HomeMy WebLinkAbout04-24-12Z;\Est\MIS\McAfoos.Carol - AFFIDAVIT.wpd
IN RE: ESTA'~:E OF CAROL DIANE McAFOOS
LATE OF MECHANICSBUPENBORLVANIA
CUMBERLAND COUNTY,
IN THE COURT OFPEONSOyLVANIAS
: OF CUMBERLAND,
: FILE NO. 21-12-0323
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA SS:
COUNTY OF CUMBERLAND '
of Stone LaFaver & Shekletski, attorneys for the
David H. Stone, duly sworn hereby certify as follows:
I' being
above-captioned estate, 6, 2012.
1, The decedent, Carol Diane McAfoos died on January
ivovarnik filed a petition for Letters of Administration
2. Emily P the Cumberland County
Emil Pivovarnik was appointed
for the Estate °f C MarchDl9ne 2012 foos w 2 Re ister of Wi11s
Register of Wills on the Cumberland County g
Administratri-2012 the Estate by
on March 19,
social security number shown on the death certificateabyd
3, The was listed incorrectly
Myers-Buhrig Funeral Home and Crematory
the social security number listed on the Petition for Letters
therefore The correct social security number of Carol Diane
was also incorrect. A corrected death certificate showing
McAfoos shoud1b e ber is being filed concurrently with this
the proper soc
affidavit.
Subscribed a:~~d sworn to by
-~ ^~~~\ ~-S'~a~-~- i'1~'~` day of
before me th;.s 2012.
(~P<,\ '
o y P lic
COMMONWEALTH OF PENNSYLVANIA
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H705.905 REV.(4/; 1?
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 with
the Vital Statistics Law of 1953, as amended.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
6725671
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Marina O'Reilly Matthew
State Registrar
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Types/Print In COMMONWEALTH OF PEN NSV LVANIA ~ DEPARTMENT OF HEALTH ~ VITAL RECORDS OOI~ O
Permanent rFRT~F~C4TE OF DEATH /{
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1. Decedent's Legal Name. (First, Middle, Last, Suffix] 2. Sex 3. Social Security Number Date of Death (MO/Des~wr) (S ell M )
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6a. Age-Last Birthtlay (Vrs) Sb. Under 1 Year Sc. Untler 1 Da 6. Date of Birth (MO/Day/Year) (Spell Month) ]a. B hplace (City andL6 o Foreign C ntry)
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]b. Birthplace (County) .]
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8a. Residence (State or Foreign Country) clude Apt No.)
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Sb. Residence (Street and Numbe 8c. Did Decedent Live in a Township?
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loD3 ~ . K~ 1 to r J l 1 {~Q~ QYes, decetlent Ilvad in wP
ed. Residence (County^) 11--
1 7 O 5 S No, decetlent lived within limits of (~s i!~ u r city/born.
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9. Ever in US mad Forces? 10. Mar e)
Ba. Residence (Zip Co
ital Status at Ti~mf of Death Q Married Q Widowed 11. Surviving Spouse's Name (If wife, give name prior to first marriage)
Q Yes ~NO Q Unknown j7 Di vorced RQ Never Married Q Unknown
12. Father's Name first, Mitldle, Lazt, fflx) 1
~ 13. Mother's Name Prior to First Marriage (FirsT, Middle Last)
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14a. Informant's Name ~ 14b. Relationship to Decedent 14c. Informant's Malltng A9~ ss (Street and Number Ciry, Stare, Zip Codel
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W ace o Death C one .. -~-"-"-~- - - ~'-.... ... ... ... .. ...".".-- -~~ -""""-- ......... .....
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If Death Occurred In a Hospital: ~ Inpatient ~If Death Occurred Somewhere Other Than a Hospital: t~ Hospice Faci hty ~] Decedent's Home
Q Emergency Room/Outpatient Q Dead on ArrNal _ Q Nursing Home/Long-Term Cara Facility O other (Specify)
S6b. F cllity Name (If not Institution,~slva street and number;
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' 15c. City. or TOW n, State, snd Zip Code 16tl. County of Death
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S6a. Method of Disposition ~ Burial Cremation -
16b. Date of Pisposition 16c. Place of Disposition (Name of cem/el tery(, crematory, or other placeJ)-~,
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Q Removal from State Q Donation
other (opacity) I /, ~ /
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I6d. Location of Disposition ICity or Town, State, and Zf )
~ 1]a. 61gna'ture of Funeral Servic Licensee or P in Cha ~e of Interment
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~ 1]b. License Number
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1]c.NameandC mpleteAddre fFUneralFaclity J r 3~ E-lVl~(f~ S-Ir~~Ll ngz~h2niesbu.r~-, PR- /~~~5
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Decedent's Education - eck the box that best describes the 19. Decedent of Hispanic Origin -Check the 20. Decedent's Race -Check ONE OR MORE races to indicate who[
18
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highest degree or level of school completed at the lime of death. box that best describes whether the decedent he Decedent consideretl himself or herself to be.
Q 8th grade or lass Is Spanish/Hispanic/Latino. Check the "No"~ White Q Korean
Q Np tlipioma, 9th - 12th grade box if Decedent is not Spanish/Hispanic/Latino- Q Black or African American Q Vletna mesa
Q High school grad ua[e or GED complet¢tl No, not Spanish/Hispanic/Latino Q American Indian or Alaska Native Q Other Asian
Q Some collage credit, but no tlegree Ves, Mexican, Mexican American, Chicano o Asian Indian Q Native Hawaiian
Associate degree (e.g. AA, AS) O Ves, Puerto Rican Q Chfnase Q Guamanian or Cha mono
Q bachelor's degree (e.g. BA, AB, BS) Q Vas, Cuban Q FIIl plnp ~ Samoan
j~ Master's degree (e.g. MA, MS, MEng, MEtl, MSW, MBA) Q Ves, other Spanish/Hispanic/Latinp Q Japanese ~ Other Pacific Islander
Q Doctorate (e.g. PhD, Ed D) o rofessipnal tl¢gr¢e (Specify) Q Other (Specify) -
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MD, DDS OVM LLB
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21. Decedent's Single Race Self-Designation -Check ONLY ONE to indicate what [he decedent considered himself or herself to be. 22a. Decedent's Usual Occupation -Indicate type of work
. DO NOT USE RETIRED.
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~, WFI[e Q Japanese Q Samoan done during
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Q Black or African American Q Korean Q Other Pacific Islander ~ T J
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American Intlian or Alaska Native ~ Vie(na mere Q Don
Q Asian Indian ~ Other Asian ~ Refused 22b. Kind of Business/Industry
Chinese Q N a Hawaiian Q Other (Specify) ~I ~f~ (~
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Q Filipino Q Guamanian or Chamorro
ITEMS 23g - 23d MUST BE f]MPLETED - 23a. Data Pronounced Dead (MO/Day r) 23b. Signature of Person Pronou nctng Death (Only when applicable) 23c. License Number
BY PERSON WHO PRONOUNCES OR
CERTIFIES DEATH
23d. Date Signetl (MO/Day/Vr) 24. Time of D
25. Was Medical Examiner or Coroner Contacted? ~ Ye No
CAUSE OF DEATH Apprpxima[e
Part I. Enter the chain of ey n --diseases, Injuries, or tom plicatlons--that directly caused the tleath. DO NOT enter terminal ey s such as cardiac a re Int rval:
26
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if necessary Onset to Death
Atld atltlitional Ilnes
DO NOT ABBREVIATE. Enter only one cause on a Iine
ng the etiolog
y
h
ow
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respiratory arrest, or ventricular fi lirillaiion without s
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IMMEDIATE CAUSE ------- ----> a.
(Final disease o ntlition Du o (o as a consequence of):
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resulting In tlea[h~ ~~ /'.Aa
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Sequentially list conditions, Due to (or as a conseq ue Y~f):
If any, leatlin
to the taus O YC w// ~I/ ~H ~ dJ ~y (,.(~ ~~
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listed on line Enter rhe
UNDERLYING CAUSE Due to (or as a consequence of):
(disease or injury that
Initiated the ey nts resultin8 d.
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Du o (o aqua nce of):
e t as a cons
in death) LAST.
j given in Part I
her i ifl but not resulting in iha and erlYing cause
Part II
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26 2]- Was an autopsy perfofinetl]
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. Q Yes No
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~71G iii~~ I ~~.~~t ~t7 ~ ~ r/ ~ 28. Were autopsy fin Inge avails ble
~. ' ~ ~" ~/~~ ~~ to plate [he cause of daathi
coO Yes r~ No
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~ 29. IP Female: 30. Did Tobacco Use Contribute to Death? 31. Manner of Death
E
g Noi pregnant within past year
~ Q Ves Q Probably
k
own
N
Q U j~ Natural [~ Hpmicitle
Q Accident Q Pending Invesilgatipn
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$' Pregnant at time of death
Q Not pregnanx, but Dregnant within 42 days of death n
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Q Q Suicide Q Could not b¢ determined
but pregnant 43 days To 1 year before death
Q Not pregnant 32. Date oP Injury (MO/Day/Vr) (Spell Month)
,
j~ Unknown iF pregnant within the past year 33. Time of injury
34. Place of Injury (e.g. home; construction site; farm; school) 35. Location of Injury (Street antl Number, City, State, Zip Cotle)
36. Injury of Work 3]. If Transpo rtatlon Injury, SpeciTy: 38. Describe How Injury Occurred:
Yes ~ Driver/Operator Q P rian
No Q Passenger Q th (Specify)
39a. Certifier (Check only one):
Q Certifyin8 Physician - To th best of led8e, tleath occurretl tlue [o the cause(s) antl manner statetl
Pronouncing !3. Certifying p a t be of my knowledge, death oc urrad ac The tune, tlate, and place, and due co the c se(c) and manner stated
h e
the time, date, and place, antl tlue co t
retl
Q Medical Examiner/Cprpn¢r he b cis q~e aminailon, and/or Invesilgatipn, In my opinion, death ~~
( ) d ~{ 2~(afed
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Signature of certlPisr: 1 ~~~~ Tltl¢ of certifier: ~/
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39 a Atltlres n~2lp Cotle of Par n ComDle n Ca of Death (Item 2 Da Signed (Mp/Day
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40. Registrar's District Number 41. gi nature ~ / 42. Re tray File D Day r)
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43. Amentlments
REV GJ/2011