HomeMy WebLinkAbout05-02-11COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HAflRISBURG, PA 17128-0601
RECEIVED FROM:
JONES DEANNA M
4 APPALOOSA WAY
CARLISLE, PA 17015
fold
REMARKS:
SEAL
CHECK# 2446
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
ACN
ASSESSMENT
CONTROL
NUMBER
TOTAL AMOUNT PAID:
INITIALS: CJ
RECEIVED BY:
REGISTER OF WILLS
REV-1162 EX111-961
NO. CD 014383
AMOUNT
537,089.00
GLENDA EARNER STRASBAUGH
REGISTER OF WILLS
yui=.na; Rj.c unrU;,
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this ceriificate, `.66.00
P 17112340
Certification Number
This is to certify that the information here given is
correctly copied-ti~om an original Certificate of Death
duly filed with me as Local Registrar. The original
certificate will l+e forwarded to the State Vital
Records Office fo; permanent filing.
-~ r ~~~ ~~ 1 01f
r ,~~ -
Local Registrar Date Issued
TYPE i PRIM ~IN
PERMANENT
0LACK INK
, 1. Name of
CERTIFICATE OF DEATH
(See instructions and examples on reverse) STATE FILE N
2. Sex 3, Social Security Number
(Pita;, middlelazt, aunix) Male 185- 34- 0982
Age (Last Bmntlay) °„ `°. - __ Moines
M°"me Days "°'S April 21,1944 Johnstown, PA
66 Yrs.
I. County of Death Bc. Gry. Boro. Twp. of Death 9d. Facility Name (II not institution. give street and number)
Cumberland Carlisle 4 Appaloosa Way
KiM of Work Kmtl of Business' Intlustry
VP 8 Chief Mfg. Office Steel
16. DecetlenCs Mailing Adtlress (Bract. ury !town, slate, zip cotlel
4 Appaloosa Way
Carlisle, Pa 17015
19. Father's Name (First, middle, last. sums) Edward L. Jones
12. Was Decetlem ever In the 16. ueceoema rww,~~ rw=mow -,.., °~y°_.. ,.__. _...,
U.S. Armed Forces? Elementary I Secondary 10-12) College (14or
^Yes ®No
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4. Date of Deatn IMonih. tlay. yea
January 29, 2011
^ ER! Outpatient ^ DOA I ^ Nurs
9. Was Decedent of Hispanic Origin? ~ Nc
(If yes- speory Cuban,
Mexwan. Puerto Rlwn, etc.)
etedl td'Wa~wed Dv~wced lSpee l)1rN
~) Married
Hama ~Resltlence ^Other-Speclty.
^ Yes 70. Race. Amencan Indan. Black. White, etc.
(Specityl
White
ied, 15 Surviving Spouse III wrfe. give maiden name)
Deanna
DeceOenfs Pa Middlesex Twp
Live Ina 170 ~ Yes. Dxetlent lived in
Actual Residence 17a. Sale Township?
Cumberland 17tl.^No. Decedent Lived within Gry Boro
17b. County Actual Limits of
19. Mother's Name (Fist middle, maiden sumama) S •f rt
I 2Oa. Inlomian(s Name (Type / Pnng
21 a. Method of Dispostion
Budai ^ Removal Irom SO
^ Other-Specy:
22a. Signature of Funeral Seri ~ e
a
Complete Items 23ac oMy n rtsying
phyacian is not available at time of tleam [o
I cerury rouse of tleam.
V
0
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J
Deanna Jones
Anna Rae ( ei e )
200. Inlorman[s Mailing Address (Street, chy r town, state. zip code)
4 Appaloosa Way Carlisle, Pa. 17015
21tl. Location IC'Iry 1 town, state. zip cotle)
]Cremation ^ DonatxNt 210. Date of Disposition (Month, day. year) 21c. Place of Disposition (Name of cemetery, crematory or other place)
Cremation or Donation Aulhorize0 February 2, 2011 Grandview Cemetery Johnstown, PA 15905
edicN Examiner /Coroner? ^Yes ^ No
1 ass 1 220. Ucense Number 22c. Name and Adtlress of Facility
Q /a0 S8L Frank Duca Funeral Home, Inc. 1622 Menoher Boulevard Johnstown, PA 15905
23b. license Number 23c Date Signed (Month, day, year)
e best of m_ y letlge. death occurred at the time. date and place stated. (Sgnature antl Utle)
~2a~k~r1 .fit / (2i~S3~3~'/ T ~. a' ~ / l
25 Date Pronounced Dead (Month, day. year) 26. Was Case Reterte0 to Medical Examiner r Coroner for a Reason Other f n Cremation or Donatron4
Items 24-Z6 must be compete0 by person 24. lime of Death _ "~~
M.
LL
5 a
~ LCLd.
r ~v(~ ^Ves (~J4O
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-
e Contnbme to Deam?
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U
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-
(/
who Droriourues Oeam. no to
Approximate interval. Pad II: Enter other ' u^ r~mmtiorw contn~ acco
s
o
death. 28. Ditl
P
b
D
CAUSE OF DEATH (See instructions antl examples)
liptions - mat directry caused th tleam. DO NOT emer terminal events such as
or mm
d
i l
cardiac arrest, Onset to Death Dul trot resunirig m the uMeOying cause given in ro
a
Ves
Part 1. 0 yNO ^ Unkrawn
p
nlii
es.
Item 27. Pan t. Enter the r"° ~ W evens -diseases,
lritWar IibmWtion wnhoN showing me etiology. list only one rouse on each line. i j8
respiratory arrest, or ven
e
.`.
IMMEDIATE CAUSE Final disease or ~
~L
({ I 1'ti 4 S~+ ~ ~ I (~~
'
~1 ~ 29. A Female.
^ Not pregnant within past year
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p
yy
y
{
cenditan resulbrg in ~eam) -~ 2. 1 l
nt at tlme d death
n
^ P
Due to (a az a uence oq: ,
~ reg
a
^ Not Pregnant. DN pregnant withn 62 days
Sequemially Gst conditions, 'rt arty, 0. r of tleam
leadi to the cause liatetl on line a. Due to (or as a consequence op:
Enter the UNDERLYING CAUSE ~ ^ Not pregnant. bN pregnant 43 Oats to 1 year
(disease or injury Inal'uiitialBO me c.
events resunirg m tleam) LAST. Due to (or as a consequence oi): ,
r
r before death
^ Unknown d pregnant withn the past year
d.
Date of Inlury (Month. day, y
32a
ear)
32b. Describe How Injury OccurreO
32c. Place of Inlury. Home Farn Sreet. actory,
ptlice Building, etc. jSpecily)
Spa. Was an Autopsy 3OD. Were Autopsy FnOings 3t. Manner of Death
.
Performed? Available Prior to CanPletion
of Cause of Death? ^ Naturel ^ Homicide
32e
Injury al Work?
321. 11 Transportation injury ISpeciryl
32g. Location of Injury ISreel, my %town, slate)
^ Accitlent ^ Pending investigaton 32d. Tune of In ury
I .
^ Dover i Operator ^ Passenger ^Pedesman
^ Yas ^ No ^Ves ^ No ^ Suicitle ^ Coultl Not be Detem+ne0 M, ^Ves ^ No Omer ~ SpecAy'
330. Signor Isle a le
33a. Certiller (check only orce)
o! tlealh when another physician has pronounced death aril completed nem 291 ,
^
• Cenifyirig physician lPhysician ceriying cause
To the Oastbmy knowledge, loam orxurted due to the ceuse(s)aM marmeraz slated--------------------
ronouncing tleam antl certirymg to cause of tleam)
both
h
b '------------
i~cense Number
L
33c
.
_` ,
^ 330 D' SgneO lMOn;h. daY yeah
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L (J ( I
P
ysi
ian
• Promuncing arm cerliyag physleimi (P
and due to the causNs) and manner as stated- - - --
antl Place
date
iM time .
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To toe Oast of my krrowkdge, deem xcurred at
Medical Faaminer /Coroner 3d. Name A ss of arson o Completed Cause D m (Item 2'i Tore' Print ~ 2,~
On the basis of euminalion aM I or investigation, in my opinion. deem occurred at the time, date, and place. and due to the oase(s) sM manner as ahted_ ^ 'Ip7 ,,,,r ~~ p rWn ~ ~ o~~~ ~ ~'(r ~1 S N •
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35, Registr Sr9iatuJ~ antl Drs}act'~n0es'" /~ I ~ I / I ( I L I ~ I
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Fried lMonth, tlay. yea0
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Disposition Permit NO. /l . 1
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