HomeMy WebLinkAbout07-06-11 (2)IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
REGISTER OF WILLS
PETI/TION FOR PROBATE AND GRANT OF LETTERS ~f
Estate of ~Q„ ~ P ~r./ rsji.~.rii, ,Deceased ESTATE NO: 21- -D /~a'
a/k/a:
alk/a:
alk/a:
ss No• r-i6- 68- S~y~
Petitioner(s) who isfare 18 yrs of age or older, apply(ies) for: COMPLETE SECTION `A' or `B' AND "C" as
applicable:
^A. Probate and Grant of Letters Testamentary orOAdministration c.t.a., or d.b.n.c.t.a. (completePart Cafso)
and aver that Petitioner(s) islare entitled to the aforementioned Letters under
the last Will of the above-named Decedent, dated and codicil(s) dated
(State relevant circumstances, e.g. renunciation, death of executor, etc.) w`~„
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the O ~_ ~:
~" x
instruments offered for probate; was not the victim of a killing, was never adjudicated an incapacitated person, and was not a J ^ ~p ~ ~
party to a pending divorce proceeding at the time of death wherein grounds for divorce had been established as defined ~ ~ may, v O
23 Pa. C.S.A. § 3323(g): O O ~ ~„
/ a
~. Grant of Letters of Administration l~~. ~ L.. ~`m~.s-or, ~ ~ c ~ a~~.
(If applicable, enter d.b.n., pendent lite, durante absentia, durante minoritate) C ~ N p m
`' x
C. Petitioner(s), after a proper search, has/have ascertained that Decedent left no Will and was survived by the ~ v
following spouse (if any) and heirs (l.f Administration c.t.a. or d.b.n.c.t.a., enter date of Will in Section A and complete list of
heirs); was not the victim of a killing; was never adjudicated an incapacitated person; and was not a party to a pending divorl
proceeding wherein grounds for divorce had been established as provided in 23 Pa. C.S.A. § 3323(g), except as follows:^
Name Address Relationshi to Decedent
i ~. 39~ ~ s
IISE ADDITIONAL SHEETS IF NECESSARY
THIS SECTION MUST BE COMPLETED:
Decedent was domiciled at death in Cumberland County, Pennsylvania, with his/her last family or principal residence
At 39~y Srdokr,'c~•e nat~vc Mtt.~,e-.,:esb~.r~,~ /?v3'o. C~..t,~l..,o~ ed~..f~
(Street address with Post Office and Zip Code, Municipality: Township, I~rough, City) '
Decedent, then ~ years of age, died 6 ! 10>/ at /ylrel~w«•~.s~~~ , ~~
(Month, Day, Yeaz of death) (City and State where death occurred)
Estimated value of decedent's property at death:
If domiciled in PA
If not domiciled in PA
^lf not domiciled in PA
Value of Real Estate in Pennsylvania
All personal property
Personal property in Pennsylvania
Personal property in County
Location of Real Estate in Pennsylvania: (Provide full address if possible.)
Signature(s)
Interim Form RW-02 revised 12.26.]0 by Cumberland County pending action by the Court
Total Estimated Value
$ ~~OdD
$ 0.00
3?.2y B~o~k.~~G~ lJ.-. tn..~..~ ~. ~P.~ l7oSo
Name{s) & Mailing Address(es) ~
g~ z
O
Page l of 2 9~
~~~ ~
OATH OF PERSONAL REPRESENTATIVE
Commonwealth of Pennsylvania ~ SS
County of Cumberland
The Petitioner(s) herein named swear or affirm 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 th
Decedent, Petitioner(s) will well and truly administer the estate according to law.
Sworn to or affirmed and subscribed
this V th da/~~ of
O/!
~, ~ .~ -~
the Register
Estate of
~/ - ~ ,~
~, x ..
'" ~w~~
O C ~ ~ ~ r
Q ~ ~ a ~ Q
~_ ~
~~ N O
x F
DECREE OF PROBATE AND GRANT OF LETTERS
d ward ~hnSo /'1 ,Deceased File Number: 21-~~- ~ 7
AND NOW, this of 0 ~ ~ , in consideration of the Petition on
the reverse side hereon, satisfactory p f havin been presented before me, IT IS DECREED that Letters
-Testamentary ~ of Administration are hereby granted to:
(If applica ter t.a., d.b.n., d.b.:
L~v~d 1. n 0 nd ~' '
the above estate and that instruments(s) dated
admitted to probate and filed of record as the last Will and Codic
etc.)
described in the petition be
Glenda Farner St
Register of Wills
FEES:
Letters ....................$ _ 9o'~a
Will ........................
Codicil(s) .................-
(, ~j Short Certificates •~d
( )Renunciations.......
Bond ............................. _
Other
Automation FEE......... 5.00
JCS FEE ................... 23.50
/3.8'0
TOTAL ................$ ~-~H-
Signature of Counsel Required to Enter Appearance
Atty's Signature
PRINTED Name:
Supreme Court ID No.:
Address:
Phone:
Fax:
in
Interim Form RW-02 revised 12.26.10 by Cumberland County pending action by the Court Page 2 oft
OCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate. $6.00
P 17556987
Certification Number
This is to certifr~ that the information here given is
correctly copied f~-o)n an original Certificate of Death
duly filed ~.~~ith rl~e ~(s Local Registrar. The original
certificate will he forwarded to the State Vital
Records O~fic~e ~;or permanent tiling.
J~~• JUN 2 1 11
Local Ret~i,trar Date Issued
REV ttl20o8 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
;ANE I" CORONER'S CERTIFICATE OF DEATH
~K INK (See InstrUCtlona and examples on reverse) STATE FILE NUMBER
u~~ ni.~
~`
w f
" ~ ~~
(=,
,~ '~ ; -;
,~ :.;
~~ ~~ZZ
~~ e~ ~~~
~~'O..~z
,, U N ~ ~~'
,. x,
r^.
~ J
t tie ~ p IRS. , ~, ) 2. Sex 3 Securky N r
1 !~6 ~S ' 5842 4. Date of DeaM (Month, day, year)
Paul E Male June 15 2011
5
p~ (Lwt B{~y) t r Under 1 6. Date of Bktlt Momh, da , e 7. & and state a camtry) 8a. Place w Death Check on ate)
, ~" ~"" tom. ~"" Richmond VA 14OSpltal. other.
3 4 Yrs. J anus r 16 , 19 7 7 ~ ^ lnpanent ^ ER ! OtApetient ^ OOA ^ Nureing Home Residence ^ other - SpecHy:
- Bb. Catxdy of Death 8c. City, of Death Bd. fadNry Name (If rat Instltuson, gNe street and number) 9. Was Decedent of Hlspenro Origln7 No ^ Yes 10. Race: Amerk;art Indian, Black, White, etc.
~ (If yea, specify ~~, (6Pec/M
Cumberland Ham den 3924 Brookrid a Drive
Mexkk;an, Pwrro Rican, etc.) Wh 1 t e
11. Decedertta Usual Kind w work d one most w Nte. Do not slate red 12. Was Decedent ever M the 13. Decedents Educatlon (SpecNy ony hlgheat grade comp leted) 14. Markel Statue: Manfed, Never Married, 15.6urvlvirtg Spowe (If wife, glue maiden name)
IOrtd w Work
l
d Khxi w Buskteae I Indushy
kin
tru U.S. Armed faces? Elem~ 2 /Secondary (0-12) Colbge (1.4 or 5+) 5~0~"~' l e (~M
oa
er g
c ^Yes No g
• 18. Decedents MeiNrtp Aadresa (street, r91y /loan,, state, zIp Dods) Decedents P e nn S y 1 V a ri 1 a °N InDeadeM
I~G
~
3924 Brookridge Dr. Yea,DacedamUvadln Ham}
1den Tv+P~
A""~lR "°•~°'° T°,~~~~ 1~°.
Cumberland t 7d. ^ No
Decedent L"ed witMrt
• Mechanicsburg, PA 1 7050 ,
"~•~"'"ty Awualumnew cny/Boro
18. Father's Name (Fkat, middle, last, aulflx)
Larry E. Johnson 18. Mokter's Name (Kral, middle, maklen stuneme)
Margaret Holmes
20e. Infonnam's Name (Type / Pnnt)
David L. Johnson 20b. Informants Melling Address (Street, city I town, state, zip code)
41670 Lawson Circle, Temecula,CA 92592
-
• 21 a. Mettad w Dfapcenlon i Cremation ^ Dortetbn 21b. Date of Dlspoaitlon (Month, day, yr) 21c. Place of OfepoaNlon (Name w cemetery, crematory a outer place) 21d. Location (Ciy I town, state, zip code) 1 7 0 6 5
^ ~ tj'n'°~I'r°°'~'te ~ ~ ~ June 21 , 2011 Hollinger Crematory Mt.Holly Springs
PA
c Yaa^N°
p ,
~ w (a person as sucft) 22b. Ucenae Number 22c. Name end Address of Fedky
• ~ D-013163-L Musselman FH&CS,Inc.,324 Hummel Ave. ,Lemoyne,PA17043
Meme 23ac oNy when osANyhg 23e. To the best w my krtovrledge, death occurred at the tkne, date and place stated. (Sigrtehrre and tltle) 23b. l.k:enae Number 23c. Date Signed (Month, day, year)
ptlysicMrt k n°t evekeble et lime w death t0
ONdy C81Ma w dBekl.
• Iterate 2428 mwt be completed by person 24. Time of Death 25. Date Prataeaed Deed (Mortdt, day, year) 28. Was Ceae Referred to Medical Examkter /Coroner for a Reason Other then Crematbn or Donatlon?
""'°pr°r'°'"°°a~°"'~ A rx. 1:00 A.M~ June 15 2011 Yea ^"°
CAUSE OF DEATH (See Instructions end ezeunpNe) r Approxlrttete kNerval: Pert II: Enter other 28. Did Tobacco Use ContrWute to Deeth9
Item 27. Part I: Enter the wtakt w everds - diseases, ir>luries, a contpkcadorts -that dtrewy caused the death. DO NOT emer terminal everks such ore cardiac arrest, r Onset to Death but not reeultlng in the urMerlyktg cause gNen In Part I. ^ Yes ^ Probably
reepketory arrest, a vemrlcular flbdketlon without showing the etiology. List Dray one cause on each Ikte. ~
r ^ No ^ Unknown
MEDIATE CAUSE disease a r
axtdtbrt resukktg In _~ a. Mu l t ip 1 e Gunshots o f Neck and Torso ~ 29. If Female:
^
Due to (a as a consequence of): r Not pregnant within pest year
^ Pregnant at kme of death
~ ~~ n ~ b ~
a Due to (or as a consequence of): ~
~
A
~
1D ^ Not pregnant, lxd pregnerH Wlttwn 42 days
- LYNI
USE
UNDER
G C
Eraer
( a ~ °. t
~
~
_ of death
• ~
) ~ Due to (or as a consequence of): ^ Na pregnant, but preynam 43 days ro 1 year
• d. ~ before death
^ Unknown M preprtam wikdn the pest year
30a. Was an Autopsy 30b. Were Aulopay Fhtdkgs 31. Manner of Death 32e. Date w hqury (Month, day, year) 32b. Deealbe Frow Injury Occurred 32c. Place of Injury: Home, Farm, Street, Factory,
Performed? AvtNleble Prior to Camplelbn
orcauaemD.atn~
^"a'"rs' ~HanfC1de
June 15 2011
Shot b known a a an
Olfae Bukdrtg, etc. (speotlY)
Home
~.~r
lyl Yes ^ No
'
'Yes ^ ~ ^ Aaident ^ ping Irnestlgetbn 32d. Time of Inwry
Aprx . 32e. Injury et Work? 32f. M Treneponatlon Injury (Speclly)
kx ^ Passen
er ^Pedeetrian
I O
^ DM 32g. Locaton of Injury (Street, cnY !town, state)
,
[ ^ Sukide ^ Couk1 Not be Delemdned ^ Yes ~j No g
er
psra
1:00 A M• `~ ^~-sa~r r. Mechanicsbur PA
33a. caNSer (wrack Dray one) 33b. sgneture and Tkk
Cartllyktp physklen (PhysicWt ceNlyttg ceuee w death when another pltysiden has praatetced death and completed Item 23)
- -
To tlw beat of my latowNdga, death oaurred due to the awe(s) end rnarrtsr p stated . . . . ... . . . . . . . .. - _ - _ _ - - _ _ . _ - .... ^ ~ o r o n e r
Prartastclrq end artlfyktp physblan (Phyeiden lakt prortaex~rtg death and cerdlying ro caws w death)
^ 33c. Llcerwe Number 33d. Date Slgrted (Month, day, year)
aC wkdge, deMh oauned et the rams, date, and plea, and dw to the cause(s) end matner as stated- - - - - - - - - - - - - - - - - -
I> ~
T
~ J
16 2 011
I
>.r /
x une
On Uta bask of etceminelbn and I a Inveatgetlon, In my oplnlon, death otxurrad N tM tlrtta, date, and place, and dw to 1M caraa(a) and manner es ataterL 34. Name and Address w Person Wtw Campbted Cause w Death (Item 2~ Type / Prkd
T
dd C
E
k
d
C
35.Regiatrer•a tu,epbaict r
"/
' ~ ~ I~ I°~ I ~ I~ I 3s~.o~. Rbd aay;y,er)
Qi/
c
~ o
.
enro
c
e,
oroner
6375 Basehore Rd., Suite ~~1
.,,;, i.
l4
Dlaposklon Permit No. D ~ ! O ~ y w
yi ~~I~r,~;,~~~•. x. .~, ,,.•`i ~~ ~'" ,s `",'.ir1 ~r " ~Y.'+1° t3 ~~ ~J. ,$ ,"1,~,'~'. ~f ~~, ,,,~F., ~'''I;r~7'A-~1. s~s. ''.~.~.+Fxirlil'~~ ~t.,, „~!~'-~:""/3Y~'~'.(d~., 7~~
-r.
,~ ...
,^
~,.;~„.
,,, ,. .•r' `, ' u' "u` ! :. ... -,\ fir,,.. 'ltc+t a ~.. .+\2 1lthsr' Orr rl ~ ~ 111'~rr h II r. a,r r I y~' , ... I {. %'. ~ ~~^~~ i11'~~ ~~~•~\ 1
1„ ~o
yM
,,. -. ~ [
. Y
1~4 ~ ~ ~. ~:
~. ~ IIY~ F.€,'t _ ~_ ~.: RNA l _ 1 - d r,-s P t i~ :- 1r; k 91F IA1 ~~! U~ ~~~~~~111IIEf1~ ~ =;_ i < ~ kil ~ ~
ti ~~ . ~ ;;. - ~ STATE: OE= FORTH C,~-ROLI~V~4, ~~, ,k:~;h,~
~, IROGKIN~HAIUI COI~MI,!"Y ~~~°~~-~~"Y
-~~: ~r~
OFFICE OF I~EGISTEf-~ OF=~ DEEDS ~ -
~ }~ `~,
„~ ,.,>
b~~. ' )r~~~.
:,~~~
\„ ~ ,;
A126~ 1 -~.-~'
NORTH CAROLINA pEPARTMENT OF ENVIRONMENT. HEALTH, ANO NATURAL RESOURCES Z " ~ , i~c
0 4 5 2 CQPI( ~ ~ 8 ~ DIVISION OF EPIDEMIOLOGY -VITAL RECORDS SECTION ~
MEDICAL EXAMINER'S CERTlFICATf O~ dEATH d~ ~ ~ ~ ti ~ S
I _ District'No...~ No. , ,~ i
N 77,~
~ rf - ° f
\`
~~~.~ - ' S
^~ - ~ ~
,i _-
x
''~,3~'_
%3,;"~
k„~':-_ _
~~
,.~~ ~~ a
u -
'- t
-; ~ ~~''
%, s .3
~`~f ~ ~~
_ ~.
k „t
~_ ~
a
N
a }_ ~
f
ay~p
/~-rkf ~-
</// '4~~ - 0 i
~ -
\- - ~~
r
3.. ;_ ~~~
~ ,._
~ o
a S
`_ ~~~
r'ii t° ~ ~
~f a ~ 2,- E .
.
~~~_ ~~
\, ~•
~~~ 1
~~~\ ~j1 S - ; ` r
t <~
~~~ ~~~
/ - ~~~
'"Y~j I vv
\\~Y`Nk
_, ~` 3~- WTK neCOlIDS
C 1 _.. .rltl!
4
-t .
,f
\ ~,, ,
_~
,
~ i
h. \\
_
_~ .
( ul OA E DEATN fMOrM. Day. roar.
1. 2 i
UL NUMBER AGE-LMt BkttWa,r UNDER 1 YEAR UNDER 1 OAY DATE OF BIRTH (Mt»lft, pay, BIRTIfPLACE f County ano Sfaro «
IYeanl twn rnuoai I Yaary Foraiprt Cotntryl
a - - ~ ss ~ a 4 T. has n
wAs DECEDENT EVER 1N uS. tfa PLACE OF DEATH fCMrca oMY onK aee atatnrmioro an oarar ata/
ARMw FOiICES lrs «roo1
a Yes Arm t1pSPITAI_ a Inpu.,, o ER/OutpNiant o DOA OTHER: a NutaMy Horne O Reneent:e Dater rspulr- °
F L rM not irsehrtion. ybe-ureaf and MMtDer1 CITY, TONM, OR LOCATION OF DEATH INSIDE CITY UMRST COUNTY OF DEATH
~ ~ Stokesdale is «"b1 ~.,
MARITAL STA Nerer SURVMrKi SPOUSE IK Wlk pM rnridan rtrrrel DECEDENT'S USUAL OCCUPATION (pica aNrd o/ w«a KND OF BUSINESSlIN &TRY
MttnM0. Wmewao, Ohorpd /swr.+Wl d«r tArrlrq moat d ~a+0/i/a Oo nar ur rataed.l
a M
i
d
,
arr
e
++•Mar area Ann HoLaes u. ,ab.
OENCE- ATE COUNTY CITY, TOWN. OR LOGTION STREET AND NUNIBEII
,,. PA „t,. Cumberland ,k, Mechanicsbur „~ 3924 Braokridge Drivs
erSR7E CITY LIMITS ZIP CODE Wp Deoedettl d HkpaNt: Oripirt4 (Sprtt:ily Yra « RACE - AmNipR kttFen. 81at:k DECEDENTS EDUCATION tSpaarlr trry ngtiar pwW
tYU «lvo! NO-II a1Me11y Cu4arL A/aruearl. PtraAO Akan, While, elc. ISpaoiyl mtt>slatadl Banw+nry/9.oabary 14t2- COllpa It}a--
,~. No 7x17050 ,.. No ,a White ,a 12 ears
FATHERS NAME (FlrraL Midd14 Lattl MOTHER'S NAME IFirK MlddMl, Malden Strrnrnal
`~' ,T. Lawrence Johnson
,a Jesse Moore Parker
MIFORIdMR'S NAI1~ (TypaPNnt1 MAILING ADDRESS f SaaN and NunWar a Rural AarM NuntE«, Cry « TowrL SMM. Zip Coal
F-
~
,,. Ma aret Ann Holmes Johnson
„a 3924 Broakridge Drive, Mechanicsburg, PA1705
PART L Einar a.. awry, itlFlrkN, «teomdlrJrbna that e><taao ele aerh. tb na sour ar moo. d tlyitp, n,Gt ea ryrefaa «raaPirabry arwsl slwek «Irart arwn.
~
e
I
~
Lke any «weawa on aaen lint B
oFrari Oro
at
it d
Death
-*--
I
IF
a.
~tq^ ~~ To (oR A$ A
ut datnl
E.
usmiie
t3er
fal
a
6
y
a
con
r
oro
N any, a rrunaarte DUE T'O IOR A°S A EOUENCE O
~
ealne. E
nIN Ul~k#LYWO
CAUi! 1Dleuae «injwy
tut initiNed anwtta e.
roultirq in t1eNh) LAST. DUE TO tOR AS A CONSEQUENCE OF-:
>~ i,,
PART II. thrkar agnkneark oonakkona tamtteutinp ro tMMn Otrt na naWWq'n ata uttoaayitq tatty. pion M cart I. WAS AU OPSY R° Wtpe Aulopey Finatga AvNrabM Pn«
FORMED f Ya or No/ b Ctxnpelion d OMU+ CwltealN
20Y. !ta t7b. f Yeo a WO
MAfJPMeR OF DATE OF INJURY TIME OF MVJVRY AT WORK? DESCRIBE MO,(Y O~IIRAEp
- yB/"
GNaexalAedant =3uteiae IMOnm
Ya
Da
1 INJURY
Y
~
~
w~
,
y.
r
/
p«NO) ~ r ~.~ 7
f`QVI.' dp
21et7 -torniaii[e P«raatp G fJal pNetrntrlea 3Ea ?~ M. 72t
PLACE OF INJURY' - At tgale, fans. etreN, het«y. t7Hip LOCATION (Stroh and Ntanher «RurY Roble Ntwr10er. City « Town. SINN Tll~ OF DEATH
htriltlrrp, NG.($periilYl
To the beat a my rretl . set. tlfW PIaOa stale0. rSipnahwe ertd rids a cnpher) DATE SKiNED Ihfonth, pay. rwr
- >~„
NAME AND WHO 00 ED CA OF TH (ITEM lTYPa tx / LATE PRONOUNCED DEAD
• f+i/«tM4 Oqt Ywf
21a. 2M1b, r
~T~ ~ ION ~ PLACE OF oIaPOSIT,oN /NaMa a pm.terr. L TION - Ctry «TOwrL stN.. Zp coa
~ Burlel G CremNron C RaatOVaf Irorrl Sate G Oauaon crot+tnarY. or Oster
Ptaw!
ua... O Orlw (Spaatfy/ f 95G
NAME AND AOOiIESS OF FUNERAL HOME Nowi- tx tRJN oA FeASnN AcnniG AS 9ucn I.K:ENt'•E Nt~1BER
,~plinshew Funeral Home, Inc.,Four Oaks, NC zkFS-802
'S SIGMA • fManNt, Dp, rrrarl
Id
3 E LICENSE Wl1n1BE11
h „eFSL-23
11' ~ ;
.~~
~_;
\:
~,~~~~
~`
_, !;r r .;
~. y~i~.~
rl4ii
;;?:~%
~-
~.
~ ~~'
,,
r~.
!~~
'f%
~,
~~N `
~! ~_
\~ \~
I Ny~~~ ~ul~ '
I ir~ii-
- ;~~ ii
~,
~ ;1`~:
:.~ ~ J } ~"
-_ ~~ -
r-~ r-. n
~Q ..i ~ ~ '%. r. -
f_; ~ ~ U l
F-I ~ O u ^ ~
N ~ ~ -~
'~ .- _
~; - ..; ,
r- ::
Volume~~ Page ~ S cam.
This is to certify that this is a true and correct reproduction or abstract of the official record filed in this office.
0?9~-7~6g28
Witness my hand and official seal
this the~day of 205 By:
DHHS 3914 (REVISED 10/02) N'C VITAL RECORDS
Rebecca B. Cipriani
Register of Deeds
Rockingham County
Deputy/~ssi$Eenrt Register of Deeds
Any alteration or erasure voids this certificate. Do not accept unless on security paper with Vital Records seal clearly embossed in left corner.
his 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.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00
'~`~ ~~~
No.
r~~
~~~
Local Registrar
j tN ~ ~ 2005
Date
3 Rev. 2187 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH ~t,r< <.,~,,,,,.o~o
^~
~~ ~z
~ ~"~
f
;~ - ~ a .r-
~ `" rt ;--; ~.-
~; C ,., ~ x
~ N ~ •-'
.~ ~. ~
.,
NAME OF DECEDENT (First, Middle, Last) SEX SOCIAL SECURITY NUMBER DATE OF DEATH (Month, Day, Year)
231 -56 -6606 /22/2005
female 3
~ ,
2•
AGE (Last Birthday) UND DE 1 ATE OF BIRTH BIRTHPLACE (City and P F D T he k on n - 'n 'ons n th r '
Months Days Hours Minutes ( th, ay Year) State or Foreign Country)
G 1 ~
~ HOSPITAL: OTHER:
NeM ^ DOA ^ NursMg Olher
Inpellenl ^ ERIOuI
F' a r my i 11 e , V A
V 1 Yrs
g ( _ ^
pe
,~~, ^ Residence (Spedry)
.
7
IS. 6a
' COUNTY OF DEATH CITY, BORO, TWP OF DEATH FACILITY NAME (1f not institution, give street and number) WA•5,.,~EGEDENT OF HISPANIC ORIGIN?
N Yes ~ If yes, speciry Cuban, RACE - rfcan Indian, Black, White, et .
(Specify
•
Cumberland Hampden 3924 Brookridge Dr. M tcan,Pue Ricen,etc. w lte
Bb. 8e. 8d. 10.
DECEDENTS USUAL OCCUPATION KIND OF BUSINESS /INDUSTRY AS DECEDENT EVER IN DECEDENTS EDUCATION
leted
hi hest rye com
al
S
+N MARITAL STATUS -Married,
Widowed
Never Married SURVIVING SPOUSE
(If wife, give maiden name)
(Glue kind d work done duri~~ttqq moat
or workMq li(e; do not uee re[ired) U.S. ARMED FS?
Yes^ No y o
ps
y
(
Ebmentary/Secondery
(a,z, p
Cdlege
r-~or5., ,
,
DlVOrced ( pacify)
we
id
~
„a. accountant boat sales
„b. 12. 312
1 4 ~r
o
+ • 15•
DECEDENTS MAILING ADDRESS {Street, CltylTown, State, Zip Code) ACTUAL NTS 17a. State P e n ri Sy 1 y a ri 1 a Did 17e. ~1'es, decedent lived in H a Bl~ r9 a n twP•
•
3924 Brookridge Dr . RESIDENCE decedent
uveina
,6. Mechanicsbur , PA17050 (See instructions C U L~ ~ a r 1 u i1 , township? 17d. ^ Wl~h nea~ al limits of ~tY/b~o~
on other side) ,7b. County
FATHER'S NAME (First, Middle, Last) MOTHER'S NAME (First, Middle, Maiden Surname)
,6. David E. Hol:r,es ,s. Estelle Parker
INFORMANTS NAME (Type/Print) INFORMANTS MAILING ADDRESS (Street, CitylTown, State, Zip Code)
FL 32225
Jacksonv111e
Dr
i
zoa. Nancy Hall ,
.,
lmore
2ob.315 F
METHOD OF DISPOS ION DATE OF DISPOSITION PLACE OF DISPOSITION- Name of Cemetery, Crematory LOCATION - City/Town, State, Zip Code
•
Donation ^ Burie Cremation ~temoval from State ^
^ (Month, Day, veer) or Other Place
Cem.
el Ch
bours Cha
N C 2 7 5 2 4
gur Oaks,
F
Otner(speciry) z,b. 5 .
p
~~ar ~
~ S TURF OF FUNE SERVICE LICENSEE OR PERSON ACTING AS SUCH LICENSE NUMBER NAME AND ADDRESS OF FACILITY T,~m O ~~e P ~ 1 ~0 4 3
ft
1
2zb. -013163-L ~~ mr
e ve.
Ma~sselman FH&CS,
ate items a only when certifying To the best of knowledge, death occurred at th time, date and place stated. LICENSE NUMBER DATE SIGNED
(Month, Day, Year)
physician is not available at time of death to
' (Signature d tie) ~
// ~
~~ ,~~f
•
~~
~
certify cause of death. 23a. _ ~ ~ 23b.
" 23c.
'
t/" `
Items 24-28 must be completed by TIME OF DEATH DATE P ONOUNCED DEAD (Month, Day, Year) WAS CASE REFERRED TO A MEDI AL EXAMINER /CO HER?
person who pronounces death.
~ r _ 26. Yes ^ No ~i
~`
~ ~~ ~ ~ M
25
,
.
.
24.
• 27. PART L' Enlsr the dlasuss, In)urin or eompllcations which caused the death. Do not snhr the mod. of dy q, weh ss csrdl or rasplrstory artast, shock or heart tallun• ~ Approximate PART fl: Other significant conditions contributing to death, but
ive
in PART I
l
i
s
th
d
ti
i
.
y
ng cau
e g
n
e un
er
ng
n
List only ons cause on each Ilns. ~ interval between not resu
onset and death
IMMEDIATE CAUSE (Final II r
disease or conditlon a S ~ ` t 1 ~ L.-..~{.~,,~ ~y~ ~
resulting in death) --~ DUE TO (OR AS A CONSEQUENCE OF): ~
Sequentially list conditions b•
' if any, leading to immediate OUE TO (OR AS A CONSEQUENCE OF,: ~
cause. Enter UNDERLYING ~
CAUSE (Disease or injury DUE TO (OR AS A CONSEQUENCE OF): r
' that initiated events ;
resulting on death) LAST d.
WAS AN AUTOPSY WERE AUTOPSY FINDINGS MANNER OF DEATH DATE OF INJURY TIME OF INJURY INJURY AT WORK? DESCRIBE HOW INJURY OCCURRED.
PERFORMED? AVAILABLE PRIOR TO
OF
AUSE
icid
l ~ H
^
N (Monet, Oay, veer)
COMPLETION
C
OF DEATH? om
e
atura Yes ^ No ^
Accident ^ Pending Investigation ^
30a. 30b. M• 30c. 30d.
Yes ^ No Yes ^ No ^ Suicide ^ Could not be determined ^ PLACE OF INJURY - At home, farm, street, factory, office LOCATION (Street, City/Town, State)
28a.
28b.
29. building, elc. (Specify)
30a.
30f.
CERTIFIER (Chad! onry one) SIGNATURE AND TITLE F CERTIFIER
'CfERTIFYiNG PHYSICIAN (Physician certifying cause of death when another physidan has ppronounced death and completed item 23)
othet»stofmyknowiedge,deathaecurredduetothecauses(s)andmannerasatated.• ...............................•••••••••••••••••••••••••••••••• n _ , / ~y
a^"c--~.. ~~-~t~..~._-
LICENSE N MBER DATE SIGNED (Month, Day, Year)
'PRONOUNCING AND CERTIFYING PHYSICIAN (physidan both pronouncing death and certifying to cause of death)
To the twst of my knowledge, death occurred at the time, date, and place, and due to the eausea(a) and manner as stated. • • • • • • • • • • • • • • • • • • • • • ^ ~t~
3, c. ~ vt ~ 7 3 31d. " aZ OZ.~~ tr
'MEDICAL F_XAMINERICORONER NAME AND ADDRESS OF PERSON WHO OMPLETED CAUSE OF DF{~TH
~,,.- _ ~~ ,,,,.~ ~~ eft.()
(Item 27) Type or Print
~
"
On the basis of examination and/or investigation, In my opinion, death occurred at the time, date, and place, and due to the causes(a) and
' ~ ~
_~~
'y~F-C!a-•
manner as stated ............................
31 a.
32. ~•i yj 0. ~~ O / /
REGISTRAR'S SIGNATURE A~ BER
~ ' DATE FILED (Month, Day, Year) fir,
~ ..
~ ~ 3 t~d
3a
33
.
- v