) e r Wa Cromatlon or Dorrtlon Authorized O on,er- r bylAadalExrdnr/CoronarY ^ Yes^ No May 15, 2010 Mt. Olivet Cemetery Fairview 'I`wp. , PA 17070 22a. signature d FuraKal Service es such) 22b. License Number 22c. Name and Address d Fec9tly C l FS 012 849 L Parthemore FH & CS, Inc., P.O. Box 431, New Cumberland PA 17070 omp ete Ibrne 23e-c Doty when phyeiden b not evaNefde at tkne d des . To beat my ,death occurred - d the time, dab end place . (Signature and tltle ) 23b. Licerme Number , 23c. Dab Signed (Month, day, yar) oeraty cause d death. ~~ ~/ Merrxs 24.28 mud he completed by person who praraunas death. 24. Tine d Deatlr ~ / M• 25. Prorauraed Dead (Month, day, year) 28. Wee Case Rafened Medical ExrMner 1 Coroner for a Reason r than remetbn a Donetlon9 ^ Yes No Nam 27. Pert I: Enter the rbaln of events - dNeases, CAUSE OF DEATH (See InetrucNons and a Ies) k~uria, or complkatlona -that dksctly caused tla death. DO enter brtnkrel everts such es cardiac anent, respiratory anent, or veMdculer ffid9atlon wltlaut show) the etio ty ng logy. List on one cause on each 9ne. r Approximab interval: Pert II: Eller other ' r r Onset to Death but rat reeultlng kl the undedybrg cause given in Part I. 28. Drd Tobacco Use Cantdtxrte b Death? ^ Y ^ Probabty . MGM DIATE GAU$E IF dssase or ~/~Il-.w ~~ m /~ JV~ „ ~, ~• q ~ -~ a. / 1' V l O~ I Pi ~/v~f j'~ r ~ M A' ~ r 'I vM No ^ Unknown 29 H Female: Ibt Coridtione N any Due to A x,010 ~~~ ~ b Y ' b' 'r •J~ e E~ ~ r i ~s~) r o• ' / S - . ^ Nd pregnant within past year ^ Pregnant et fime d death oauee ebd an lin a. UNDERLYpNi CAUSE Due or as or F~rv Md Inpbted the c ~ s~ ~ C ~ ~ roeraW in death) LAST r ~ r ~~-~Yy1J(' ~ ~~ ~ pregnant, but t wHhhr 42 ^ 01 dedh pregnen days y . Due to 1p/f.88~~ ~~~IaaqusnoB,af1 ^ - ,~ /~~~ ~!L'i!J[! / /T~l'll / L/ ,f~~( d rl// V r r ~~J1 ~ i ^ Not Pregnant, but Pregnant 43 days b 1 year b f P ~ . / / r .7 •~ r e ore death Unknown M pregnant within the pest year 30a. Wee en Aubpey 30b. Were A utopey FYrdngs 31. A4~rrer d Death 32a Deb d Ir~ury (MaMh, day, year) 32b. Deecrbe How Inwry Occurred Performed? Avesebb Prior aCompletion [~ , 1,./, Nat l ^ ff 32c. Place d In)ury. Flortre, Fenn, Street, Factory, ura omidde d Cause d Deeth7 ~ // ~. Tkrra d ~ry 32e In)ury at Wak'/ ^ Accident ^ P >4 I ^ ~ ~ OfAce Building, etc. (sP~fi) 32f N Traru o btb I . erW q nvestlgetlan Yes No ^ Yea No . gr r n n)ury (SpecYly) 32g. Lacetbn of In(ury (Street, c ity 1 faun, state) ^ Suicide ^ Could Not be DNermined ^ Yec ^ No ^ Ddver /Operator ^ Pasaenper ^ Pedeahbn M 33e. Certlfbr (check oNy one) Othe r - Sped/y. • nA PhY•bbn ( ~YMg cause d deaM when aralher physkieri has pronaxiced death and To du hat of my IotoWadga, dent occumd due to the auae(t) end manrrar a stabd- _ _ _ _ _ _ ~ Nam 23) - - - - - ~. d Certlger • Praroundrg and ortMybg phytkbn (Phydcbn boll pronorxxing death and oeANykg to cause ddeath - - - - - To iht beat of my fatowbdgt, loth oaurtad N drs time, deb, and place, and dw b 1M aun(t) and manner a stated _ _ • MadkalExamNnrlCorontr - - - - - - - - - - - - - - - - _ _ _ _ _ ^ ----------- 33c. / v ' Z'/ ~~~ ~~~ S~ (M0^/~Y, )~ ~~ ,/~ ~ "/ % On 1M halt of axamMatlon and / or Invadgetlon, b my oplnbn, death oecurrod at Na tlme, dab, and pba, and dut to Urs aun(t) rat manor a stelad_ ^ , a( 34. N end Addrea rsa ld P ~e Cause of Deatlt (R T rNrt en ~ 35. Regletrar'e and Dbtrki ~ ( 1 / V V ~~ "v`" ` ~ ~.,, y / / ~ ~'y/1 ~ /N'~` ~ S / j I 70 Disposition Permit No. _ ~! ' `- 2 1 O V