HomeMy WebLinkAbout10-5579IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
o (t - ?L?a?e ?` vl P
IN RE: l xl\ ^ nn
t7n
NAME CHANGE OF File No. ID - S 57 (7
SURVIVING SPOUSE
NOTICE TO RESUME PRIOR SURNAME
(PLEASE PRINT OR TYPE)
Notice is hereby given that the above named P erl?
l C,? l.,J v? 1? l Jc c /L resi at, y
o L-Q ?L e r e- c )--) P-o a -!Lo A S bein aw .
"
surviving spouse as of YML r &N 01 hereby in Ads
to resume and hereafter use the previous name of
a l,0 e e? y e- A- 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 Death for the decedent is attached.
Date:-9 o (c) gwox' ('J
Signature of Petitioner
/0 wv?'O-
(L-xf-
Signature of name bein esumed
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
auto
On the _0%4k day of ,296?, 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 hand and official seal.
1k
Notary Publt
(Note: This notice must be accompanied by an-briginall certificate of death for the
decedent)
P tt 66 pjllw sm $92.00 Cash
0* 2-, -73W
10, 40 R1
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
This is to certify that the information here given is
for this certificate, $6.00 correctly copied from an original Certificate of Death
'del
. ,? duly filed with me as Local Registrar. The original
?_..? certificate will be forwarded to the State Vital
Records Office for permanent filing.
P 14334281 A ?.?...,` M 6 2W8
Local Registrar Date Issued
"..4] Certification Number
1410611/ REV IMM COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH' VITAL RECORDS
TYPElPMYYW CORONER'S CERTIFICATE OF DEATH
Y +? (See Instructions and exampiss on reverse) STATE FILE NUMBER
,!`^3 BLACK Y1K #31-228 2.80 &Bow Saadd Nadw /. DAN d DOI W"* dry•
1. Nwr d DwaMP k araa. WL ft %) Yinger Male 209 - 50 - March 1, 2008
Richard E
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50 ?bpalW ?ailUlplYaY ?DDA ONl.anaNOm. ?RrNwa -sb•dM
°'" "" Sep. 9, 1957 Mechanicsburg, PA
Y. W . Dradra d NNprI OW C; N. ? Yr 10. FMV Amalrn ban, U-I YAIr, W-
ee. Cm* of Drri a. Cny.. T orb III F.^ N" (11 0 MUM On art as nnhlr) In r•F WI ahn. I*wM White
i Cumberland South Middleton Forge Road at Fairview Street Mall PYdewrl,.b)
h dn1 MIN G! II Do not d1h 12. w,. D...daa aua b tlu 1a Olaldr ra EAIaYp lsplaM ab 1190" B W"p"'dl u. 0, aid (sP•dM Lnrd.d. ?5.9.wlbo aaa r In.r.. p+ nr ds an)
11. DaadllPa Uwal aas U.B. M . Foi.r7 Ebaanbry l eaoaxrry (612) omwp (1.1 a S.)
,D,d,,pgh nbdaBuiwlbaelY Married Diana W. Belt
Customer Service Lumber Yard ?ar ?? 8 oaoeaaY S. Middleton
td. Daoadwi'a rdigAddnr (sM•L dly Mows. ar/.,iP opd1) a PA lid in a 170. M Ya, ONO" Lhad In T.P.
661 Lerew Rd. 1,, A" RMdana 7b, sbb TM*W 72d. El No, Daadtl U.W Wft
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Diana W. Belt-Schaffer Yinger 661 Lerew Rd., ling Springs, PA 17007
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?D"""sP'°" 22b.lI NOW za?NwrndnmwraPrs,• Hoffman-Roth Funeral Home & Crematory,Inc.
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put'"V Y AM"Pdab ca?prm ?r March 1,2008 isle that failed to yield at stop sign
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3M. WAn as Coroner
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36. ?y.1..arq?y? Dr P-d*PM 6375 Basehore Road Suite #1
lIOL ?rh, ?.? l o'l l L I d U 1 01 Mechanicsburg, PA 7050
Dlpomm PwffA No. 019 31-{40