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HomeMy WebLinkAbout09-02-111505610101 ` ~" OFFICE E ONLY REV-1500 Exfp1-1e)~ File Number Pennsylvania County Code Year ~ ~ ~,~ PA Department of Revenue , A. E E E ~ ~ ~ ('~, Bureau of Individual Taxes INHERITANCE TAX RETURN ~„/ PO BOX 280601 RESIDENT DECEDENT ~ I _. Harrisburg, PA 1'7128-0601 MMDDYYl'Y ENTER DECEDENT INFORMATION BELOD to of Death MMDDYYYY Date of Birth Social Security~Number ~O ~ ~ o ~ o /_ O ~ ~ ~ `3 ~1;~ ~J MI ~+~ ~ ~~ ~ ~ ~ ~, `"1 Suffix Decedent's First Name Decedent's Last Name ~ ~ ~ S ' MI ~~~ ~5 (If App ~ Souse's Information Below Suffix Spouse's First Name licable) Enter Survrving p Spouse's Last Name se's Social Security Number THIS RETURN MUST BE FILED IN DUPLIiATSE WITH THE sp°" REGISTER OF WIC O 3. Remainder Return (date of death FILL IN APPROPRIATE OVALS BELOW O 2 Supplemental Return prior to 12-13-82) ~ 1. Original Return 5. Federal Estate Tax Return Required O 4a. Future Interest Compromise (date of O O 4. Limited Estate death after 12-12-82) ~ g. Total Number of Safe Deposit Boxes 7. Decedent Maintained a Living Trust O of Trust) O 6. Decedent Died Testate (Attach Copy 11. Election to tax under Sec. 9113(A) (Attach Copy of Will) Credit (date of death O (Attach Sch. O) O 9. Litigation Proceeds Received O 10. Spousal Poverty between 12-31-91 and 1-1-95) ~- SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL T~TION SHOULD BE DIRECTED T _ Daytime Telephone Number CORRESPONDENT THIS / Lff~n, ~~ i ~ ~ ~ ~~ / ) ~ ~ ~~ Name ~ ~Gwv ` ~ ` `"'~.. REGISTER _ ~yILLS USEtONLY ~~~1 i ~7 E"'- ,-, -r _ ~; -_;y ,_, ._,.1 - :: 7 ..}.} .. ~ - . First line ofeaddress j~ ~ ~~ ~ ~ ~ ~... ~.: " __-. ;-, ~~ ~ cs Second line of address MATE FILED City or Post Office ~P~~ 1 v~ State ZIP Code ~~l ~~°~~ ~ ~ E S ~I I~ ~ ~ ~ `y vv - ~ st of m ge and belief, Correspondent's a-mail address: in schedules and statements ana ~~ ~~ re arer has any knowledge. 1 declare that I have examined this return, including accompany 9 Under penalties of perjury, ersonal representative is based on all information of~ P p DATE lete. Declaration of preparer other than the p -- it is true, correct and comp SPONSI E FOR FILING RETURN _~~„~~, SIG TU E OF PERSON,F~ ` ---r~_~,_.._.~ .,. occc s/liJ~ __ -_'~"~.~..-~. DATE .~~in-ri ~RF OF PREPARER OTHER THAN REPRESENTATIVE 1505610101 Side 1 1505610101 _J REV-1500 EX 1505610105 Decedent's Name: Decode it's Social Security Number __~_ RECAPITULATION - - "..._ - __- ~ C~ ~.__.__ _ 3 ~ ~- 1. Real Estate (Schedule A).. .... ............ 2. Stocks and Bonds (Schedule B) .. , . • • 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... , 3 4. Mortgages and Notes Receivable (Schedule D) ... ~ .................... 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).. 4 5. • /~ 5. Jointly Owned property (Schedule F ~ ~" ~ • 6 l! 7. Inter-Vivos Transfers & Miscellaneous Noon-Proba±rate Billing Requested ..... . fSchedu!e G) e Propert 6. ~ Separate BiAing Requested........ 7. • 6. Total Gross Assets {total Lines 1 through ~.~ • ~. _. -----------~_ __~_u__.._ _._ _._.._ 8. ___ __ 9. Funeral Expenses and Administrative Costs tSCti ___. edu!e M • 10. Debts of Decedent, Mortgage Li;abiGties. and Liens (Schedule I) 9. ~~~, 11 Tatai Deductions {total Lines 9 and 1pj 10 11 12. Net Value of Estate (Line 8 minus i_ine 11) _ 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 1 ~ • ~~ ~ ~ , l an election to tax has not been made (Schedule ,1) . _ V 13 ~4. Net Value Subject to Tax {Line 12 minus Line 131 , 14. TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES ~ ~ ~ ' ~ V 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X 0 _ 16. Amount of Line 14 taxable ' 15. at lineal rate X .0 __ ~ 17. Amount of Line 14 taxable • 16. at sibling rate X .12 18. Amount of Line 14 taxable ' 17. at collateral rate X .15 18. 19. TAX DUE ...... ~ 3 ~• ... 19. q 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~~O • L ~~ 0 ~.~..., 1505610105 Side 2 150561010 X Page 3 File Number ent's Complete Address: __ ! I NAMlt .DDRES ,..~` ~.~no~1-Cl ~~ ~~ _yments and Credits: sue (Page 2, Line 19) is/Payments or Payments :count 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. Total Credits (A + B) (2) (3) (4) (5) (1) Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Ditl decedent make a transfer and: Yes No a. retain the use or income of the property transferred :........................................................................................ ^ b. retain the right to designate who shall use the property transferred or its income : ............................................ ^ c. retain a reversionary interest; or ......................................................................................................................... ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ............................................................................................................. ^ 3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? .............. ^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ........................................................................................................................ ^ ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. ~f death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 72 P.S. §9116 (a) (1.1) (i)]. of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent :116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and return are still applicable even if the surviving spouse is the only beneficiary. ~f death on or after July 1, 2000: x rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an ~e parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)]. :x rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in . §9116(1.2) [72 P.S. §9116(a)(1)]. x rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under i 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. STATE i ZIP m 0 N N r O O 0 w r w O N r• rE O r r. -v v~ a Zoo . c3o ~ m ~ o ' o o ~ .~ 0 2 o '' y _ ~ ~z ~ ~~ rn gO~cmpOy ~ ~ ~7_7'p~9y~ O c9~~o= r ~~9~ZO y ~mcno~c~ T' ~ C Z opt pN ~ v N y .< m G y m y S 9 9 ~; o ~ wyZ w Z '~ O T T_ C7 m ~. -. '.~ ~. ~, ~` {~ 5 ~ d,~ "'. ~ w . " '"' ~ * C ~, ~ G ,t y ~ O „ ~. ° ~ ~ ~ °~ o ~* .: 3 f a j N N Oeta4ls a on back. 1ea Wte . a S~ ""~ } N' 0~ N ~~ 77 CU~'1MUNWEALTH OF PENNSYL~/gNIA OFFICE OF ATTORNEY GENERAL July 12, 2011 Doris Ann Riley 3 Santa Maria Avenue Camp Hill, PA 17011 Re: Aspen Dental; FILE NO. HCS-09-OS-002883 near Consumer: Health Care Section 14~' Floor, Strawberry Square Harrisburg, Pennsylvania 17120 Telephone: 717.705.693 8 Facsimile: 717.787.1190 The Public Protection Division - of Attorney General has reached a settle enttwith AspenlDentPleased to inform as Aspen Dental ("Aspen") that allows for the you that the Office eligible claims. To determine eligibility for restituti al Management, Inc., doing business Payment of partial restitution to consumers with and considered: the nature of your complaint; the date of o on, our office carefully reviewed your complaint purchase; the amount of any discounts you received; the a our purchase; the amount of your through another source, if an y; and, the amount of your refund request previously reimbursed to you Enclosed with this letter please find a restitution check that monies you paid for Aspen products or services. We are aware th full amount of your refund request, but due to the large number Pr°vides a partial refund of the limited amount of funds available, our office distribut at you may not have received the among consumers with eligible claims. of consumers requesting refunds and ed restitution funds as evenly as possible Please note that, regardless of this restitution a a private legal action. You ma P Yment, you may have the right to brie this time as the Attorne y w>;sh to contact an attorney to determine your legal options at representation. y General s Office cannot provide you with individual private legal attention. "~' r:e-"-e*al Li::da r . ICPiI., hgn~ ~ s t ynr! fnr hrino' ~tno this rrlaffer to our Very truly yours, Enc: /~,(jy~'LCt.Q ~, ~ D(~{/ Thomas M. Devlin Chief Deputy Attorney General ' REV i5o8 EX+ I,ii-io) ~ Pennsylvania pEpgRTMENT OF REVENUE INHERITANCE TAX RETURN ____~ rc~CNT SCNEDt~LE E CASH, BANK DEPOSITS & MISC. PERSONAL PROPERTY ESTATE OF: FILE NUMBER: Include theopr~1Y ow~~~W~h ~9httof uarvivorsh p must be d uifosed onhSchedule F. All property j --------'-'- VALUE AT DATE Of DEATH ITEM DESCRIPTION ____-____.---------- ~-~~~ UMBER ` ~~~ ~~ ~( ~ 5~ ~~ TOTAL (Also enter on Line 5, Recapitulation) $ ~ V E If more space is needed, use additions paper of the same size. IN THE COURT OF COMMON PLEAS O REGISTER OF BE)(~AND COUNTY, pENNSYLVA PETITION FOR p ~'~'ILLS NIA Estate of ~ '_ ROBATE AND GRANT OF LETTERS a/k/a: ~ f' ~ ~.~ a/k/a; _~ Deceased ESTATE a/k/ NO: 21- ~~ - ( ~C a: ~- Petitioner(s) who is/are 18 SS NO; a t~~ ~ ~ ~ / aApiicable: yrs of age or older ~"- ~A• Probate and ' apply(1eS) for: COMPLETE SECTION ~A~ or ~g~ AND « » and aver that Petitioner(s) ~S m-etenht]ed oa hentar the last Will of the above- Y orpAdmtnistration c.t.a. C as e aforementioned Letters ~' or d.b.n.c.t.a. named Decedent, dated (~Omplete Part C ___ also) ------ -__ and codicils .:::-under Odated ~--: CJ ___ -, Except as follows ~- ~~- (State relevant circumstances, e, ~ T,E~> ' instruments offeredlforedent did not to g renunciation, death of executor, eta .`~ mTY, was not divorced -' rT~ t Party to a Probate; was not the victim of a killin' and did not have a child born or adopted after. ^' ~ pending divorce '_' ` x ~`~' 23 Pa, proceedin g, was never adjudicated an Inca C.S.A• § 3323 gat the time of death wherein grounds for divorce had f~~~°n o#~e (g)' pacitated persmnd was abt a . ~ B• Grant of been est~ ed as d`efi'ned in,,~ , Letters of 'T' Administration C~ ~, C. Petitioners (1f aPPlicable, enter d.b.n., pendent lite, durante absentia, dur ( ), after a proper search, following spouse (if an has/have ascertained that Decedent left no Wi]I and ~, ante minorirare) heirs • Y) and heirs (If Administration c.t.a. or d.b.n.c.t.a., ), was not the victim of a killing; vvas never adjudicated an in proceeding wherein grounds for divorce had been established a as survived by the enter date of Will in Section A and complete list of capacitated person; and was not a paM Name s Provided in 23 Pa. C'.S.A• § 3323(8) ex ept asdfolglows~rce ,~ -~ / e.~., r --- •~ ~eceaent t } v' 2r TNIS SECTION ...mac"`CRY Decedent was dom cs dBat deoth Pn CumD• At ~ ~~~ =h t~ ~ ~ --.-~..~y, rennsylv~nia, wi h (Street address with Post Office and Zi ~./' ~ his/her last famil Decedent, then ~ P Code, Munici a ; ~ Y or Principal residence years of P ty TO~ship, Borou h age, died ~7 aO~j ~g 'city) Estimated value of decedent's at L-Q ' _If domiciled in PA prOpenY at death: (Month, Day, eaz of death) ~ _If not domiciled in Pq (C'ty an State where death occurred) _If not domiciled in Pq All Personal property _Value of Rea] Estate in Pennsylvania Personal property in pennsylvania $ Personal property in County $ _ $ _---~- Location ofReal Estate in Pennsylvania: $ -~- Total Estimated Value $ • _ (Provide full address if possible.) Signature(s) ',~~ C.~ Name(s) & Mailin g Address(es) orm RW_02 revised 12.26.10 b / 1~/ t (7 y Cumberland County pending action b y the Court Page 1 of REV~1511 EXr (10-09) ~ Pennsylvania OEPAR7MENT OF REVENUE INHERITANCE TAX RETURN cFCrOENT DECEDENT ESTATE OF SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS Decedent's debts must be reported on Schedule I. FILE NUMBER ITEM DESCKIH i Iviv ------------ NUMBER q, FUNERAL EXPENSES: i. ~ , d~ ~' ~ o ~v ,acs l 5 ~ ~In,v ~-~ S [Q ~ ~ ~ B, ADMINISTRATIVE COSTS: 1, Personal Representative Commissions: /~ ILA -~ ,.' _ .~ ~ ~_r.,, ..~~-~------------ _-_- Name(s) of Personal Representative(s) __ Street Address __~~ G3-..~1~~~~--~ "-- / ---- State .~~ ZIP ___~~ ~-~ ~--- _ _-.. _._ ..- ----- __ ___. Years} Commission Pai : __ ____ ___.-_ _ --- - -- Z, , Attorney fees: 3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address --____- --------------------------- --- ----------- - State _-- _ ZIP -_-_-___ .__ __- - - -- City .__ -___- ------------------ - - ---------- - ---_--- Relationship of Claimant to Dece en ____-- ________ 4, Probate Fees: ~ S~ ` L~ 5, Accountant fees: J 6. Tax Return Preparer Fees: i c~.~ .~~ I..e :~~..Q l S :"`~ ~ d ~ ` ~~ V+ O ~~'~v ~ ~ °~a TOTAL (Also ine 9, Recapitulation) $ ~ ~~` ~~ If more space is needed, use additional sheets of paper or the same s~~c. REV-1513 EX+ (01-10) ~ pennsylvania pEPARTMENT OF REVENUE 1NHER]TANCE TAX RETURN .. uT nr-~'FDENT ~- ESTATE OF: SCHEDULE ~ BENEFICIARIES tj r'1 - r REIgTI0N5ttir Do Not list NUMBER NAME AND ADDRESS OF PERSON(S) RECEMNG PROPERTY I TAXABLE DISTRIBUTIONS [1ncluSec. 9116t(a) (152).]~y~ributions and transfers under ~ ~--~(1 ~~ ~ ~ ` `'Z ~ ~~ v ~~ G~ ~~ r ~ / , ~:L~ ~ S ~ ~` G~ -~ ~ , c. ~ ct (~ L.. ut, FILE NUMBER: AMOUNT OR SHARE OF ESTATE 5~~d ~ G ~° LLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE' ENTER DO II NON TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAK 1. B, CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II -ENTER TOTAL NON TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-150~ ~R SHEET. ~ if more space is needed, use additional sheets of Fa'er of the same size. I,ewisgals3@aol.com, 8/22/112:41 PM -0400, renounce administratorship 2 ~ Q ~ ;~, ,~ - - -~, .~TC~ _"~ - -; } °~~~~ -,, 1tE~h~C1.aT1U~ ~~~_ - .- v ~ ~ . --r, ~_~.,~,~,, Cllt~1~1~F;R OF still l f ,rata +~t _-__ _,... ~ d.~ F ~ _.-.~"`.~~~.1 ~._~._ ___._...__ .._.._ _ _..__._.___. ___-.. 1 tJY-t~t~ ~I ~eU ~ttm~. ~a~a.ttt tcixl+~~r~rhi~;tt ~+WV ~ ~~ ~ ++~ IhC +1 k'M ~tC k)l't C.~s 1'1. hCrC1~V (t"I+~I+r+C tliC rt}llt (,4 ;1.1nu•+~tict the F state ~~f tl`~c l)cicdrr~t ~¢1itt rti,;~e~tlullti rc,d,tc•+t th.~s l iutr+ ht t•.t~~r+1 t.• ,. °l~ ~~~~ ~ 3~ Zvi ~ ,, ,~::., ~svc.~~~_~,~~~c.~ , x« klr,l ~n Rr~;litri'+ II/Jive' tiu~~rt~ t;, fittr ~ su -.~r+t•+c~9 ,! U~put~ 4+~r Rcgi,tcr vt N tf.~. °$22 d~gCh2d Cel~l~ert w i M . + . ~ i renoun<:e.pdf F;1ei ultJaul ~,,~/teg;l~lrr'w tl//k. liet~,tr titr urz,l.ni~nr.1 lar'w+nall~, aj~j+earctl the hen. r~r~utintt tht~: rCtllrflG1.61t+Ki arltl tCrt111C~.1 thrt h~r ++r ~he c.e.+ttrJ tl'ic rrtr+~n:~;att~+n t.+r th~s purl'+t,sc, ~rutc.i w,thin ++n th~~ ___..___.____..,_.._ ~•+~ ++t _ _. '~1~ t'«~mrnu~i+~r7 l Bpi.*c~. Sv LY Pe ,~ J ! ~„ i T .'S. fJ. r+lYt 4's a + t e ,_ !.L^~ i T.. 'r e. r. i Printed for Brandy Riley <br.summer@cox.neb ^^^w~~ •~~^TLJ eeelel-IT cTeTEMENT GOYERNMENTCODE§8202 See Attached Document (Notary to cross out lines 1-6 below) ~-i See Statement Below (Lines 1-6 to be completed only by document signer[s], not Notary) .-- Signature of Document Signer No. 1 State of California County of~~ /t~C^ ~ Signature o" Document Signer No. 2 (If any) Subscribed and sworn to (or afficrx~ed) before me on this.~<~27day of I,}VT z, 201~~ Date Month Year by Name of Signer proved to me on the basis of satisfactory evidence to be the person who appeared before me (.) (,) (and .-, - WAITER E. PUESCHEL Commissfon # 1795955 . -m Notary Public - California ~ = San Diego County M Comm. F, Tres Jul 9, 2012 Place Notary Seal Above OPTIONAL Though the information below is not required by law, it may prove valuable Top of thumb here Top of thumb here to persons relying on the document and could prevent fraudulent removal and reattachment of this form to another document. ~_:~ -: ~'. Further Description of Any Attached Document f. Title or Type of Document: /:`,y. Document Date: ~ J ~ ~ ~ ~ t / Number of Pages: Signer(s) Other Than Named Above: _ / " . rev i, onn o~G_CR77\ Item #591C Name of Signer proved to me on the basis of satisfactory evidence to be the person who appeared before me.) Signature ~" - Signature of ary Public © 2010 National Notary Association • rvanonairvura~y.~~y - ~-~~~ ~~ ~^ OATH OF PERSONAI. 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 the Decedent, Petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed and subscribed ,~ before me this { t ~ `~~ day of _1 r, .~" t ~( ~~~ , ~ - ~ .. ~ t For the Register Estate of .L p t ~ c- ~ p~ ,Deceased File Number: 21-~- I ~_.l ~ AND NOW, this day of the reverse side hereon, satisfactory proof Testamentary of Administration 3 ~, r av ~ been pr sent (IC applicable, enter c.t.a., d.b.n., d.b.n.c.t.a., etc.) the above estate and that instruments(s) dated described in the petition be admitted to probate and filed of record as the last Will and Codicil(s) of Dec;edent. ln. lenda Farner Strasbaugkt,.~~ -~~~ ir'; ~ ~, )~`E. ~,,--~~'- Register of Wills FEES: ~, .~: ',( Letters ....................$ Will ........................ Codicil(s) ................. (-~~) Short Certificates i-~ ~ ~ ., -- ~~ ( )Renunciations....... ""l •~,-~ Bond ............................. Other ............................. ................. Automation FEE......... 5.00 JCS FEE ................... 23.50 TOTAL ................ $ Ct' t~ . ~'~-~ ~~ n a, Pnr ~~ .~ ~ n %l - e.uc`o .-- r-T ~ ; ~' - r-- > `"~ -~ `_ _ ;~`+ ~ -a ~ .~ ~ ; -T~ c. ~-, --~, DECREE OF PROBATE AND GRANT OF LETTERS Signature of Counsel Required to Enter Appearance Atty's Signature _ PRINTED Name: _ Supreme Court ID No.: Address: Phone: Fax: r ~ , in consideration of the Petition on before me, IT IS DECREED that Letters are hereby granted to: hiterim Form RW-02 revised 12.26.10 by Cumberland County pending action by the Court Page 2 of 2 111.9115 RF.\'.ilrl ll This is to certify that this 'is a true copy of the record which is on file in the Pennsylvania Department of Health, in accordance wit`T the Vital Statistics Law of 1953, as amended. WARNING: It is illegal to duplicate this copy by photosi:at or photograph. -~, r-i~- ~~~ ~;~~ Q Marina O'Reilly Matthew +-- ~: t~ -- ~ ~ Acting State Registrar ~- ~~ '_~ _ ~9~N 2,5 211 ,~~ . `~ ;180 e` Date - e ~ .--r-~- Ci_ ;--; Y~ r_ r]= L'G C.> H1os-143 REV ttrzoos COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS p89192 TYPE I PRINT ~, CERTIFICATE OF DEATH P~IMANENT (See instructions and examples On reverse) STATE FlLE NUMBER BLACK INK 4. Date of DeaN jManth, day, year, p ~ 3. Sadal Security Nurtbe'r 7 22 1. Name of Decedem (I~~st, coddle. IasL sufhx) - p(~ ~L.~ ~~ l 7. Bldh lace C' aM state er fore n coon be. Place of DeaN Cherie o one Under 1 er Under 1 da fi. ate d BiM tAmN, da , ar Hospital: Other. 5. Age (last Bidhday) Hwrs _ 1 /y Mamhs Days Minaes ~ 16v1 ^ Residence Other ~ SpedlY `,{I ~ L. ~. I (~ ~O ~ Irrpary'em ^ ER r Outpatient ^ DOA ^ Nursing Home 1g. Race: American Indian, BWck, Whhe, etc. Yrs c.J I 9. Was Denedant of Hispania Origin? ~ No ^ Yes (S • Bc. C'ay, Boro, Twp. of Death Bd. Facility Name (g not mstikNon, give skeet and number) • (It yes, spautity Cuban, • ' gb. County of Death ~ Mezicen, Puedo Rican, etc.) 14. Marital Btatus: Martied, Never Marred, 15. Surviving Spouse (k wge, give maiden name) Widowed, DNorcad (Spedh) 1'~um ~ ~'~~ ° 1t.Decedem'sUsual fionKindotworkdonedud moslof dti I'ne.Donotstaterekre 12.USSA Forces?r Ne 1Elemen~rylSec ryj(0-12) cely~College(1dor5+) ~V Cad ~ !1 IGrd of Wo Ki f Businesslyndustry ~'I C ^ Yes No Did Decedent OecetlenYs A Live in a 17c ^ Yes, Decedent Lived in Twp. • 16, Deces~Ys Maigng ss (r t, city I town, stale, zip codel gcWyl Residence tie. State \ _ I Township? 3 ~ 1 P( ~V~~ ~ e- (~ I I M ~ P C li 1 (1 /i 17d ~Na, Decedent Lived within 1 ) Cityl Boro \~ (~ 17h. County Actual Limits of ~; • 1 111 ~ O 19. MoNeYs Name (Post middle, maiden surname) 18, Fathers Name (First m rile, last, suffix) Li ~, ~ I 2Db. InfomanYs Maikng Address (Street ciy f tenon, slate, np code) r .t 1 a ,L`1 20a. Inhmp~('s Name Rype I Pdnf) 2 ~~1~ ,^ ~ ~, 11 (`J 1C ~~W'IS J 21d.L ~on (Ciryltawn, state,zry coda) y~ „ 21h. Date of Disposition (Monet, daY, Year) 21c. Place of Disposition (Name of cemetery, cmmatory or other place) 21 a. Method of D~~sposflion i ^ Cremation ovation n ~ ~ ~ ~' ~I~Il ' ^ r~oo~ JI.•11• S o ^ Burial ya Removal Irom Slate i bV°~droal tbxam nerlCoroner~on~ Yes No J' ~ 1 w • ^ Other- ~ ~ dY ~L.1 , 1 ~`~`^~ ' ~' ~ 22h. License Number 22c. Name and Address of Fadt a : ~ nature of Funeral Service Ucensee (ape ac'n as su h) ^ ~_ C 12`06 _` ~ 1 ~ ~'~ < - _ 01 23h. license Num r 23c. Date Bigned jMonlh, day, year) Complete items 23a-c only en certih/irrg 23a. To the best my knowledge, death~loocerred al the time, date and place staled (SignaWre end kbe) ^ ,yx ~~~ ~^~ ~ [~ ~ O . physidan is not availahle at time of death to I i ,, f , , ~ 1 w /6 '(V`V~ o~ C/ 1 cerkh/ cause of death. ~ ^- 1,L1 V~^ Y/ K^ 26. as Case Retened to Medical Examirrer I Cororrer for a Reason 0 her than Cremation or Donation? 24. Time of D Ih 25. Data Pronounced Dead Month, day, year) yeS ^ No Items 2426 must be rmmpleted by person ` ~p ~ r~ hG C who prorwuntxs deaN. n I "^ d r Approximate rolarvaP. Pad II: Enter other Syni nt~ndi ion _ nW in load Ath. 28. Did Tobacco Use ConlnLute to DeaN? CAUSE DF DEATH (See ~nstructlons and examples r Onset to Death but tint resulting in Ne underrying cause given in Part I. ^ Yes ^ Pmbabty r ^ No ^ Unkrwwn Item 27. Pad C Enter the chain of ev n -diseases, injuries, or complications -that tfirecll roused Ne deaN. DO NOT enter terminal events such as cardac amesl, respiratory avast, or ventricular fibrillation wbhoul stmwing Ne etiology. List only one reuse on each line, t 29. II Female: r r ^ Nat pregnant witlun Past year IMNEOIATE CAUSE ((Fetal disease or ,~•~ L Q - condikon resuttWg in rleaNj --~ a `~ I P it I l/, 1 t~l ~ i 164'I n r T YI /r r `' ~rA~r i`$ i ^ Pregnant at tlme of deaN Due to (or as a consequence op: r _ ^ Not pregnant, but pregnant wiNin 42 days r Sequentially fist condflions, N any, h, t of deaN lea ng le cause ksled on line a. Due to (or as a ronsequence oq: i dr Ne r Emer the UNDERLYING CAUSE t _ Not pregnant but pregnant 43 days to 1 year • (disease ar inryry that mtdated Ne c r hetore deaN events resulting m deaN) LAST. r - ^ Unknown g pregnant wihin Ne past year Due to jar as a consequence oQ: r • r ~ d 32c. place of Injury: Home, Farm, Street, Factory, 'V 32a, Date of Injury (Monty, day, year) 32b. Describe Hex Injury Occurted Office Binding, etc. (Specify) ~- 30a Was an Autopsy 30h. Were AWOpsy Findings 31. Manner of DeaN Pedomted? Avanable Prior W Completion ~ Natural ^ Homidde 32g. Locetron of injury jSlreet city I town, state) of Cause of DeaN? 32d, Time of Injury 32e. Inryry at Work.? 321. II Traraporlation Injury (Speatyl r~ r~ ^ Aoabent ^ Penrkng Irrvesfigatim ^ Yes ^ No ^ Driverl0pereta ^ Passenger ^ Pedestrian ~J i L^J Yes ^ No 1_xl Yes ^ No ^ Suicide ^ Could Not be Dehm'ned M. ^ Other -Specify ~` 33b. SignaMe and 1'dle of Cedilie 4 /^~ 33a Certifier (beef Doty one) ~ ~ ~ ~ 1••'-• Ceditying physicWn (Physioan ceNlying cause of deaN when artoNer physidan has pronounced deaN and completed Item 23) ~c Lines Number 33d. Date Signed (Monty, bey Year) Ta the best of my knowkdge;deelh Donned due to the reuse(s)and manner asatated-------------------------------- ~ n ~ ~G • Pronouncing and cedltyMg physlcien (Physiaan beN gonouncing death and cedirying to cause of deaN) ~n ~~ L ~~ Z GC To the best of my knowledge, deaN occurred at the rime,date, and place, and due to the ceuae(s)end manner es slated------------------^ /•1 i w Nedleel ExaminerlCoroner end lace, end due to the cease(s) and manner as stated. ^ 34. Name and AdNess of Person Who Comoleled Cause of DeaN (gem 21) I>e not ~ On the basis of euminekon and I or Investigation, In my opinlan, death occurred et the lime, date, p v f ~ ~ w ~G / `'1 t ~ 11~~ ~ ~~ ~ ~ ~ I ~ I S I 36. Date Flied IMomh, day, year CV~rn rJ . t ~ 1 S A ~' 011 35. Register's are and Dishki Number , '") ~ l,(~ 147 Li~ Disposfkar Permit No.