HomeMy WebLinkAbout09-13-10PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF CUMBERLAND
Estate of Maria Finestra
also known as Mary Finestra
__ ,Deceased
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
last Will of the Decedent dated December 20, 1960 and codicil(s) dated
named in the
(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 c.t.a.
(If applicable, enter: c. t. a.; d. b. n. c. t. a.; pendente liter durante absentia; durante ~minoritate)
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.)
Name Relationshi Residence
Carmen Finestra son 865 Indiana Avenue, Lemoyne, PA 17043
e~
c~ _
.-~ _ ; ; :3
(COMPLETE INALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in Cumberland
Z06 N. 34th Street, Borough of Came Hill, Cumberland C
(List street address, town/city, township, county, state, zip code)
Decedent, then 99 years of age, died on April 11, 2010
COUNTY, PENNSYLVANIA
File Number ~ ~ •- ~'~~
Social Security Number 195-07-8 i~ 57
~~~ ~ `T1
t~ ~ t'Ti ...._
County, Pennsylvania with his /her last principa~`i~s~derl~c~e at
7011 _ ~~ ~ mw _ _~
~..~ C?~ ~
at 206 N. 34th Street, Camp Hi11,~011 ••
~~ , _--~
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property $_ .~; D~''~
(If not domiciled in PA) Personal property in Pennsylvania $_
(If not domiciled in PA) Personal property in County $_
Value of real estate in Pennsylvania $
situated as follows:
Form RW-02 rev. 10.13.06
Page 1 of 2
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:
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
S5
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. ~, f
Sworn to or affirmed and subscribed
before me the ~ day of
.,-~ ~ G l ~
Signature of Personal Representative ~
-~- .: _,
Signature of Personal Representative ~-~-~ ~--~rn~. ~-' ' ~'
~--
~~ _ €~ ~ f _
... -tee ~~ - - f.__ :i
For the egister Signature ojPersonal Representative ~ ~ t~ ~ ; ..
.> C~ -~~ ,
f '~'
File Number: ~ ~ ~ ~ ~~ - C_~'~
Estate of Maria Finestra ,Deceased
Social Security Number:
Date of Death:April 11, 2010
AND NOW, ~~ 1~ 7~ ~ 11 ~..~k' ~ ~ ~ , -~ ~ ~ , in consideration of the foregoing Petition, satisfactory proof
having been presented before me, IT I_ S DECREE that Letters Testamentary
are hereby granted to h Y' ~' ~
in the above estate
and that the instrument(s) dated ~ ~ ` 2 ~ " ~ ~~ I` ~
described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent.
L, ,, ~' _ ~, _~ ~..A ,,
FEES .~'~~~~ ~ ~L~<~ ~(..,V l_-~`.~~ ~~ ~~o~,, L tf
., ~ Register of Wills ~?.i'r ~ lr: `:'-i~ ~ `~~;
Letters ............... $ ,~ ~ L
Short Certificate(s) ........ $ {
Renunciation(s) .......... $ ~? ~ ~' ~-}
~ ( $ ~~
t 1~ ... .a
... $
... $
... $
... $
... $
... $
TOTAL .............. $ ~~~ ~~, 0.00
Attorney Signature: /~~"""'"' ~ -`'~~'~"~y^--
Attorney Name: Karen M. Balaban
Supreme Court I.D. No.: 28160
Address: P.O. Box 821
Harrisburg, PA 17108-0821
Telephone: 717-232-3708
Form RW-02 rev. 10.13.06 Page 2 of 2
r•OCAL RE~aISTRAR'S CERTIFICATION OF DEATH
'~d~-RNING: It is illegal to duplicate this cap~i by photostat or photograplh.
[~c~~ 1~~~r this Lcrt~ti~i~,:at~~~ ~~(~.i~~''r
P ~.64~?~~a~
ei-till~:i~i~~l~ ;~i~iil~~~~r
H105-143 REV 1172006
TYPE /PRINT IN
PERMANENT
BLACK INK
,,,;,,,"",~ -
TN QF p
~~~''' Thiti I, tcl :~ertii~~ th,ut tl~t aril-orrl~ation here <~i~~en is
~,
~; t y~~~' - --- fiy~;~ ~
t ~x~~>'rr~~:tl~~ ~ t ~E~ie~l tt ~~l rl yin ~~ci~inal CertiFicate cif- Death
-
q~;' ~~~~,,
la,~~
~~'l
' clulti t
ilt:i9 with 1i~~~ ~.f.; L~yca~ Registrar. 'The ~~~iginal
~e,~t;i~ral~~ ~~lili ~~
u ti~r
rd
d t
th
Vig
Sh
t
l
~
~
( ~
4
«a
e
o
e
ii
e
i
. ~~ ~;= ~a..i >rlc~~~clr~i~, t)f~ti~•~ I~t/r ~~crmunent filing.
~ `~ 1~tt' ~- ~ ~- ~C
_ ,,
~ ~T
~~////,.i./1!///~.7lj~~r~
-_. - - ______ __ _-
~_ly~•al e~rl:~rr.il- Date I~sueci
rvr
G 3 `~
-
-
-..
a
~(~ ~ .~. / -.1
~ ~ ~; . }
~
-p ~ : ,
t
J~
1 ~
_
_ _
~~ C:7 'T'7 ~ '
~
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH ~(~ ~ ;-~ '`~'`
• VITAL RECORDS c
CERTIFICATE OF DEATH ~ .~° _ .~:~ ~'~-~
(See instructions and examples on reverse) STATE FILE NUMBER
A 1
1. Name of Decedent (First, middle, last, suffix) 2 Sex 3. Social Security Number 4_ Date o! Death (Month, day, year)
Maria Finestra Female 195- 07- 8157 April 11, 2010
5. Age (Las't Birthday,) Under 1 yrar Under 1 day 6. Date of Binh (Month, day, year) 7. Birthplace (City and state or lor ergn country) 8a. Place of Death (Check only one)
Moni15 Days rlou•s Mulules HOSPIId: Other:
99 Yrs. February 27, 1911 Penne, Italy
^ Inpatient ^ ER /Outpatient ^ DOA
^ Nursing Florae Residence ^Other • Specify:
8b. County of Ceath 8c. City, Born, Twp. o! Death 8d. Facility Name Qf not institution, yive street and number) 9 Was Decedent of Hispanic Origin? ~] No [_] Yes 10. Race: American Indian, Black, White, etc.
~
Cumberland
Camp Hill
206 N. 34th St. (tl yes, specify Cuban,
tvlexican,PuedoRican,etc.) (Specity)
White
11. Decedent's Usual Occu whoa (Kind of wcrk done B urin roost of workin file. Do not state retired) t2. Was Deuedent ever in the 1 3. Decedent's Education (Specity only highest grade comp leted) 14. Marital Slalus: Ma«ied, Never Married, 15. Surviviny Spo use (II wife, give maiden name)
Kind of Work Kind of Business! Industry U.S. Armed Forces? Elementary /Secondary (0-12) College (1-4 or 5+1 Widowed, Divorced (Specity)
Seamstress Garment ^Yes ^No 3 wIli'~~
16. Decedent's Mailing Address (Street, city ; town, slate, z•p cade) Decedent's Did Decedent
PA
206 N
34tH St Actual Residence t 7a. Stale
Live in a 17c. ^Yes, Decedent Lived .n _ _Twp.
T
hi
?
.
.
PA 17011
Hill
Cam owns
p
17d. No, Uecedent Lrved wilhir
,7b.cennty Cumberland ~
Camp Hill
,
p ACtualLimitsof
city/Born
18. Fal s Name (Firs!, middle, IasL suflixt 19. Mo!her's Name (First, middle, maiden surname)
~ i~ `~ L n,~r ~L A ~..~ ~'1 n 22A- O Qsc.~»
20a. Inlorrnant's Name (Type / Print) 20b. Informant's Mai(ulg Address (Street, city /town, state, zip code)
Carmen Finestra 865 Indiana Ave Camp Hill, PA 17011
21 a. MethW of Dispcsrtion ^ Cremation ^ Donation 21 b. Date of Disposition (Month, day, year) 21c. Placo of D~sposif,on (Name of cemetery, crematory or other place) 21 d. Location (City; town, stela, zip code)
® Burial ^ Removal Irom State i Was Cremation or Donation Authorized April 16 2010
~
Holy Cross Cemetery
Harrisburg
PA 17109
^ Other -Specity: by Medical Examiner I Coroner? ^Yes ^ No ,
22 ignalure of Funeral Service Licensee (or person wrung as such) 22b. License Number 22c. Name and Address nl Facility
- j FD-13845-L Gilbert L. Dailey Funeral Home 650 South 28th S1:. Harrisburg, PA 17103
Complete Items 23a-c only when cedityuty 23a. To '.he bes~ of my xnow!edye, death occurred at the time, dale and place staled. (Signature and t~,tle) 23b. License Number 23c. Date Signed (Month, day, year)
physician is not available at time of death to
Certify C3USe Of death.
Items 24-26 must be completed by person 24. Tine of De~rdr 25. Uete Pronounced Dead (Month, day, year) 26- Was Case Referred to Medical Examiner r Coroner for a Reason Other than Cremation or Donation'?
who pronounces death. } ~ ~:-{~ ~ M - nom` I I ~ ~ J ^ Ves •,~] No
CAUSE OF DEATH (Sec instructions and examples) r Approximalo interval. Pad II'. Enter other sionilicant conditions conli¢ in .~@aLh, 28. Did Tobacco Use Contribute to Death?
Item 27. Part I. Enter the i<i in Lev_gnts -diseases, ~nju~ies, or complications -!hat directly causeU the death. UO fdOT enter to«n~.nal events such as cardiac a«est, r Onset to Death but not resulting in the underlyiny cause given n Part L ^Yes ~] Probably
respiratory arrest, or ventricular fibrillation w out showing the elioloyy. Lrsl only one cause on each line- r
r r
^ No ^ Unknown
IMMEDIATE CAUSE (Final disease or
condition resulun
m death) 1
29. It Female:
y ^
Due to I r as a consequen oil: ~
Sequentially lis'I conditions, if any, o ~ / •,-~~ / ( l 1
T
a L ~ L"°-- / ~ --~ I ~ 7J/Z /1 1 f-' ~1 ~(/ S ~U +/ 1 Nol pregnant within past year
^ Pregnant at time of death
leadingg Io the cause listed on Ime a.
1
Enter tlw UNDERLYING CAUSE Dec to for as a onsequence otj:
1 ^ Not pregnant, but pregnant within 42 days
(disease or injury that initiated ;he ~ 1
events resulting .n death) LAST
1 of death
.
Due .o (or as a ^onsequence of): r ^ Nol pregnant, but pregnant 43 days to 1 year
r
cl. r be!ore death
^ Unknown it pregnant within the pall year
30a- Was an Autopsy 30b. Wore Autopsy Findinys 31_ Menncr of Death 32a. Date of Injury (Month, day, year) 32b. Describe How Injury Occurred 32c. Place of Injury: Home, Farm, Street, Factory,
Performed? Available Priol to Completion C(fice Buildiry, etc. (Specity/
of Cause of Death' ^ Natural ^ Homicide
^ Yes ^ No
[] Yes ^ No ^ Accident ^ Pending Investigation 32d-Time of Injury 3'Le. Injury al Work? 321. If Transportation Inlwy (Specity) 32g. Locatron of Injwy (SYreet, city! town, slate)
[ J~ Suicide ^ Could Not be Determined
^Yes ^ No ~~11
IJ Dover /Operator ^ Passenger ^Pedestrian
M. ^Other - Spoc~Iy-
33a. Cenitier (check only one) 33b. Signature :rod Title of Cemlier
an has pronounced death and completed horn 3)
Y 9PY ( } Y 9 PY~
•
r
^
1
-
~7
To the best of my know
ledge
death occurred due to the
ause(s) and man
nerasstated--------------------------------- ^ lc
i
Clan both pronouncing death and ceNtymg to cause of doath)
fa
l
d9
h
i
d
l
h
t
[~
• T
h
b
d k
h
t 33c License (dumber 33d_ Uate Signed (Month, day year)
rt
cu fe
death oc
me, dale, an
p
ace, and due to t
e cause(s) and mamrer as s
o t
e
est o
m
now
e
e,
y g al t
e l
ated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
• Medical Examiner! Coroner /~'7j " ! C'~, ' C~ ,L ~ - /~ - ~~I
On the basis of examination and 1 or investlga(icn. in my opinion, death occurred at the lime, date, and place, and due to the cause(s) and manner as stated- U 34 Nnmo anJ yddresv c ~rson `Nho Completed Cause of pee^ (Item ?!) r Print _
35. Registrar's Sig i e and Dig Ir~~tt (dumb,r~ '
L
C
~ I ~ I ~' ~ ~ I Y I
C
~ 36. Dalu Filed (M ih, do ,year)
~
~
~
`~ ~cr~
~
/>~
~~
,-
L.t-c~ I
(..C,c.,
-- GL (~C_
- C-~- ~_
_
C~ l D U ~ ,a , _
, j a~si,
,
t~~ , f,~ ~ _ rd,. ~~-t 3~~ ~I
rj~j ~ ~~~ ~~~,/
N
_
!~ c, c1
,
_
. CT- ~
_
~-~
~' ~ C.s
' ~ ~J
c_.j ___.
~_l.. '._'':7
Q..
i 1 ~..!
{.
.._
f., i~`l... ~, Q
ems: ~
ra
~~1.~T WILL AND TE~_T~~`~IENT OF Mt'~I'~.Y FINE'rP~~
I, t4L-CRY FIA?E::>TR~, of the City of Harrisburg, County of
Dauphin, and Mate of Pennsylvania, being of sound mind, memory
and understanding, do make and publish this my last Will and
Testament, hereby revoking any and all will or wills by me at any-
time heretofore made.
~Ks to such estate as it hath pleased God to entrust me
with, I dipose of in mannEr as follows:
1. I direct my Executor hereinafter named to pay all of
my just debts and funeral expenses as soon as conveniently
may be after my decease,
2. X11 of the rest, residue and remainder of my estatq
real, personal and mixed, of whatsoever nature and wheresoever situate
at the time of my decease, I give, devise and bequeath unto my hu:.band,
Carmine Finestra, to him, his heirs and assigns, in fee simple estate.
In the event my hu;band, Carmine, pre-deceases me, or that we die
at or about the same time, then I give, devise and bequeath all of
my estate unto my two sons, ~'~:.nthony Finestra and Carmine Finestra, ,Tr.,
to them, their heirs and assigns, in fee simple estate, share and
share alike.
3. I nominate, constitute and appoint my husband, Cr~:rmine
Finestra, Executor of this my Last Will and Testa~ent, and in the e`,,~nt
of his decease, then~I nominate, constitute and appoint d~rio Andret~ii,
Executor of this my Last Will and Testament and Guardian of my sons
until such time as they respectively arrive at the age of twenty-one
(21) years.
IN WITNESS THEREOF, I have hereuntosset my hand and seal
this 20th day of December, 1960.
WITNES~~Eu :
~, ~ SE
OATH OF NON-SUBSCRIBING WITNESS(ES)
REGISTER OF WILLS
CUMBERLAND
COUNTY, PENNSYLVANIA
Estate of Maria Finestra ,Deceased
~~r ~ ~ ~~s n~ s f ~'c~ and /~-~ y~ ~d~~J ~~---~
(each) being duly qualified according to law, depose(s) and say(s) that she / he /they was /were well-
acquainted with Maria "Mary" Finestra and am/are familiar
with the handwriting and signature of the decedent, and that the signature of r~~ ~ ~ ~ .~`~ ~ ~ rT~' ~
to the foregoing instrument purporting to be the Last Will and Testament/Codicil of /~~.~ ~ ~ ~ K~ s f r=t
r
is in his/her own proper handwriting.
A v'/"
(Signature)
(Street Address)
C-_ ~'
(City, State, Zip)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this +~ day
\ ~ ~ f
Deputy for Register of Wil s
(Signature)
/~G' •~~~ X ~'~ `
(Street Address)
(City, State, Zip)
~ _~
0
~ ~
-
;
~? :
c~
k J
~~ f
~
fi '
~:~C
-
n ~
;
:.~ w _
- , .
~s
D ---~ ~ -_
~ ?`i
.
Form RW-04 rev. 10.13.06
na
~_ ~.3
.,.
~
` _.
C/3
rl
_
f
~
RENUNCIATION t--- _~ rn
~ -- ~-' ' ~_.
t a
~.
~
;~,. CI) ~ ~,.,
REGISTER OF WILLS `"-=~ ~ ~ , -
~~.,
CUMBERLAND COUNTY, PENNSYLVANIA ~'. -~ ,~- ~~- ~'~~ ~:
rv
Estate of Maria "Mary" Finestra ,Deceased
I~ Ario Andrioli , in my capacity/relationship as
(Print Name)
Executor and Guardian of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
Carmen J. Finestra
MaY , C~ 2r"i1~%
(Date)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this i ~ day
of rL , ~ ~ (~.
(Signature)
,. f~ ~- . 3 ~ t-~ s~ .
(Street Address)
~ ~ j 7 ~' f ~
(City, State, )
Executed out of Register's Dffice
Before the undersigned personally appeared the
party executing this renunciation and certified
that he or she executed the renunciation for the
purposes stated within on this , l"7 day
of ~ ~ ~ , „ 2c'~1_i:~
~OMMONWE:AI_TF? CF PENNSYLVANIA
Notarial Sea! _____
`~n~'d, N4tary Publit~
Notary P 1 Lemoyne ~3oro, Cumberland Counfiy
My Commission E ~ C~mmisskon t" xpire, June 22, 2010
Mernbe~, Pe~~n_;~~~~~vE~ni~ Assoc+a°ion o~ Notaries
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's Commission.)
Deputy for Register of Wills
Form RW-06 rev. 10.13.06
;,I.
P
e VS-i 1 (REV. 3e9
~...~ ~,.._r ~..TT
••
I~L..~. ..._.
I .t _
`
c:. ;~
C, ~. ' ~,1' C''7
c ~.__, 1.-a ......
,
t
_ 1.J V~
~._ rsL OF ~ hl, cV
kU
~OUNT`Y OF SONOMA ~`~~~~ ~,~~rl
- ~)
SANTA ROSA, CAL{FORN{A `-""'
,.
_. ~ .~~~'
CERTIFICATE G1F DEATH 3-92 49-003'376 ~`
____ STATE OF CALIFORNIA ~~
' USE BLACK INK ONLY LOCAL:REGISTRATION DISTRICT AND f.ERTIFICATENUMBER
1 A,NAME OF DECEDENT-FIRST ( iB. MIDDLE 1C. LAST (FAMILY) 2A. DATE OF DEATH-MO. DAY. YRt2BiHOUR 3.SEX
(GIVEN)
ANTHONY ~ PHILLIP FINESTRA Nov. 12, 1992 FND 11257 M
4. 1= ACE $. HISPANIC-SPECIFY 8. DATE OF BIRTH-MO. DAY, YR 7. AGE IN IF UNDER 1 YEAR IF::UNDER 24 NOUR9
YEARS MON~ THS-r-DAYS HOURS .MINUTES
Whit : a
YES No Aug . 14, 1943 49 ~ ~
DECEDENT 8. STATE OF __
9. CITIZEN OF WHAT tOA. FULL NAME OF RATHER tOB. STATE of 11A. FULL MAIDEN NAME OF MOTHER 116. STATE OF
PERSONAL E-IRTH
P;~ COtUl NTRY
USA
Carmen Finestra ; Ital
Mar
Canda
ll
; Ital
DATA y ga
y
o
y
12. MILITARY SE ~'.VICE7 1'd. SOCIAL SECURITY-,NO. 14, MARITAL STATUS 13, NAME OI%. SURVIVING SPOUSE (IF WIFE, ENTER MAIDEN NAME)
19_ TD ,9_._ X NDME onknawn Divorced None
IBA USUAL OCCI IrATION 188. USUAL-KINp OF BUSINESS 18C..USVAL EMPLOYER 160. YEARS IN 17. EDUCATION-YEARSGOMPLETED
1
~
I
'.: w OR 1NDU¢7RY
( ~ ( OCCUPATION
S
•
i
'
t
oany ~~
us
iusicial~. ~ heco>
c
, Se:i= Gtnpioyec~ ; 15 Y2
18A. RESIDENCE- STREET AND NUMSER'OR LOCATION 188. CITY ! GC. 2lP CGOE
20200 River Blvd 10#~ i
~
Monte Rio
95462
USUAL
I
RESIDENCE 18D. COUNTY 18E. NUMBER OF YEARS 18F. STATE pR FOREIGN COUNTRY 2O. NAME. RELATIONSHIP, MAILJN<i ADDRE53
~
IN Tl/18 COUNTY I AND ZIP CODE OF INFORMANT
Sonoma '
'
15
California Carmen Finestra~-Brother
19A. PLACE OF C~~rATH 198. IF HOSPITAL, SPECIFY 14C. COUNTY 206 NO• 34th St
PLACE
OF .
~ ONE: IP, ER/OP, DOA I
Geirage o::_ Residence ' -- '.Sonoma C :H111~...PE3RRS lvana 1ZOi
DEATH 19D. STREET ADC~~iESS-STREET AND NUMBER OR LOCATION 19E. CITY
I TIME INT<rRVAL
22. WAS DEATH REPORTED-TO CORONER?.
BETWEEN DNS
20200 1'tiver Blvd. I Monte RIO AND DEATH REFERR7IL NUAABER
~ YES la-~Q~7 ^ NO
21. DEATH WA$ C:AUSED BY: {ENTER ONLY ONE CAUSE PER LINE. FOR A, B, AND C) I 23. WAS BIOPSY PERFORMED?
CAUE ELATE (A) INVESTIGATION PENDING ' ~ ~.
~- ^ YES ^ No
CAUSE - 24A. WAS AUTOPSY PERFORMED?
OF
DEATH (
~ 1
lBl
~
®
^
DL1E TO
I
_ YES
N
O
___
_
_
_ _
_
_
~ 248. WAS IT USED W DETERMININGCAUSE:
1 OF DEATIi1
DUE TO (CI , ( ~ YES ^ NO
25. OTHER SIGNIFIC/1NT CONDITIONS CONTIi18UTING TO DEATH BUT NOT RELATED TO CAUSE GIVEN VN 21 26. WAS OPERATION PERFORMED FOR ANY COMDtTION IN ITEM 21 OR 25?
IF YES, L13T TYPE OF OPERATION AND DATE.
I CERTIFY THAT TO TiFIE BEST OF MY KNOWLEDGE DEATH 278. SIGNATURE AND DEGREE OR TITLE OF CERTIFIER 27C. CERTIFIER'S LICENSE NUMEtER 27C. GATE SIGNED
I
PHY51-
CLAN'S OCCURRED A7 THE HOUR, PATE AND PLACE STATED FROM THE
I I
CAUSES STATED. I - I I
27A DECEDENT ATTF~.NOED SING Et D^CEDENT LAST SEEN ALIVE I ~ 1
CERTIFICA_ MONTH, DAY, DEAR i MONTH, DAY, YEAR i 27E. TYP LADING PHYSICIAN'S NAME ANO ADDRESS
TION /`"!
I I r
1 CER'17FY THAT IN MY OPINION DEATH OCCURRED AT 28 E /~ TIT G ER OR DEP4TY CORONER
28B.DATE SIGNED
1
THE HOUR, DATE AND PLACE STATED FROM TH£ CAUSES _
$TATEI). ~
II
CORONER'S
USE ~
~~ ~~
-11
29. M!4NNER OF DEATH-SpeCllr OIIC: natUtal, aeCldenl, 30A. PLACE OF INJURY '~ 308. INJURY A; 'NURK 30G. DATE OF INJURY 37, HOUR
swclde. Ilomiclde, pending In,restrgation oI could nol bE dete/mined ~ 1 I MONTH. DAY, YEAR
P
d
^
^
DNLY e:l~
lng Invests ation i
YES
NO 1
32
LCCATION (STREET
D
I
t .
AN
NVMBER OR LOCATION AND CITY) 33. DESCRIBE HOW INJURY OCCURRED {EVENTS WHICH RESULTED IN INJURY(
FUNERAL, ~
DIRECTOR _
3Gin. C%ISPOS!' ;^f:!Sj 13 E p E AND ALi:Rc°S 13A~.. Q :T •
TR
~ BII ~
/~ ; Harrisburg, Pennsylvania 11-G1-~77G R __
35.a~: SiYAAT_Iti~ OF t`AL':1LMkR ' _ B. L
~ VJ .i`1;1~9ER
n`
ii
AND --
--- ~
t
a J„
LOCAL 36A. NAME OF FUNERAL CNR£CTOR (OR PERSON ACTING AS SUCH) ~ 368. LICENSE NO. 37. SIGNATURE OF LOCAL REGISTRAR 38 REGISTRATION DATE
REGISTRAR 1 Lafferty&Smith Colonial Chapel ~ FD 356 ~, .'
~'~`
~ ~ N~V 1 8 1992
~,.r..s....
..
~.
~ , (
STATE A, B' C. D. _
E. F. ~ CENSl15 TRACT
REGISTRAR 1
,•~.-. •+.- ,.v cn novnca, r•n++r_vv+a, vr< vrr+crt nt_r cnMl+vrva
C~ ~ ~
~C v7 ~.'.
cc
LJ (~
U
41. ~~+.
CERTIFIED COPY OF VITAL RECORDS
STATE OF CALIFORNIA, COUNTY OF SONOMA * O O O 3 2 9 3 3 7
This is a true and exact reproduction of the document officially registered
and placed on mile in the office of the Sonoma County Clerk-Recorder.
{~~ ~y tt-
DATE ISSUED .~ ~~'A 'l. ~ ~ ~ ~ ~1 JA E ATKINSON,CLER -RECORDED
T--~ SONOMA COUNTY, CALIFORNIA
This copy is not valid unless prepared on an engraved border, displaying the date, seal and signature of Clerk-Recorder.
fKev. ~t-L'.9) ANN
1
1~tJUNTY OF SONOM~
SANTA ROSA, CALIFORNIA
AMENDMENT OF MEDICAL AND HEALTH SECTION DATA
.DEATH 3-92-49-003376
_~-"________ _ ,...._.._,_..,,_ _._._._.. USE BLACK INK ONLY--MAKE NO f.RASURES. WHITEOUT, OR OTHER ALTERATIONS ._- ~,
':last I I1 NI II,7IIr 1; - LUCAL '~ilE CiIS TgAT10N DISTRICT ANU CERTIFICATE NUMBER
y ~ ~ 1,'1 N.\hikJF Il",1 !(;IVENI ;Ili h111)I)I.F~ _-- ;1C LAST (FAMILY) 2 SEX
I 1
IDENTIFICATION ANTHC IVY ~ PHTLLIP ~ FINESTRA M
OF THE t DA"t OI~ VFM -L+1"~NU~ n,» '.InR .!. tali F)F OCt;URRINCI ~-^ ~ ,49 COUNTY OF OCCURRENCE
RECORD +
Noveml:er 12, 1992 FND Monte Rio Sonoma
__ INCORRECT INFORMATION ON QRIGlNAL CERTIFICATE
21. DEATH WAS CAU;iED BYt (ENTER ONLY ONE'. CAUSE PER UNE FOR A, B, AND C) nMe errv+EEN 22 wns nEaT oRT' c oNEq>
ON';Ef A DEAL/1 ~~.~.~~~
IMMEDIATE ~ -_ ". ~ ®YES REFERRAL NUMBER ^ NO
cnusE (A) INVESTIGATION PENDING , 23
WAS BIOPSY PERFORMED(
I ^ VES ® NO
1
E 24A. WA$ AUTOPSY PERFORMED+
L"LJE TQ (Qi 1 _
INCORRECT ~ ~ ~ t.5~lT USED IN OE EORMINING CAUSE
INFORMATION ~ 24B. OF UEPTHI
ON ORIGINAL o_u_E_ To (C) _ _ -1 ®YES rJ rlo
CERTIFICATE 25• „rf l N rl r.Nt r CINOr rU)Na 4ONTHWUIM+; I(r U; AIN RVI NI,i RII AfLD 7U AI),',1 141•;FN IN ., ^- 26. WAS OPE RA LION PERFORMED FOR ANY fbNDiT!UN IN ITEM 'll ul q5J IF Yf S. UuT
IvPf. 1)f OM RATION ANC (LATE
29. h'r.~r 11..t 1 it . Nf N11lIRA1 AI II1lN1 ~. JI(:II1F 3DA. NI ACI C)f IN.141f1Y j30B. IN.IiIRY .1 VJU(tl;3DC, DATE OF IN.Il1P.Y -MONTH. DAY. YFAN
I.t r,. 11 I I 1! '1i.)IN Nll 11 .F,1 1N (li rOE1(n N t Nf. DEFLRMINI-D I t
Pen~iin~~ Investigation ^ YFS ^ N(1
32. t ~ I, ~!J !..'I'FI t fNl I,1".nf N; .,,, ! N :IJI` ~ ii v. 33. UE,SC(IIRk ftC~W IN.Il114Y OCl'IMRED Ik VENTS WNICH RESULTED IN IN7UPY)
INFORMATION AS IT SHOULD BE STATED
21. DEATH WAS CAUSED $Y: (ENTER ONLY ONE CAUSE PER LINE FOR A, B, AND GI ONSE7R DEATH L'~•
~
"' V`~~"9 L~~47 G^v„`n
IMMEDIATE I
k (
~
l;jy{ YES DEFERRAL NUMBER ^ NO
cnusE (A) CARBON MONOXIDE INTOXICATION -, Un 23• WAS IUP$Y ME
'I ^ VES ~ NO
DuE To (B) Blood 32~ saturated with carbon monoxide -; Unk 24A. WA§ AU70PSV PERFOPMED~
I.~yl VES ND
'"
INFORMATION ~ oF ~EA~ sto IN oE,ERMIAIHC cni)sE
24B,
AS IT SHOULD DUE TO (C) None
- -i ~i7
Fly vES ^ NO
BE STATED 25. - __-- ._..__--
I.;,~I ..J :..,JI ~UN,r II.'rN.. r'I ~NTf•IRU NIL, ~ i~.l I. FI'I NISI Illli 1!. Ilr , AlJ"-.1 (,(VIN IN '. 26. 'JJS`; (,PE
,Yt'k nT RATIUN PERFORMED FOR 4NY CONDITION IN ITEM :1 ~r 2S~ IF YES. LIST
DP1.NA710N ANG DATE
1 _ __-__._` I I
29. e,1:,I JI( J f+.1.111 ,'t I:IFY ONI. NATI.)I7Al_ At (.1! I.NI ',1I1f 1111 30A. REAEI Of INJIINV 13OB. INJURY A7 WORt. 13OC. DATE OF INJURV-~MUNT H, DAY, YEAR
r ,.,, II. 1 vlr.Nl. NvL..,l:;,.l„ IJ Iu fUVI(. ,.:)1 R• (11 TEIJMIEII lJ ; Betty No•v 9 , 19 9 2
Suicide Privat~~~es~d~nce ^ YES Ixi NO ;and Nov 12 , 1992
31, HOUR
betty 0 8 30
and 1257
32. I rt JIJ ", 11'tf' r.IJI' NUM!rtI O!k IUCpiIU!•: ..NC I1T'rr 33. DE Cf,PIRk HUW IN IUrJV OC(:IJRRFD IF VE NT$ WHICN Rk SUFTEU IN INJUR I'1
20200 River Blvd, Monte Rio Death by his n hands (car exhaust)
7A SIGNATURE OF ERTIFIER ~ ,76 DATE SIGNED
o RAVING F'ERSCNAL KNOWLEDGE Of SUP- ~---.~, i
DECLARATION PLEMENTAL INFORMATION b'HHICH MODIFIES - - 1 ~ ~ ` J
OF T;iE INFORMATION ORIGINALLY REPORTED. I BA NAME OF CERTI'IER (PRINT OR TYPE) ;9B DEGREE OR TITLE.
CERTIFYING
PHYSICIAN DECLARE UNDER PENALTY OF PERJURY THAT
TFtE ABOVE INFORMATION IS TRUE AND COB- N. Tom Siebe Chief Dep.Cor,
OR CORONER
RECT TO THE BEST OP MY KNOWLEDGE _
HC ADDRESS---STRcET AND NUMBER
.BD CITY 18E. STATE
I I
3336 Chanate Road ;Santa Rosa ;CA
EU R
STATE/LOCAL ~~ !/"Fll:f I.1F ,TWIT: iif(;ISiRAl7 OR 51(;NAT~!Rl- OF LOCAL RLGI~TRAR ;y6 DATE ACCEPT D FOR REGISTRATION
REGISTRAR C 7`r •~~ rf °~. ~r ~~B 8 1993
___U~E ONLY - ~ t-~T:. .~! ./ ! ~ ,~~`"'
STATE OF CALIFORNIA. D RTMENT OF HEALTH SERVIl.ES. OFFICE OF STATE REGISTRAR I vezaslRJn.eiaol
/.
~ CSATE OED COORNIAO, COUNTY OAF SONOMADS * O O O 3 2 9 3 4 O
I
~~' ~ This is a true and exact reproduction of the document officially registered
~ i and placed on file in the office of the Sonoma County Clerk-Recorder.
JA E ATKINSON,CLER -RECORDER
~, ~ DATE ISSUED SONOMA COUNTY, CALIFORNIA
This copy is not valid unless prepared on an engraved border, displaying the date, seal and signature of Clerk-Recorder.
lRz~. 41091 ABN