HomeMy WebLinkAbout10-4949IN THE COURT OF COMMON PLEASE OF CUMBERLAND COUNTY,
PENNSYLVANIA
IN RE: K;L? 6LW- c?I; (1
NAMECHANGE OF
SURVIVING SPOUSE
(PLEASE PRINT OR TYPE)
Notice is hereby given that the above named Petitioner,
Oly-en 600-
`95
residing at,
Lb C
being a
Surviving spouse as of N)0,184--yi
hereby intends to resume and hereafter use the previous name of
hoe W1 i11
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: o? 6 y
Si . 4ture of P oner 1 -
Signature of name being resumed
PP,DL a?4( 14? 9a.,Y
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
On the "Iday of , o701d , before me, the Prothonotary or the notary public,
personally appeared the abov affiant known to me to be the person whose name is subscribed to the within
document and acknowledged that he / she executed the forgoing 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)
File No. j0 - W3 /?p
NOTICE TO RESUME PRIOR SURNAME
[' r
-r 7 _
2M S ` 28
so -- -on
H105.305 REV (01/07)
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 15037364
Certification Number
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 filing.
4& e , ?? /l /,A I/ d "f
Local Registrar Date Issued
H105-143 REV 11,2006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH a VITAL RECORDS
TYPE / PRWT W
SL VIK ACK NT CERTIFICATE OF DEATH
E
(see Inahucdons and examples on reverse)
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