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HomeMy WebLinkAbout06-12-12i ELIZABETH B. STONE, ESQ. ATTORNEY ID NO. 60251 3507 MARKET STREET, SUITE 303 CAMP HILL, PA 17011 (717)909-1500 ATTORNEY FOR PLAINTIFF IN RE: PERMANENT GUARDIANSHIP: IN THE COURT OF COMMON PLEAS OF K.Z.M. and E.B.M.M., :CUMBERLAND COUNTY, PENNSYLVANIA Minor Children ORPHANS' COURT DIVISION ,~ ~ -101 - C5-C..QI~..L r..a ~~ ~~ c__ r--, ~r-,; c~ C! ~~' PETITION FOR PERMANENT GUARDIANSHIP ~ ~ ,, - ..; r=,a NOW comes your Petitioners, by and through their attorney, Elizabeth B. Stone, Esqui~, and files this Petition with a Proposed Order for Permanent Guardianship of Minor Children, representing as follows: 1. Your Petitioners are Donna R. Weiss and Charles A. Weiss, adult individuals who have resided for the last 14 years at 18 Ardmore Circle, New Cumberland, Cumberland County, Pennsylvania 17070. 2. The Petitioners are the maternal grandmother and step-grandfather of the minor children, Kaiden Zaide Montgomery, born May 11, 2002, and Elaysia Blue Marie Montgomery, born October 23, 2003. 3. Prior to and up until February 8, 2011, the two minor subject children were living with their natural mother and father, Kimberly Marie Cox-Montgomery and David Montgomery, at 10 Lakeside Trail, Covington, Georgia, 30016-2543. Kimberly is the daughter of Petitioner, Donna Weiss. 4. On the morning of February 8, 2011, Kimberly Marie Cox-Montgomery, ~~ -~~ w / ,_-,._ ~i i% -~ ._. ~.~.~ _ ` y, '=: T -- ~ ' --x-~, ,,, n died suddenly and very unexpectedly at her home. See the Attached Certified Copy of the Georgia Death Certificate, dated February 18, 2011, marked as Exhibit #1, attached hereto, and made a part of the record herein. 5. It is averred that within hours upon being notified of their daughter's unexpected and sudden death, the Petitioners drove to Georgia to help with their grandchildren and possibly bring them back to the grandparents' home in Cumberland County, Pennsylvania. 6. It is averred that after many conversations with their son-in-law, and after seeing their son-in-law's distressed mental state, it was believed and agreed by both father and grandparents that letting the children move to Pennsylvania was in the best interests of the children. At that time, the grandparents prepared a temporary guardianship agreement that allowed the grandparents to transport the children legally up to Pennsylvania, register them into school, attend to their medical needs through regular wellness and sick visits, and travel freely with the children both in this country and outside its borders. 7. On or after February 8, 2011, the Petitioners drove down to Georgia and returned to Pennsylvania several days later with the minor children and a custodial agreement signed by the children's father and your Petitioners. At that time, it was believed by all parties that this custody arrangement would last until the Father was stable enough to parent his two minor children. See Attached Agreement, dated February 14, 2011, marked as Exhibit #2, attached hereto, and made a part of the record herein. 8. On or about February 28, 2011, your Petitioners filed a Complaint for Custody, a Petition for Emergency Relief, with a Proposed Order with the Prothonotary in the Court of Common Pleas in Cumberland County. The essence of that Complaint was that the 2 Plaintiff Grandparents believed that they needed a more legal document and thus sought to obtain a Court Order granting them physical custody and shared legal custody of their minor grandchildren to register the children into school, to schedule medical appointments and attend to any and all other health education and welfare needs. 9. On March 7, 2011, the Honorable Judge Guido signed a Court Order granting the grandparents their request for Emergency and Special Relief. See Attached Court Order dated Mazch. 7, 2011, marked as Exhibit #3, attached hereto, and made a part of the record herein. 10. On or about, March 17, 2011, the grandparents received yet another phone call giving them yet more unimaginable horrific and sad news. This time they were notified that their son-in-law, the children's biological father, David Montgomery, had also just died suddenly and unexpectedly. See the Attached Certified Copy of the Georgia Death Certificate, Copy dated October 28, 2011., marked as Exhibit #4, attached hereto, and made a part of the record herein. 11. Shortly upon the Petitioners' return to Pennsylvania with their two grandchildren in Februazy, 2012, they sought out grievance counselors for them. Over the last year and moving farwazd, the grandchildren have and will continue to receive mental health counseling through. private therapy sessions. Both children aze now playing sports and their grandson is active in Cub Scouts. Both children, according to the grandparents, have adjusted as best as can be expected to this tragedy. They have been told of both of their pazents' deaths, but not the manner in which they both died. 12. It is averred by the Petitioners that the children should now live permanently with their maternal grandparents as it is their belief that this nurturing and loving t living arrangement: is in the best interests of the minor children. 13. It is averred that the children will remain with the grandpazents at least until they each reach the age of majority. 14. Your Petitioners, the Grandpazents now are requesting and are desirous of obtaining a Court Order to make them the sole legal and physical custodians and legal guardians of the minor children. This Order will allow the Petitioners/Grandparents to attend to any medical needs, educational needs, and all other needs, including extra-cumculaz activities that the children may become involved in from time to time. Essentially, the Grandparents, your Petitioners, wish to raise their grandchildren as if they were their own, with all of the rights and privileges of parents. 15. The Petitioners have not participated as a party, witness or in any other capacity in other litigation concerning the custody of this children in this or another court. 16. The Petitioners have no information regazding any other custody proceeding concerning the children pending in a court of this Commonwealth. 17. The Petitioners do not know of a person not a party to the proceedings who has physical custody of the children or claims to have custody or visitation rights with respect to the children. 18. The Petitioners believe and therefore aver that the best interests and permanent welfare of the children require that the parties have both sole legal and physical custody of the children and ask this Court to enter an Order granting them Permanent Guardianship of the Minor Children. 4 WHEREFORE, the Petitioners respectfully request that the Court enter an order providing for the legal and physical custody of the children as stated above by granting the request of Petitioners and award permanent physical and legal custody of the minor children to the Grandparents; or, in the alternative, schedule a hearing on the matter as soon as judicially possible. Respectfully submitted, By Elizabeth B. x,#60251 et, Suite 303 7011 ~~' (717)0 Dated: ~ ~ Z- Attorne or Petitioners 5 Birth Number GEORGIA DEATH CERTIFICATE ~•un'rmr LU11liA000UU/604 1. DECEDENTS LEGAL FULL NAME (First, Middle. Last) ~ 1a. IF FEMALE, ENTER LAST NAME AT BIRTH 2. SEX '~ 2a. DATE OF DEATH (Mo., Day, Year) KIMBERLY MARIE COX COX 'FEMALE ;ACTUAL DATE OF DEATH 02(0&2011 3. SOCIAL SECURITY NUMBER 4a. AGE (YEARS) 46. UNDER t YEAR 4c. UNDER 1 DAV 5. DATE OF BIRTH (Mo.. Oay, Year) 25445-6149 30 Mos. Days Hours Mies. 07!25!1980 6. BIRTHPLACE 7a. RESIDENCE -STATE 7b. COUNTY 7c. CITY, TOWN -- - - - GEORGIA GEORGIA JASPER - _ _ ,MANSFIELD 7d. STREET AND NUMBER 7e ZIP CODE 7f INSIDE CITYLIMITS? g ARMED FORCES? 867 BAER CREEK POINT -_ _ _ - __ -_ -. __-- __ _ J30055. _I NO ~ NO --_ 8a. USUAL OCCUPATION ~ 8b. KIND OF INDUSTRY OR BUSINESS _- -- - _ ARTIST ART WORK 9. MARITAL STATUS 110. SPOUSE NAME 11. FATHER'S FULL NAME (First, Middle, Last) NEVER MARRIED _ (ALAN W COX 12. MOTHER'S MAIDEN NAME (First, Middle. Last) 13a. INFORMANTS NAME First, Middle, Last ( ) 13b. RELATIONSHIP TO DECEDENT DONNA ROSETH ALAN W COX FATHER 13c.MAILINGADDRESS -.. _-_ -._ _ -_._. -. -__.... - __. __ _._ -_. - 14. OECEDANT'SEDUCATION - - - - 867 BAER CREEK POINT, MANSFIELD, GEORGIA 30055 _ HIGH SCHOOL GRADUATE OR GED COMPLETED 15. ORIGIN OF DECEDENT ptalran, Mer..French Engrish, arc) 16. DECEDENT'S RACE (lNhrte. Black, Amer. lrxiian. etc.) (Sper.Yly) N0. NOT SPANISH/HISPANICILATINO WHITE 17a. IF DEATH OCCURRED iN HOSPITAL - ""--- - -- -- _- - --- -- - - 17b. IF DEATH OCCURRED OTHER THAN HOSPITAL (indicate DOA. OP/EMER.. Rm.. lnpat;ent) /Specify) EMERGENC'I ROOMlOUT~ATictvT 18. HOSPITAL OR OTHER INSTITUTION NAME (llnot in edher, gave street and No _- - _ - -~ -- - 19. CITY, TOWN or LOCATION OF DEATH 20. COUNTY OF DEATH NEWTON MEDICAL CENTER 5126 HOSPITAL DRIVE NE COVINGTON, GEORGIA 30014 COVINGTON NEWTON 21. METHOD OF DISPOSITION (SP~iIYI 22. PLACE OF DISPOSITION ~. 23. DISPOSITION DATE (Mo., Day, Yeah CREMATION DOGWOOD HILL CREMATORY COVINGTON, GEORGIA 30014 NEWTON 02/12/201 t - - _ _ - --- __ - _ 24a. EMBALMER'S NAME ~ 24b. EMBALMER LICENSE NO. 25. FUNERAL HOME NAME - CALDWELL AND COWAN F H INC 25a.FUNERALHOMEADORESS ----- - - - - -- -- - - -- ----- ---- COVINGTON, GEORGIA 30014 26a. SIGNATURE OF FUNERAL DIRECTOR 26b. FUN. DIR. LICENSE NQ _ /S/ JUDSON CALDWELL_ 2712 27. DATE PRONOUNCED DEAD(MO., Da .near ------- --- - - v ) 26. HOUR PRONOUNCED DEAD 02/08!2011 . 10:38 AM 29a. PRONOUNCER'S NAME 29b. LICENSE NUMBER 29c. DATE SIGNED HAI HONG TRINH 55991 102/08!2011 __ __i 30. TIME OF DEATH 31. WAS CASE REFERRED TO MEDICAL EXAMINER - - - 10:38 AM ;YES 32. Part I. Enter the chair of events-diseases. injuries, or complications that directly ceased the death. DO NOT enter terminal events such as cardiac arrest. - - reslrratory artest. a venticular fibrillaUOn without showing the etidogy. DO NOT ABBRVIATE. ApprOXlmate Interval t)Btween ODSet and death IMMEDIATE CAUSE (Final A. PENETRATING GUNSHOT WOUND OF CHEST UNKNOWN disease or condition resulting in Due to, or as a consequence of death} 8 - Due to, or as a consequence of _ - - - - - - -" -- C Due to. or as a consequence of - - _-- -- D. D'art II. Enter sgniiicanr conditions conult:uting w death Lut not reWtetl to cause given in Part 1A. (If femere, indicete iI pregnant a birth occurred within 90 days of death.) ---- 33. '..^lSS AUTOPSY FCRFORb'IED~ , 34. WERE AUTOPSY FINDINGS AVAILABLE TO 'COMPLETE THE CAUSE OF DEATH? NO 35. TOBACCO USE CONTRIBUTED TO DEATH 36.IF FEMALE NO 37. ACCIDENT, SUICIDE, HOMICIDE. UNDERTERMINED (Specfy) UNKNOWN UNKNOWN IF PREGNANT WITHIN THE PAST YEAR SUICIDE _ - _ _ - - 38. DATE OF INJURY (MO., Day, Year) ;39. TIME OF INJURY 40. PLACE OF INJURY (Nana, Farm. Street, Factory, OH~ce, Etc.) (Specify) 41. INJURY AT WORK? (Yes otNO) 02)0812011 UNKNOWN OTHER ADDRESS 42.LOCATION OF INJURY (Street Apartment Number, City or Town, Slate, Zip, County) _ NO - - - "- - -- - - -- - -- 10 LAKE SIDE TRAIL, COVINGTON, GEORGIA 30016 NEWTON 43. DESCRIBE HOW INJURY OCCURRED SHOT SELF 44. IF TRANSPORTATION INJURY 45. To the best of my knowledge death oxurred at Lhe time, date and lace and due P t h - - - -- - - - - - - ~ --- 46. On the basis of examination and/or investigation in my opiniondeath occurred at th ti d o t e cause(s) stated. Medical Certifier (Name. Title, license No.) , e me, ate and place and due to the cause(s) stated. Medical Examiner/Coroner (Name. Title, License No.) ', /S/ TOMMY DAVIS CORONER 901071 45a. DATE SIGNED (MO.. Day, Year) .4Eb. HOIJR OF DEATH "' 46a. DATE SIGNED (MO Da Ye r - - - ~- ., y, ) a 46b. HOUR OF DEATH _ - - 02/18/2011 10:38 AM 47. NAME, ADDRESS, AND ZIP COUE OF PER$Oh! COMPLETING CAUSE GF DEATH TOMMY DAVIS 1124 CLARK STREET, COVINGTON.. GEORGIA 30074 48. REGISTRAR - - -- (Signature) - ~ 49. DATEFILED -REGISTRAR (MO. Day, rear) _ /S/ Kenneth Bramlett 04/26/2011 Form 3903 (Rev. 11)2008). GEORGIA DEPARTMENT nc w-u~ero or:eni ~o~« DO NOT FOLD THIS CERTIFICATE ~X ~ t { February 14, 2011 I David Montgomery paternal father of Kaiden Zade Montgomery, born 5-11-2002 (# 667-16-6070) and Elaysia Bleu Montgomery, born 10-23-2003 (# 165-82-9669), do hereby grant the authority and guardianship for Donna and Charles Weiss to transport Kaiden and Elaysia across state lines to their home in New Cumberland, Pennsylvania, where they will take care of their healthcare, education and insurance needs. ~``~ ~~~~ David Montgomery Donna R. Weiss Charles A. Weiss a~ .~ Y ~~~_V ~ ~~~ ( iiJJ m~~.~~ ~X ~~ ,~ _ ,. 5:1ESTONE CLIENTSUny documents~tllCUSTlweissCOMPLAINT-PETITION FOR EMERGENY & SPECIAL RELIEF-ORDEr.wpd ELIZABETH B. STONE, ESQ. ATTORNEY ID NO. 60251 1300 MARKET STREET, SUITE 10 LEMOYNE, PA 17043 ATTORNEY FOR PLAINTIFF DONNA R. WEISS and CHARLES A. WEISS, :1N THE COURT OF COMMON PLEAS OF Husband and Wife, :CUMBERLAND COUNTY, PENNSYLVANIA Plaintiffs v. CNIL ACTION -LAW NO. 2011- ~t~/~, -CIVIL TERM DAVID MONTGOMERY, Defendant. : IN CUSTODY ORDER OF COURT AND NOW, this ~ day of ~ , 2011, upon presentation and consideration of the within Petition for Emergency and Special Relief, and attached complaint, it is hereby ordered and decreed as follows: A. The parties shall have joint legal custody of the two. minor children, Kaiden Zaide Montgomery, born May of 2002, and Elaysia Blue Marie Montgomery, born October of 2003. B. The Grandparents shall have primary physical custody of the minor children. C. Father shall have liberal visitation rights as the parties agree. D. Fathec• shall not remove the children from the Commonwealth of Pennsylvania without first providing the maternal Grandparents with an address and phone number where the custodial party can be reached in the event of an emergency. E. The parties shall have reasonable telephone contact, emails, or other contact as age permits while the children are in the other's custody. F. The parties shall keep each other advised immediately relative to any emergencies ~x u,.3 concerning the minor children and shall further take any necessary steps to insure that the health, welfare, and well being_of both children are protected. G. The parties shall do nothing that may estrange the children from the other parties or hinder the natural development of the children's love or affection for the other parties. H. The Court of Common Pleas of Cumberland County has jurisdiction over these issues and shall retain such jurisdiction should circumstances change and any party desire further or require further modification of said Order. BY T~tS~;.} ,{' _ > Judge TRUE COPY FROM RECORD M Testimony whereof, .I here unto set my hand and the seal of said Co~u~rt~at~C, a~dlsle, Ps. (~, - ~ ,(,, Prothonotary ~;f r~r-r-.,,~... ELIZABETH B. STONE, ESQ. ATTORNEY ID NO. 60251 1300 MARKET STREET, SUITE 10 LEMOYNE, PA 17043 ATTORNEY FOR PLAINTIFF %~~ ~ l F~`l' 2II ~lP~ gin: ', :.~ DONNA R. WEISS and CHARLES A. WEISS, : IN THE COURT OF COMMON PLEAS OF Husband and Wife, :CUMBERLAND COUNTY, PENNSYLVANIA. Plaintiffs/Petitioners v. :CIVIL ACTION -LAW N0.2011- -CIVIL TERM DAVID MONTGOMERY, . Defendant/Respondent : IN CUSTODY PETITION FOR EMERGENCY AND SPECIAL RELIEF TO THE HONORABLE, THE JUDGES OF SAID COURT: Petitioners, DONNA R. and CHARLES A. WEISS, by and through their attorney, Elizabeth B. Stone, respectfully represents as follows: 1. The Plaintiffs are Donna R.Weiss and Charles A. Weiss, adult individuals currently residing at 18 Ardmore Circle, New Cumberland, Cumberland County, Pennsylvania 17070. 2. The Defendant is David Montgomery, adult individual currently residing at 10 Lakeside Trail, Covington, Georgia, 30016-2543. 3. The Plaintiffs are the maternal grandmother and step-grandfather of the minor child; Kaiden Zaide Montgomery, born May, 2002, and Elaysia Blue Marie Montgomery, born October, 2003. 4. The Defendant is the natural biological father of the subject minor children. 5. The children's mother, Kimberly Marie Cox-Montgomery, died unexpectedly and very suddenly on February 8, 2011. At the time, the two lived with both their biological parents at 10 Lakeside Trail, Covington, Georgia, 30016-2543. 6. Upon being notified of their daughter's unexpected and sudden death, the grandpazents immediately drove to Georgia to pick up their grandchildren and bring them back to New Cumberland to live, go to school, and to be brought up by family. 7. It is averred by the Plaintiffs that all interested parties agreed with the decision that the that children should live with their maternal grandpazents full-time based upon what was in the best interests of the minor children. 8. It is averred by Plaintiffs that the parties signed a~ .guardianship agreement so that the grandpazents, your Plaintiffs herein, could transport the children across states lines, register them into school and take them to a physician. See Attached Agreement, signed by the parties, and dated February 14, 2011, attached hereto as Exhibit A and made of the part of the record hereto. 9. It is averred that the children will remain with the grandpazents, who now desire to obtain a Court Order so that they can attend to any medical needs with the pediatrician, place the children on the step-father's medical insurance, follow-up visits and emergency needs and register the children for school, as well as, other extra-cumculaz activities that the children may become involved in from time to time. The Plaintiffs have no intentions of keeping the minor children from their. father; however, they do believe that this is in the best interests of the grandchildren to ensure adequate care, a clean environment, and a loving home while the minor children live in their home. 10 The Plaintiffs have not participated as a party, witness or in any other capacity in other litigation concerning the custody of this children in this or another court. 11. The Plaintiffs have no information regarding any other custody proceeding concerning the children pending in a court of this Commonwealth. 12. The Plaintiffs do not know of a person not a party to the proceedings who has physical custody of the children or claims to have custody or visitation rights with respect to the children. 13. The Plaintiffs believe and therefore aver that the best interests and permanent welfare of the children require that the parties have joint legal custody of the children, that the Plaintiffs have primary physical custody of the children and that the Defendant has temporary physical custody of the children in accordance with this Court's Order. WHEREFORE, the Plaintiffs respectfully requests that the Court enter an order providing for the legal and physical custody of the children as aforesaid; grant the request of Plaintiffs and award temporary physical custody of the minor children to the Grandparents, and order a hearing on the matter as soon. as judicially possible. Dated: ~. (2 SI II 4 February 14, 2011 I David Montgomery paternal father of Kaiden Zade Montgomery, born 5-11-2002 (# 667-16-6070) and Elaysia Bleu Montgomery, born 10-23-2003 (# 165-82-9669), do hereby grantthe authorityand guardianship for Donna and Charles Weiss to transport Kaiden and Elaysia across state lines to their home in New Cumberland, Pennsylvania, where they will take care of their healthcare, education and insurance needs. David Montgomery ~• ~rs3 -Zip ~, :. .. `` . _ - ,, =._ ~ =" w~. -tee. Donna R. Weiss Charles A. Weiss rn I ~~ ~~(I. ~ ~ ~U ELIZABETH B. STONE, ESQ. ATTORNEY ID NO. 60251 1300 MARKET STREET, SUITE 10 LEMOYNE, PA 17043 ATTORNEY FOR. PLAINTIFF DONNA R. WEISS and CHARLES A. WEISS, Husband and Wife, Plaintiffs v. DAVID MONTGOMERY, Defendant. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION -LAW N0.2011- -CIVIL TERM IN CUSTODY COMPLAINT FOR CUSTODY NOW comes the plaintiffs, by their attorney, Elizabeth B. Stone, Esquire, and files this complaint and agreement for custody, representing as follows: 1. The Plaintiffs are Donna R.Weiss and Charles A. Weiss, adult individuals currently residing at 18 Ardmore Circle, New Cumberland, Cumberland County, Pennsylvania 17070. 2. The Defendant is David Montgomery, adult individual currently residing at 10 Lakeside Trail, Covington, Georgia, 30016-2543. 3.The Plaintiffs are the maternal grandmother and step-grandfather of the minor child, Kaiden Zaide Montgomery, born May, 2002, and Elaysia Blue Marie Montgomery, born October , 2003. 4. The Defendant is the natural biological father of the subject minor children. 5. The children's mother, Kimberly Marie Cox-Montgomery, died unexpectedly and very suddenly on February 18, 2011. At the time, the two lived with both their biological parents at 10 Lakeside Trail, Covington, Georgia, 30016-2543. 6. Upon being notified of their daughter's unexpected and sudden death, the grandparents immediately drove to Georgia to pick up their grandchildren and bring them back to New Cumberland to live, go to school, and to be brought up by family. 7. It is averred by the Plaintiffs that all interested parties agreed with the decision that the that children should live with their maternal grandparents full-time based upon what was in the best interests of the minor children. 8. It is averred by Plaintiffs that the parties signed an guardianship agreement so that the grandparents, your Plaintiffs herein, could transport the children across states lines, register them into school and take them to a physician. See Attached Agreement, signed by the parties, and dated February 14, 2011, attached hereto as Exhibit A and made of the part of the record hereto. 9. It is averred that the children will remain with the grandparents, who now desire to obtain a Court Order so that they can attend to any medical needs with the pediatrician, place the children on the step-father's medical insurance,. follow-up visits and emergency needs and register the children for school, as well as, other extra-curricular activities that the children may become involved in from time to time. The Plaintiffs have no intentions of keeping the minor children from their father; however, they do believe that this is in the best interests of the grandchildren to ensure adequate care, a clean environment, and a loving home while the minor children live in their home. 10. The Plaintiffs have not participated as a party, witness or in any other capacity in other litigation concerning the custody of this children in this or another court. 11. The Plaintiffs have no information regarding any other custody proceeding concerning the children pending in a court of this Commonwealth. 12. The Plaintiffs do not know of a person not a party to the proceedings who has physical custody of the children or claims, to have custody or visitation rights with respect to the children. 13. The Plaintiffs believe and therefore aver that the best interests and permanent welfare of the children require that the parties have joint legal custody of the children, that the Plaintiffs have ~. pximary physical custody of the children and that the Defendant has temporary physical custody of the children in accordance with this Court's Order. WI~REFORE, the Plaintiffs respectfullyrequests that the Court enter an order providing for the legal and physical custody of the children as aforesaid; grant the request of Plaintiffs and award temporary physical custody of the minor children to the Grandparents, and order a hearing on the matter as soon as judicially possible. Respectfully submitted, Dated: ~ I a`'S ~ ( I By BETH TONE, ESQUIRE preme C ID #60251 1300 M t Street, Suite 10 Le , PA 17043 9-1500 Atto eys for Plaintiffs ~. VERIFICATION We verify that the statements made in this Custody Complaint are true and correct. We understand that false statements made herein may subject me to penalties of Pa.C.S. §4904 relating to unsworn falsification to authorities. ~ '~ Date Donna R. Weiss, Plaintiff ., as r~ ~ e,s Date axles A. Weiss, Plaintiff GEORGIA DEATH CERTIFICATE Bath Number araro r-ne nUmDer LU 1 ~ (iA000049874 1. DECEDENTS LEGAL FULL NAME (First. Middle, Last) 1a. IF FEMALE, ENTER LAST NAME AT BIRTH 2. SEX 2a. DATE OF DEATH (MO., Day, Year) DAVID CHRISTOPHER JEFFREY MONTGOMERY MALE ACTUAL DATE OF DEATH 03/17!2011 3. SOCIAL SECURITY NUMBER 4a. AGE (YEARS) 4b. UNDER 1 YEAR 4c. UNDER 1 DAY 5. DATE OF BIRTH lMo.. Day, Year) 258-07-1868 2g Mos. ~ Days Hours Mins. 11!10/1981 6. BIRTHPLACE 7a. RESIDENCE -STATE - ~ ~ - -- - - - -- - - 7b. COUNTY 7c. CITY, TOWN GEORGIA 7;EORGIA NEWI"ON - - COVINGTON - _ _ _ 7d. STREET AND NUMBER "- - - _ _ _ 7e ZIP CODE 7f. INSIDE CITY LIMITS? 10 LAKESIDE TRAIL 8 ARMED FORCES? - - _ __ _ 30016 NO _ _ 1_ NO ea. USUAL OCCUPATION 8b KIND OF INDUSTRY OR BUSINESS - - --- SALES _ _.. - (INSURANCE 9. MARITAL STATUS 10 SPOUSE NAME 11. FATHER'S FULL NAME (First, Middle, Last) NEVER MARRIED I - - (JEFFREY DARWIN MONTGOMERY 12. MOTHER'S MAIDEN NAME (First, Middle, Last) 13a. INFORMANTS NAME First, Middle, Last - - ( ) 13b. RELATIONSHIP TO DECEDENT NANCY CAROLYN MAULDIN (NANCY D BRUSS - - MOTHER 13c. MAILING ADDRESS - -- _ - - -- - 14. DECEDANTS EDUCATION - - -- - -- -- _-- 1710 OLD DALLAS ROAD, MARIETTA, GEORGIA 30064 _ 'HIGH SCHOOL GRADUATE OR GED COMPLETED 75. ORIGIN OF DECEDENT (tte6an, Mex..F-ranch, F_nglish, etc.) 16.DECEDENTS RACE -- ~- - --- -- (Whtte, 81adr. Amax, MW"an, etc.) (Speddy) NO, NOT SPANISWHISPANICMTINO WHITE 17a. IF DEATH OCCURRED IN HOSPITAL - - - - - -- 17b. IF DEATH OCCURRED OTHER THAN HOSPITAL (Indicate DOA. OPiEMER., Rm .Inpatient) (Speedy) DECEDENT'S HOME 18. HOSPITAL OR OTHER INSTITUTION NAME(l/notmedher. rvastreetandNO. 9~ 1 19. CITY. TOWN or LOCATION OF DEATH 20. COUNTY OF DEATH 10 LAKESIDE TRAIL COVINGTON, GEORGIA 30016 COVINGTON - _ __ _ NEWTON 21. METHOD OF DISPOSITION (Speciry) 22. PLACE OF DISPOSITION 23. DISPOSITION DATE: (Mo.. Day, Yeah CREMATION WEST CO86 FH AND CREMATORY MARIETTA, GEORGIA 30064 COBB 0 410 6/2 01 1 24a. EMBALMER'S NAME __ - _ - - - - _ _- 24b. EMBALMER LICENSE NO- - -- -- -- - 25. FUNERAL HOME NAME DAVID MCLEROY - - 4089 W COBB FUNL HM 8 CREM INC 25a FUNERAL HOME ADDRESS _ MARIETTA, GEORGIA 30064 26a. SIGNATURE OF FUNERAL DIRECTOR 26b. FUN. DIR. LICENSE NO. /S/ CHRIS MESSINA ~~ 27. DATE PRONOUNCED DEAD (MO., Day. Yeah ---- _ - - - - - - 28. HOUR PRONOUNCED DEAD _ - 03/17@011 _- 06:55 PM 29a. PRONOUNCER'S NAME 29b LICENSE NUMBER 29c. DATE SIGNED THOMAS EDAVIS - - _ 9180319 03/17/2011 30. TIME OF DEATH 31. WAS CASE REFERRED TO MEDICAL EXAMINER - - -- _ -- 06:55 PM YES 32. Part I. Enter me chair of events-diseases, injuries, or comp{ieations that direGly wusetl the tleath. DO NOT enter terminal events such as cardiac arrest, -- - "- ---- --- respiratory arrest, or verdicular (dlrillation wdhout showing the etiology. DO NOT ABBRVIATE. Approximate interval between onset and death IMMEDIATE CAUSE (Final A. CARDIAC DYSRHYTHMIA ASSOCIATED WITH LEFT VENTRICULAR MYOCARDIAL FIBROSIS UNKNOWN disease or condition resulting in _ - -_ - -- - - _ __. _ __ -- Due to, or as a consequence of - -- - "- -- death) B Due to, or as a consequence of - _ - - - -- - -- -- -. - _.. C Due to, or as a consequence of - - - _ - -- - _. D. Pan II. Emer signifxant wntlitions contributing to death but not related to rouse - - ~ _ - -- 33. WAS AUTOPSY PERFORMED - -- __ -- given in Pan tA. (I//emab, indicate it pregnant or birth occurred within 9o days ordeath J ~ 34. WERE AUTOPSY FINDINGS AVAILABLE TO YES COMPLETE THE CAUSE OF DEATH? _ - _ _ YES 35. TOBACCO USE CONTRIBUTED TO DEATH 36. IF FEMALE - - - -- 37. ACCIDENT, SUICIDE, HOMICIDE. UNDERTERMINED (Sperry) UNKNOWN NOT APPLICABLE NATURAL 38. DATE OF INJURY (Mo., Day, year) 39. TIME OF INJURY 40. PLACE OF INJURY (Home, Farm, Street. F _ -- aetory, OWce, Etc.) (Speery) 41. INJURY AT WORK? (Yes or NO) 42.LOCATION OF INJURY (Street, Apartment Number, City or Tow;7, State, Zip, County) - - - 43. DESCRIBE HOW INJURY OCCURRED -- 44. IF TRANSPORTATION INJURY 45. To tl7e best of my knowledge death occur2d at ttie time, data and place and due 46. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and to the cause(s) stated. Medical Certfier (Name, Ti(k:, License Nc.) - ;lace and due to the cause(s) stated. Medical Examiner/Coroner (Name, Title, License No.) _ ~ /S! THOMAS E DAVIS CORONER 9180319 45a. DATE SIGNED (Mo.. Day. Year) 45b. !-:OUR OF DEATR Mia DATE SIGNED (Mo., Day Year) _ _ - 46b. HOUR OF DEATH - 10/28!2071 06:55 PM 47. NAME, ADDRESS, AND ZIP CODE OF PERSGN COMPCE i iriG~^.PI I ~ - - - - _SE OF DEATH _ - - THOMAS E DAVIS 7124 CLARK STREET. COVtNGTON. GEORGIA 3b01a --- -- - 48. REGISTRAR _ ... - ' .. - - - - - -- 49. DATE FILED -REGISTRAR (MO., Day Yeary -" -- (Signazure) /S! Deborah C. Aderhold - 1 1 /1 71201 1 Form 3903 (Rev. 11/2008), GEORGIA DEPARTMENT OF HUMAN RESOURf:FS u0 rvU I FOLD THIS CERTIFICATE --_. t VERIFICATION I verify that the statements made in this Petition are true and correct. I understand that false statements made herein may subject me to penalties of 18 Pa.C.S. §4904 relating to unsworn falsification to authorities. Date: (~ ~ (~~ ,~-- C~ <33~ Donna R. Weiss