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HomeMy WebLinkAbout05-31-12PETITION FOR GRANT OF LETTERS REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA Petitioner(s) named below, who is/are 18 years of age or older, apply(ies) for Letters as specified below, and in support thereof aver(s) the following and respectfully request(s) the grant of Letters in the appropriate form: Decedent's Information ~ Name: Helen L. Foster File No: l- t 2 'Q a/k/a: (Assigned by Register) a/k/a: a/k/a: Social Security No: 188-12-5703 Date of Death: 5/11/12 Age at death: 97 Decedent was domiciled at death in Cumberland County, PA (State) with his/her last principal residence at 1000 Claremont Rd Carlisle Middlesex Township Cumberland Street address, Post Office and Zip Code City, Township or Borough County Decedent died at Claremont Nursing Center Middlesex Cumberland PA Street address, Post Office and Zip Code City, Township or Borough County State Estimate of value of decedent's property at death: If domiciled in Pennsylvania ............................... .All personal property $ 1, 500.00 /f not domiciled in Pennsylvania ............................ .Personal property in Pennsylvania $ If not domiciled in Pennsylvanin ............................ .Personal property in County $ Value of reel estate in Pennsylvanin ......................... ..................................... $ TOTAL ESTIMATED VALUE.... $ 1 500.00 Real estate in Pennsylvania situated at: None /Attach addiuonal.cheets, {'fneces.eary,) Street address, Post Office and Zip Code City, Township or Borough County ® A. Petition for Probate and Grant of Letters Testamentary Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated 1 /6/03 and Codicil(s) thereto dated D.O D of Ruth I. Kuhn June 16 2007 D.O.D. Russel L. Kuhn May 25 2008 State relevant circumstances (e.g. renunciation, death ojexecutor, etc.) Except as follows: after the execution of the instrument(s) offered for probate Decedent did not marry, was not divorced, was not a party to a pending divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(g), and did not have a child born or adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. ® NO EXCEPTIONS ^ EXCEPTIONS ^ B. Petition for Grant of Letters of Administration (If applicable) c. t. a., d. b. n., d. b. n. c. t. a., pendente Irte, durante absentia, durante minoritate If Administration, c.t.a. or db.n.c.t.a., enter date of Will in Section A above and complete list of heirs. Except as follows: Decedent was not a party to a pending divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(g) and was neither the victim of a killing nor ever adjudicated an incapacitated person. ^ NO EXCEPTIONS ^ EXCEPTIONS Petitioner(s), after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and heir attach additional sheets, if necessary): Name Relationship Address n -- 'C T ^It° ~ c < ~ ~ ~. - -dc ~ t.: ; W !; ___.. ~,-- ~' ~ , -- - + ~ __ ~~~ C_" } ~~ _.r J ~_; t•~„ ~m aw-oz r~r. lo~l zo~l Page 1 of 2 Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA } } SS: COUNTY OF CUMBERLAND } -- - -, ~ial Use Only ;, _-, ;- ; \l l r~ ~ ~ r ~ ~ I 3~' ~~_~ ...- =D -~ ' C,J ~~ E.''... _..- '. -. -=; , - -;- '7`_-- _. Petitioner(s) Printed Name Petitioner(s) Printed Address j ; ~ Miriam E. Stambau h P.O. Box 96 ~. -" as ers PA 1730'4 The Petitioner(s) above-named swear(s) or affirm(s) 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, the Petitioner(s) will ell and truly admin, i~s/ter the estate according to law. Sworn to r affirmed and cribed before r'Y7~-+.~t,c.~-~2• ~ Y'~ Date 5/31/12 me t i ~ day f ~~~~~ gy: L `~/~' ~~ Register Date Date Date BOND Required: ^ YES ® NO FEES: Letters ....................... $ ~ ~ ~ ~~ (~ )Short Certif`icates(s) ...... • ~ ( )Renunciation(s) ......... . ( )Codicil(s) ............. . ( )Affidavit(s) ............ . Bond ......................... Commission ................... . Othe~ ......... C ......... t7Ct Automation Fee ................ . JCS Fee ....................... TOTAL ......................$ . (~ dt ~~ To the Register of Wills: Please enter my appearance by my signature below: Att rney Signature: ~~ PrinltedrPhame: John C Zepp III Supreme Court ID Number: 52662 Firth Name: John C. Zepp III Attorney At Law Address: P.O. Box 204 York Springs PA 17372 Phone: 717-528-8900 Fax: 7170528-7381 Email: attorney~a iohnzepp.com DECREE OF THE REGISTER Estate of Helen L. Foster File No: ~~~ / ~ - Q~/~ a/k/a: AND NOW, ~ _ ~!t__ ~~ r ~ , in consideration of the foregoing Petition, satisfactory proof having been resented before me,IT IS DECREED that Letters of Testamentary _ are hereby granted to Miriam E Stamba~h in the above estate and (if applicable) that the instrument(s) dated januar~/ 6th 2003 -- described in the Petition be admitted to probate and filed of record as thMast Will (and Codicil(s)) of Decedent. - - ~r,' _! r~ --c-~ Register of Wills f~ ~% F,~r~,aw-oz re,~. ioiiiizorr 1~~ ~ Page h of 2 2~=j'~-o~o~ WAF~~f3W~; it is €~le~~~ to ~:a~~#+c~te th°s~ s:o~~ day ~hoto~tat or glhotograph. I~t.~ fur ;!(i< certificate, `i(-i.t)O ~ 1~-5833-0 t'rrtij(cation ti(imlx'r ~l~h , i~ti to rertil~~ that the information here ~~i~en is ~~~,~~-'~ Jf f}~~;~\, cut lecl?~ '~~}?ied from an original Certific ue of Death e'~~' ~{ ~ slur, iik°tl ~iith me as Local Kcgistlar. The original 9,] cc!I~!~)ca;e ~~ill 1,e forw~arsled to the State Vital ~, '~ ~-;, ~. ;,,. !Zs.~ilrs~~. t:?i~l~i,r l~n r~erm;.u~cnt filing. a ~ -~ ~- ~~~ ~ n ' , (: ~ ~~"~=- ~ t.~?rat !~ci'ISir~n~ Date L;sued n T~ ;7,~ C O '-~ T- __ ~ ~- ~. m --~' - ,- - _. v~ - ~° t/.' ~~_ D ~ c• ~ (_ ~ ~, H105.143 REV 112006 ttPE ' PRPJT IN PERMANEN( Bl ACK INN a 3 V J d z COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH (See instructions and examples on reverse) ._.__ _.. _ ..... 1 Name of Deceaed (First, mitldla, last sago) 2. Sez 3. Social Security Nlmmor 4. Dale of Deem (MOnm, day, year) Russel L. Kuhn Male 197 - 09 - 1097 May 25, 2008 5. Age (last Birthday) Ulltler t year UMer 1 day 6. Dale of Binh (Month, day, year) 7. BiMDlace (Chy arM slate or lor dgn country) Ba. Place of Death (Check onN one) 89 Mnmla Days Lbura Minvles Hospital: Weer: Yrs. May 31 , 1918 GArdners, PA Inpaaent ^ ER / Wtpanenl ^ DDA ^ Npraing Home ^ Reaidence ^otner . spetdy: Be. County of Deam &. City, Boro, Twp. of Death Bd. Fadliry Name (II Iwt inskldwn, give sired and number) 9. Was Decedem d Hispank Origin? No ^Yes 10. Race. American Intian, Black, WhAe, eb. Cumberland U Allen Uf yes, spec0y Cuban, ISae°iM Health South Mexban,PuenoRican,elc) White 11. Decedent's Usual Occu lion Kb0 of work done Our mod of world Ide. Do nd slate retired 12. Was Decedent evenin the 13. Decedent's Ed/calbn (Specity only highest grade competed) t4. Marital Slaws: Marred, Never Married, 15. Surviving Spouse (11 wife, give maiden name) Nind d Work Kind of Business! Iritluslry U. S. Armed Farces? Elementary / Secondary (0-12) Cdlege (1-4 or 5a) WMOw~~ Drv°rce0 (~rM Sll 1 De t p }]Yes ^NO V Wldaaed 16 Decedent's Mailing Address (Skeet, city /town, slate. zip code) 21 Maryland Avenue Decedents Penns lvania °ie °~~"' Carol A<lnal Residents na. SWIe Y Live in a „~ [~ Yes Decedent Lived n T As rs PA 17304 . , wp_ York T°w~hv? ,7d. ^ No. De<aeed L~aa.„wn t,b. D°°nry Adad Limits d city / BorO IB Falhei s Name (First, mltltlle. last, 6uf(ix) 19. Momer's Name (Flrsl midde, maklen SurrNme) John Kuhn Eva Frost 20a. Infomlanl's Name (Type /Print) 20b. Inlormanfs Mahing Address (Skeet, cdy / bwn, state, zp code) Miriam Stambau h P.O. Box 96 Aspers, PA 17304 21 a. Melhotl d Disposition ^ Cremation ^ Donation Q(Burldl ^ Removal Iran b C 21 b. Dale of Disposition (MOem, day, year) 21c. PWCe of Usposilgn NName d cemetery, crematory er omer place) 21 tl. t.ocdapl (Gry /town, slate. zip code) Wae remation or Donation Aullwn:ed ^ Other-Specity: hyM tlkdExemlrrer/Cororrert ^Yes^NO Ma 31 2008 Westminster Cemetery Carlisle, PA 17013 22a. $igllalw of a Io< in uchj 22b. License Number 22c. Name andAdOress of Facility Neill Funeral Hane, INC. - FD 013239 L 3401 Market St .Cam Hill PA 17011 Complete he Sac only wren certifying 2 To the bell of my knowledge, math occurred at me limo dale and plate staled. ISgnawra and title) 23b. License Number 23c. Date Signed ( N, day, year) pnYryiani lavahakleattimeaaeamm tam t aeaaeam. `/l7t~lq•-~. _ ~ ^ • l R~ Y 1' T~ i~l.A.lJ1~.IC~U '~~SaLfC] O `-l ~S Z5 b8~ Items 24 26 must be tnnplele0 by persor~ 21. Time OI Deam 25. Dale Promwrced Dead (MOWN, day, year) 26. Was Case Referred b Mdscal Examiner I Coroner for a Reason OINer an Cremabon a Dwlbn7 ntw Vralounces deaN. 2Z OO M. ^Yes ^ No CAUSE OF DEATH (See Instructions end examples) r Approximate IntarvaL Item 27. Pan I'. Enter the chainpt.DYfr015 - tlisedaes. iryunas, or complications - that dr ily cause0 the deem DO NOT enter terminal events such as cardiac arted Onset t D th Pan II'. Enter Durst ~glgjggpLcanMims conbMnin° to ggolh, b t d i n h 2B. Die Tobago Use CaltnbAe b Death? Y P b b , o ea respiratory arrest, or vemrlcular IibdldlXar wimoul showing the eliobgy. list only one cause on each line. u n result ng t e uMedyhq cause given n Pan 1. es ^ ro a ry ^ WYEDIATE C USE IFi dsease or ^ No ^ Unknown A a i /~QS, wrlditan res de a ! /"'H"~jj / FR r LLy~.~7 n 29. II Ferrate: _~ . ^ Due to (or as a Cro A~s ~ ~ Nd DregrlaM wimm pall year • SequerioalN Nsl conditions, tl anY. b. lead W me cause listed pn line a r ^ Pregnant at tme d deem . Due to (or as a copse Enter gie UNDERLYING CAUBE quence ol): r ^ Na aognanl, Ixn pregnam wANn 42 nays (dsease or injury that initiated mo c ~/,~ ~ ~ evenLS resulting ui deem) LASL d death Due to or as a cons ( equence ol)~. ^ Not Dregnanl DW pregrud 43 daYS b t year d, r before deem ^ Unkrwwn it pegnant wimin me pall year 30a. Was an ANOpsy 30b. Were Autopsy F dirt's 31. Maurer of Death 32a. Dale d Injury (Month, day, year) 32b. Descnhe How Iryury Occurred 32c. Place d Injlxy: Hums, Farm, Sued, Fancy, Penoime0? Availade Prbr to Colrylehon ^ NaWral ^ Ho nx W Office Bldaing, etc. l5vet'iM d Cause of Deam7 ; r e ^ Yes ^ No ^Yes ^ No ^ Acndern ^ Panmlg Invesligalion 320. Tme of Iryury 32e. Injury at Work? 321. It Transponatxm Iryury (Specify) 32g. locatbn d Injury (Street, cry I town, stale) ^ Suvade ^ Could Not be Delelmined ^Yes ^ Nu ^ Dnvel / Operator ^ Passenger ^Pedeslnan M 33a. cend'ier Itnetk o„Ir «.e) • CenUying physician IPnysxtian certifying cause of deem when anuNer pnysklan ha> pmmuncetl Oealh and cunpleted ham 23l 33b. sigluwre are ri wr //~Y / ~ /J ~~ l. To Ne hest of my Nnowkdge, death occurred due Lo the cause(s) ana manner ea steterL _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ - ,~~~ ~ / " • Plonouncing and cerldylrg physicWn (Physician Oolh pronouncing deem and cemlying to cause of death) To the heal d m Nr bd B m t Ir Li d tl d W ^ 33c License Number 130. Dale Signed (Momh, day, eel) y ww ge, ea occurre a e ma, ele, an p U, and due 1o Na cause(s) arM manner es claled_ _ _ _ _ _ _ _ _ _ _ • Medical Examinar /Coroner ~1.~ ~j e7 / ~ ~ Q (-t \ S ~E ©~ Z- ~ 2 O F~ On the basis of examinagon and / or investigation, in my opinion, death occurred at the time, sale, and place, and due to the ceuae(s) end manner as sated_ ^ 34. Name alb Address of Person W~^fho Co~m-Tpl-eted Cain of Deem gtem 27) Type I Pml 35 Re ist 's i awr -~tl Dist- um 36 D le Fgetl (Norm ar ) da ~ ~0.rnp$ /-F \`'/V~~-+G L~ 7 I ( - ~ IT ~ A ~ ~ ~ / ~~ ~ , y^,~y ~y o ~,/ , ~ ~S °~ Lo w'1~+ ~1 . 6 ! a4, d. aT' `Q 1'7~ Disposition Permit No. v ~ a1 ~ ~/S "' ~' a #; - - a €,+;'s4.rti<,; ``i' a (.`~~:''~' ;3 r' ~a°~ ~.ri.dSu~z'3~ G"~ ~;~@J~:L'~~t'c'3~i1: P ~_~~ r ~~~~_ ~~ -,+, rata n~ooh iPF PNINI IN PEHlIANENi BLACK INK ~r - ;.,~ r~ . ~, ,r ~,ti° i, I`, ti. L:,t);~ _'(; r! i! !f-Ir)fi~kll ii?il Ilt. !-C CIiCil t•, 1.,i r rti• ,,lu,`EI~II flf _IL1 l'-1~111!!~ ~ c'1-llll,- 31i !;~ ~-)c`~l]i; ti's ! fc:} i. r I ~ /TCrI~ )~.c L'(~Ll;lj~. I L I)I l~i~ ~~- ',u_I(, 1~.f! ,-e F.;C'.Y ttli:~r1 tFy fi9ic 5._t(;~ 1',I.(1 k° ICI-!'~. tt• ,-.C 1i Y[ ~',t.?l P,.t;r~~.?l ~•~ICI:. • ., ~`~~--- ~ _ C O _ r~~: M1L ~ -t-: - ; -j , ;, - ~ _- ~ --- L7,- :~~- - ~" ~_: ~; __z: _ _ c D -- ~~., ~ . _ ~ .~ ~ COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT Of HEALTH • VITAL RECORDS C.~. '~i CERTIFICATE OF DEATH (See instructions and examples on reverse) ~,ar< <„ ~ h,,,,,,,~~ 1 I Decadent IFirsl mltldle. lass. suhlx) a U-r 2 S ~ 3. Social Security Number 4. Date of Deals (Month, tlay year) -aa -~e9 5 Aya ILasl Ulnhdayl Under 1 year Untler I tlay 6 Oare of Binh (Month. tlay. year) 7 Blnhplace ICny End stale or for eign country) 6a Plere of D6alh (Check only one) /~ .` l-/L ( ` fAaian DnVS nouns ht,niaes ~ 1~ 1 Q !~^Y ~ Hospllal- Other. Yrs. I v ` ,S ~u 1~1 n I I ER / Oul al ^ DOA •Va ten ^ p'ienl ^ Nursin Mome ^ Ras~dence g ^Othar-SpOC~ry 3h COUnIy of Deem 3c. CIIy, Boro T • Of Death &1 Facihry lll not Instilubon, give street an umber) 9 Was Decedent of Hispanic Ongm? ~ No ^ Yes 10. Race. Anlentan Indian Black, Whae. etc ~~ PA`A~ ~ '~ ~ ~ 1 r C pt yes, speciry aban. M P i I ec I ~ ~Iv1~ ~ / ex can, uerto Hlcan, ac j 11 De~eoanFS Usual Occu h~;n (Kind i,l w0ik l one Bunn most of workln Isle Do not slate relnedl 12. Was Decedent ~ In Ih6 13. Dacedem's EtlucallOn (5peal Doty highest grads wmp leletl) 14. ManWl BIatJS, IAarnatl. Never MarneQ 15. Surviving Spo use jll wde gne maldon name) Kintl of LVurk ~ ~ ~ Kintl cl Bii~ss / lutlusti~~ RN U ~nnetl F ~ s? Yes NO Elamenl'ary I S,ec` ary (012) J-- College (7-4 or 5•) ~~'"ad. Onorced (Specilyl ~~~1 t D , u `. 16 D«edanl's Maeing Address ISUeet ly ~ tov~ Ilale~, npZ~cod/eI~ DecedonPS Did Decedent i ~NNS~tu) ~ N 114 Li 0 / r~ \ {~ t Y ~ I 1 1 ~ ~ I ~~ ve AaWel Resldenv'e I7a Slnle n a 17c. ^ Yes. Uecetlent lived In Twp // / D ~~~ ~U ~ \ ~P 1 9' Tow st tpv I7tl. ^ No. Decedent Livetl wlRiin 17b G6emy 0 Actual Llmlls of Clry r Boro Iy F~al ~ers Nume IFUSI dJre. Iasi suHixl VJ1l.l-1 AtY~ F. k~~ L. 19 MoUer's Name (First, mitltlle, maiden Surname) ~U~R E i tl C.B L 20' Inlamanl's Name (Type / PnnO K 20D. Intormanl' Malling Address (SDeel Town, 51a(e, Zlp ) ~ ~ v S L. u N oC. N 5 o ~ 8U 1 ~- 2ta M e thod of Disposition ^ Cremalnn ^ Datation 21b Date of Disposition (Munro, day, year) 21c. Place of Disposition (Name of cemolery, crematory or of er place) 21tl. Lxauon (City I sown, state, zip code) z . ~ pl Bunal ^ RemOVal nom Stela i Was Cremation or Donation Authorized ~ M i ] ^ , ~ ~O ~ oo~ ~S 4 - ed cal Examiner /Coroner? _ Omar - Spe; pry: by Yes No ~ 1 22a na1 a of Funeral S e for pars ding as ucn) 22n Lkense Number 22 Name and Addre Facility - ~D l 3$ ~ E 'S 0 ~~ llL i I Complete hams 23a-c only when c nl -rt 23a. TO the bell 01 my knOwletlge, tlealh acurree el Ine rime. dale and place staled. (signalwe and title) 23b. Cleanse NWnher 23c. Dale Slgrretl IMonlh, day, year) Vwsio o not available at Ume cl atlr to rnmly cause 0l doath. /...~, ~./\J~L'~L'1 -~ ~'~ /~ ~ / ~ ' b :~ 7 Ilelns 24 ~6 must be completed by Verwn 24. Tune ul beam , 25 Dale Pr0n0unced Deed ( MOnUI, day, year) 26. Was Case Referred lu Medical Examiner I Coroner for a Reawn Oltwr than Cremation or Donalron? wLO piunounces Ikath. ` C3 ~ M // b (~ ~ J ^Yea ~No CAUSE OF DEATH (See InatrucUOns Bnd esamples) , Approx male inlenal. Part II'. Enter aver JgnilcanlSppQpjgp~COnlr GUlinO tp,g@y7D, 2B. Did Tobacco Use Canlribule to DeaN7 Mein 17 Pan I Emel Ina SIWhI Dl flYPJha - tllsaases. injuries, or eomplh:allons -mat directly caused the tlealn. W NOi enter lemanal events such as cartliac arrest, Onset b Death but nut resuhing In Ine uMenying cause given in Pan I. ^ Yes ^ Probably respiretoiy mresl, or ventricular fibrillation wi1h0N showing the elmlogy Lisl only One cause on each hrre [7rNO ^ Unkno n w IMMEDIATE CAUSE lFinal disease or LA ~ [ ~ • ` ~ ~ jj F, 5C condlllon resunin In tlealn) '1 ~l ~ l I 6 ( G~Y '~i7 /l~G~ 29. It Female'. g _~ Z - - L . {/-J y I J C--L, 1 a ^ V . Due b (or as a consequence ofj. ~ Nul pregnant wnnin pass year '1 J1/ Scyuenii&Ily Ir61 wntlhions, d any, b. 7 1 ~ leaa to th c ti l d li ^ Pregnant al time of tlealn nAA e ause l e on ne a Due to as a consa Enter the UNOEflLYING CAUSE (or quen,:e olj: N I lent, Dul nam wlrtnn 42 da s ^ o Dra9r Dreg Y (disease of injury Ih t Innrated me events rawlung vi tlealhl LAST of dea9i Due 10 (or as a consequence ofj. ^ Nul pregnant, WI pragnaM 43 days to I year d' b6fwe death ^ Unknown H pregnant within Ine Dabl Year 30a. Was an Autopsy 30b Were Autopsy Fintlings 31 Mannar of Death 32a. Date of Injury (Monln, day, year) 32D. Descnbe How Injury Occurretl 32c. Pace of Injury: Hwne. Form. Slreel, Factory, Panonnetl? Avertable Pnor to Completmn Odke Buikkng, etc. (Spcvrry) 01 Cause of Dram? ©Neluml ^ Hom¢ida ^ Yes Q No [ ~ Yes ^ No ^ Acadenl ^ Pending Invevigauun 32tl. cane of Injury 32s. Injury al Work? 321. II Transponalion Injury (SpectlyJ 32g. Location of Inryry (Street, city I sown, slate) ^ Swrlde ^ Cuuld Not be Doteiminue ^ Y6s ^ NO I ^ Dover I Opjrala ^ Passonyer ^Petlasaian M ^Olher Specily 33a CeNher (chat only one) 33b. SignaWre and Title of Candler ~ ~ ' - ~ • Gertilying physician IPiiysician cenilyiny cause of death when anulner physician rtes pmnouncv0 tlealh and camploled hanr 23) I _ _ ~- - -~ C- / - j ly _ - L, ~ - To the best of my knowledge, death ixcurted due to the cause(s) and manner as staled_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ • Pronouncing and cMilying pnYSielan (Physician bum pronowrcing death and ca~ulVmy to cease of death) To Ina best o1 m knowled deals occurred •1 the time s dale and lace end due to the cause(s) and manner as sMted ^ 33e Litt~nso Number 33d Dale S nee (Moron, day year) ~ '7 y g , , , p , _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ • Medical EaaMrrer /Coroner / ~ ~J , u ~ / On the basis of examination and 1 or invesligalion, in my opinion, death occwred at the lime, date, and place, and due to the cause(s) and manner as staled_ ^ 34 Name end Address of Person Who Gornpkle0 Gau>e of Death (Item 27j type / Pnnl ar s Siy wie antl Dsrnci Numb 36 ath Filed (MOnm, daY. Yam) ~'~ `' S I~ Z ~ S E S ~l ~ e_k l [•.7 (~ 4' ~ `~ 5 dry) (~ " Uispusiliun Permit Nu. ~..~ (.•1 .1 ~ ~/ 3 n~ ~ ; ~ .. ~J Type/Print In Permanent Black Ink ~_ Uht' ~J',i ~ ,U,~~,, i a '~ ~~ COMMONWEALTH OF PENNSYLVANIA ~ DEPARTM ENT OF HEALTH ~ VITAL RECORDS CFRTIFI["ATF AF IIFjsT{.J 1. Decedent's Legal Name (First, Midtlle, Last, Suffix) ' 2. Sex 3. Social Security Number"a~ rv4. Date of Death (MO/Day/yr) (Spell Mo) oSTE,e N£LE/~ L. F F /88- /Z- 5?03 /~.9 y //, .2a/~ 6a. Age-Last Birthday (Yrs) 6b. Under 1 Year Sc. Under 1 Da 6. Date of Birth (MO/Day/Near) (Spell Month) 7a. Birthplace (City and State or Foreign Country) 9 ~ Months Days Hours Minutes ,S'EPTE/~fBesR lv ARRiS au.~6 P~+. /4 ~+~ , 7b. Birthplace (County) y7q N PHiN Ba. Residence (State or Foreign Country) 8b. Residence (Street and Number -Include Apt No.) Sc. Did Decedent Llv¢ in a Township? P6a/VNf ~ v.rN i~ V3Yes decedent lived In M / ~D/-£SE~ /ooo P~q/1 Sd. Residence (County) , r two. /Q j7, Cfr/i,~ ( „r 8e. Residence (Zip Code) / 7p/ 3 QNO, decedent lived within limits of city/born. 9. Ever in US Armed Forces] 10. Marital Status at Time of Death Q Married Widowed 11. Surviving Spous¢'s Name (If wife, give name prior to first marriage) Q Yes ~ No Q Unknown Q Divorced Q Never Marrietl Q Unknow 12. Father's Nama (First, Middle, Last, Suffix) 13. Mother's Name Prior co First Marriage (First Midtlle Last) W/L~-/AM F. IEHL , , EL/Z~pBE'TiY C. BART?%ciC 14a. Informant's Name 14b. Relationship to Decetl¢nt 14c. Informant's Mailing Address (Street and Number, Cify, State Zip Cod¢) /Yji2i M SIAM AH , /YIECb Po. Bo>~ Oro ASPr25 Pq _....:... ------ - 15a. P ace o Deat C ec on on¢ f ~ s ................ .. P ...Pa........................... •- --- -------------------• If Death ocwrrea Ina Hos ital: In [lent y ................................... _ _ _ _ ........................ ......................... ...... ..... ....... ....... ..... "--""-----...------------•---- :If Death Occurred Somewhere Other Than a Hospital: ~ Hospice Facilit Q D d ' ° Q Emergency Room/putpatlent Q Dead on Arrival y ece ent s Home _ Nursing Home/Long-Term Care Facility Other (Specify) ~ 15b. Facility Nam¢ (If not Institution, giv¢ street and number; f ' ' ISC. City or Town, State, tl Zip Code 16d. County of Death /YN )n/~y f L. /./~RF~'tonlT RF-/!RB CENTE'R Ci4RL% G E Pq . f 70 /3 ~s/I+1BEQtR i/~ m 16a. McShod of Disposition Burial Q Cremation Q Removal from State D i 16b. Date of Disposition 16c. Place of Disposition (Name of cemetery, crematory, or other place) v .~ onat on Q p Diner (Specify) ~~ J MAy /7, 2oi~ !'~~DCA w../ /-7r' ae).~~. GARDEiI/~ Z 16d. Location of Disposition (City or Town, State, and Zip) 17a. Signature of Funeral Service L i ce nsee o r Person to Charge of Interment 17 b. License Number _ Nf}R 2456 K ~A. / 7/09 - ~ / ~ ' - /~L~4-~s.~- a /~) ~ 3 c_ 0 17 c. Name antl Com late Address pf Funeral Facility /FiLL u EitffL E SA/c . 3So 1 ~E'~GJQ S T'- A RJSO u~ G ~R . [ 7/ I/ ~ 18. Decedent's Education -Check the box that best describes the 19. Decedent of Hispanic Origin -Check the 20. p¢c¢dent's Race -Check ONE OR MORE races io indicate what r- highest degree or level of school compleced at the time of d¢aTh. box that best tlescrib¢s whether the derodent the tlacedenf considered himself or herself to be. 0 8Th grade or less is Spanish/Hispanic/Latlno. Check the "NO' ~ White Q Korean Q No diploma, 9th - 12th grade box if decedent is not Spanish/Hispanic/Latino. Q Black or African American Q Vletnames¢ High school graduat¢ or GED completed ~ No, no[ Spanish/Hispanic/LaSlna Q American Indian or Alaska Native Q Other Asian Q Some college credit, but no tlegree Q Yes, Mexican, Mexican American, Chicano Q Asian Indian ~ Native Hawaiian Q Associate degr¢e (e.g. AA, AS) ' Q Ves, Puerto Rican Q Chinese Q Guamanian or Chamorro Q Bachelor s degree (e.g. BA, AB, BS) Yes, Cuban Q Q Filipino Q Samoan Master's de ~ gree (e.g. MA, M5, MEng, MEd, MSW, MBA) Q Yes, other Spanish/Hispanic/Latino Q Japanese Q Other Pacltic Islander Q Dottorate (e.g. PhD, Ed D) or Professional degree (Specify) Q Other (Specify) . MD 005 DVM LLB JD 21. Decedent's Single Race Self-Designation -Check ONLY ONE to indicate what the decedent considered hims¢If or herself to be. 22a. Decedent's Usual Occupation -Indicate type of work ® White Q Japanese Q Samoan done ^uring most of working Iif¢. OO NOT USE RETIRED Q Black or African American Q Korean . p Dinar Paaflc. Islander Q American Indian or Alaska Native Q Vietnamese Q Don't Know/Nat Sure Boo/1KE6PEi2 Q Asian Indian Q Other Asian Q Refused 22b. Kind of Business/Industry Q Chinese Q Native Hawaiian ~ Other (Specify) nn Q Filipino Q Guamanian or Chamorro IOMMIaN Its( SSfL JtcE ITEMS 23a - 23d MUST BE COMPLETED 23a. Date Pro unce BY PERSON WHO PRONOUNCES OR 4~ ead (MO Day Vr) 23b. Signa of Person Pron n D¢ath (Only when applicable) Num er ,/~ CERTIFIES DEATH 23d pate Si d (MO/ 24 Ti f ` !~ 0~ ~j~ /~ ~~~ ~~~ y g y . m Dea' / ~J O ~}x 25. Was Me al miner or Coroner ContactedT Q Ves No a CAUSE OF DEATH A r i t pp ox ma e 26. Parr 1. Enter the chain of events-diseases, injuries, or complications-that directly caused th¢ death. DO NOT ¢nter t¢rminal events such as cardiac arrest Int¢rval: respiratory arrest, or ventricular flbrillatlon without showin gs eSlplogy. DDO NO ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary Onset to Death IMMEDIATE CAUSE -----> ~/r///c (I~ ~ ~ (Final disease or condition Du¢ [o (or as onsaqu¢nc¢ of): r¢sulting in death) b. Sequentially Ilse conditions, pue to (o as a consequ nee of): if any, leading to the cause listed on Iin¢ a. Enter the UNDERLYING GUSE Due to (or as a consequence of): (disease or Injury the[ initiated the events resulting d. In death) LAST. pue [o (or as a consequence of): rj 26. Part II. Enter other significant conditions contribut'n o death but not resulting to the underlying cause given in Part 1 27. Was an autopsy performed] D Yes No ~ L 28. Were autopsy findings available m _ to complete the cause of death? (] Yes O No 29. If Female: 30. Did Tobaccq Use Contribut¢ to Deaths 31. Manner of Death o No[ pregnant within part V¢ar ~P t t ti f d h Q Yes 0 Probably -~ NaTU ral Q Homicide m regna n a me o eat Q~ Not pregnant, but pregnant within 42 days of death Q No ~ Unknown Q Accident 0 Pending Investigation Q Suicide Q Could not be determined ~- Q~NOt pregnant, but pregnant 43 tlays to 1 year before deatF 32. Date of Injury (MO/Day/Vr) (Spell Month) Q Unknown if pregnant within the pas[ year 33. Time of Injury 34. Place of Injury (e.g. home; construction site; farm; school) 35. Location of Injury (Street and Number, City, State, Zip Code) 36. Injury at Work 37. If Transportation Injury, Specify: 38. Describe How Injury Occurred: Q Ves Q DNVer/Operator Q Pedestrian Q No 0 Passenger Q Other (Specify) 39a. Certifier (Check only one): ~CCertitying physician - To the best o£ my knowledge, death occurred due to the cause(s) and manner stated Q Pronouncing H. Certifying physician - To th¢ best of my knowledge, death occurred at the time, date, and place, and due tp the cause(s) and manner stated Q Medical Examiner/Coroner- n the of examination, a r rnvestigation, In my opinion, death occurred at the time, dale, and place, and due to the a u e(s) and c s m stat e d Signature of certifier: / - am / ~ pQ / /{ ~ p Title of certifier: License Number: t'r / Q ~ / / / f:,Q /~' 39b. Name'( Address and Zip Code of Person Completln Cau of Death (Item 26) 39c. Date Signed (M /Day/Yr) I en +Tn vJPi O G Jwr c ~ V e Cat ~>S ~P 1 7Q ~ ) 40. Re istrar's District Number 41. Reg? Si natu 42. Registrar File Date (MO Day r) 4 .Amendments - Disposition Permit No. ~ / ~ ~ % f ~ H305-143 GG REV 07/2011