HomeMy WebLinkAbout06-02-12PETITION FOR GRArT OF LETTERS
REGISTER OF ~~'ILLS OF COU~iTY. PEN`~1SY"LV aNI:-~
~et:C10Cc'~~~) ,-~:Ired Je~C~.6. ~,~':10 i~,fi:_ l;~ '~ -, ~ ~~. ~ ;
`tiearS ~: CC Or(le.. 3~~pi ".e~j f~ L~~tle:~ a5 ~~Z~Ii.c'i: bC 0~ti'. r~ill~ 1
s~:pport therec aver{sj tie tollo•,v;n and respectfully, ec,tiest(s) the U:art o; Letters uz the appropriate .`orm:
Decedent's Information 1
Name• ~~ ~J , /~-ce d ~ih~ File No• /~l " ~ ~. ~ ~ ~ 7
a/k,'a: (Assigned by Register)
a,'k,'a: _
a/k/a: Social Security No: ~~~ ~ ~~ - ~ ~ ~~
Date of Death: ~~~~?? Age at death: 7~
Decedent was domiciled at death in sc, ~1~~~~0 County, ~ (Stare) with his/her last
principal residence at ~ t23 t,JgNt~.r,:. ~jly ~iE ~ ,CC ~~~t4 r~~lfX//~
Street address, Post Office and Zip ode City, Township or Borough Cou
Decedent died at ~ ~{ Z it,~~~~1 ~ ~ ~ ~, ~/~~ t~ G~ ~}.er,~~i.~l,/~`4 ,~,~
Street address, Post Office and Zip Code City, Township or Borough County State
Estimate of value of decedent's property at death:
If do»:iciled in Pennsylvatria ............................ All personal property $ ~~~ D ° O
!f not domiciled in Pennsylvania ........................ Personal property in Pennsylvania $
If not domiciled in Pennsylvania ........................ Personal property in County $
Value of real estate in Pennsylvania ......................................................... $ ~ ~ O
TOTAL ESTIMATED VALUE.... $ ~ v , yU c
Real estate in Pennsylvania situated at: ZfZ 3 1.,~~nt{~~.tz,~l7t ®~ ~A.jn~ (-~CL. C-~-.~~~-r-!/rV
(Attach additional sheets, ijnecessary.) Street address, Post Office and Zip Code City, Township or Borough County
A. Petition for Probate and Grant of Letters Testamentary Gr ( ,~ c
Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated ~ (, ~ ~ and Codicil(s)
thereto dated
State relevant circumstances (e.g. renunciatiar, death of executor, 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.,t.c.t.a., pendente lice, dttrunte absentia, durunte minoritate
If Administration, c.t.a. or d.b.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 heirs (attach
aclditiona! sheets, ijnecessary):
,a
Name Relationshi Address S'~ N =z'
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V
cri 1'V '
Q
Q ~___~ ~
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Fors, aw-nz ,~~~. !nilvzn!! Page 1 of 2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA }
SS:
COON"I'Y OF } oee~~ai u5~ oniyr=
r`T1 C..
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r-r - r"'- r`i
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Petitioner(s) Printed Nome Petitionerls) Printed
A
ddress nC~ ~
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~
The Petitioner(s) above-named swear(s) or affirm(s) the statements in the foregoin 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 Pe ' to r(s) wil l y administer the estate according to law.
Sworn to r affirmed an~~5ubscribed before l ~' Date 6 - l2 ~z-
meth' ~_t~day_of, G/.? , Zv~Z `~` Date
BY~ ~%' /t--'~ ~ '~ Date
Register
Date
BOND Required:~YES ~NO
FEES:
Lette s ......................
( ~) Short Certificate(s)..... .
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commission ................. .
$ ,~
~~
Otie! - ....... '
t`
."_
Autotnatioit Fee .............. .
~O
JCS Fee . .................... ~
TOTAL ..................... $ .. 1
To the Register of Wills:
Please enter my appearance by my signature below:
Attorney Signature:
Printed Name:
Supreme Court
ID Number:
Firm Name:
Address:
Phone:
Fax:
Email:
DECREE OF THE REGISTER
Estate of ~i ~~ ~ ~,~~, ~~f~/ /~ File No: ~ / ' ~Z -
a/k/a:
AND NOW, ~~ /'f ~ / Z U ~ , in consideration of the foregoing Petition,
satisfactory proof having been presented before tne, IT IS~CREED that Letters _ -
are hereby granted to ~'~~/'/~ . ~/~J t'% „f~~
in the above estate and (if applicable) that
the instrument(s) dated ~
described in the Petition be admitted to probate
F~,~,,, Rw-na rw. tnilliznlt
filed of record as the last W' 1(and Codicil(s)) of Decedent.
L~ ~ ,~.
Register of Wills ~ u ~ ,~,t`~,_-
Page 2 of 2 "
_~ ~,. d ~,
l~i':' f~:jr Ui;, i.utili;ii( tili.i;,1 >c'~IL ~~~ 12 PN, G' ~~
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,: ~`
fl r ,^ ~ f -~ ~ ~~ CUMBERLAND CO. f , ~ // /~
Cam'` .i ~ (.~ ~ h.) ,~ "~ ~°`
:~r;ili .,u. I ;,I~~t
Type/Pri nT In COMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF HEALTH ~ VITAL RECORDS
Permanent CERTIFICATE OF DEATH
State File Number:
q~q_
r~.
lack In k
1. Decedent's Legal Name (Fl rst, Middle, Last, Suffix)
2. Sex 3. Social Security Number 4. D to of Deaih (MO/Day/V r) (Spell Mo)
PANL W%NDSoR H Ti// /~9ALC ,SSS- 'a/6 -'7 '~3~ ~v/L)E /L ~ZaL.Z
6a. Age-Last Birthday (Yrs) 6b. Under 1 Year Sc. Under 1 Da 6. Date of Birth (MO/D ay/Vear) (Spell Month) 7a. Birthplace (City and State or Foreign Country)
, Months Days Hours Minutes ~
/936
~ MO E T CA-
76 ,
/
9/vRCN 7b. Birthplace (County) ,S'T/j/~//SL q
once (Stara or Foreign Country)
8a. R
esid 8b. Residence (Street and Number -Include Apt No.) 8c. Did Decedent Live in a Township?
2
-
T7~./NSY LVItw/iA Yes, decedent lived In ~eh/Lri~ /rjLG 6/J twp.
Bd. Resmenpe (county) of / ~$ BIdTLa~o RTH ~R.
CWa/ ESL ey 8a. Residence (Zip Code) / 70 // Q No, decedent lived within limits of city/boro.
9. Ever in US Armed Forces? 30. Marital Status at Time of Death Q Married Q Widowed 11. Surviving Spouse's Name (If wife, give names prior to first marriage)
Q Ves ~ No Q Unknown Q Divorced )Never Married L7 Unknow
12. Father's Name (First, Middle, Last, Suffix)
13. Mother's Name Prior to First Marriage (First, Middle, Last)
GNA/ WEw/DEI-t_ AN T/~1 /E T
14a. Informant's Name 14b. Relationship to Decedent 14c. Informant's Malting Address (Street and Number, City, 6Tate, Zip Code)
g o GAR NDE ScvL/ ~~ ..J S 35G /L,/oc.i Dq R D. M i/IJNdroN.r M n/ .SS3 a/S
G _
.......................................................... .......................................
r~w -~
atient ~
In
H
it
l
d 1 .':.. acgo--Dear , c ec ________ ____ __ .....
... .........on y one _ __ _ __ _
urred Somewhere Other Than a Hospital: ~ Hospice Facility ~ Decedent's Home
If Oaath Occ
~ p
in a
osp
a
If Death Occurre
: LJ
Q Emergency Room/OUtpatienT Dead on Arrival _ Nursing Home/Long-Term Care Facility Other (Specify)
16b. Facility Name (if not institution, give street and mbar; 15c. City or Tow=, State, and Zip Code 1Sd. County of Death
T N/A /.. ~Y/RC Fi./T C T C/9 /e L / t. rc Q / 70 / L^V
16a. Method of DisposiTion Q Burial ~ Cremation 16b. Date of Disposition 16c. Place of Disposition (Name of cemetery, crematory, or other place)
(] Removal from State Q Donation
l
E
/
o
other (specify) o/R
„T4w/6 /.? /IJ ,e
icK
!/i!N Ti
16d. Location of Disposition (City or Town, State, and Zip) 17a. Signature of Funeral Service Licensee or Person in Charge of Interment 17b. License Number
~ /-1AEFF~.e57~e/i./ A-. L7o~r9 `!~~ ~/2/T2 ~.
17c. Na nd Complete Address of Funeral Facility
'
3 70//
/LL /~/ t. GI:T ST. tic ~. .4. (
°.i6 18. Decedent's Ed ucaYlon -Check the box that best describes the 19. Decedent of Hispanic Origin -Check the 2 .Decedent's Race -Check ONE OR MORE ra o Indicate what
t
f- highest degree or level of school completed at the time of tleath. box that best describes whether [he decedem th decedent considered himself or herself to be.
Q 8Th grade or less Is Spanish/Hispanic/Latino. Check the "NO" ~ White 17 Korean
an American Q Vietnamese
r Afri
i
Bl
k
no.
ac
o
c
Q No diploma, 9th - 12th grade box If decedent is not Spanish/Hispanic/Lat
Q High school graduate or GED completed $( No, not Spanish/Hispanic/Latino Q American Indian or Alaska Native Q Other Asian
Q Some college credit, but no degree (] Yes, Mexican, Mexican American, Chicano Q Asian Indian O Native Hawaiian
p Associate degree (e.g. AA, AS) Q Yes, Puerto Rican Q Chinese Q Gua manlan or Chamorro
Bachelor's degree (e.g. BA, AB, BS) (~ Yes. Cuban Q Filipino (] Samoan
Master's degree (e.g. MA, MS, MEng, MEd, M6W, MBA) Q Yes, other Spanish/Hispanic/Latino Q Japes nose Q Other Pacific Islander
17 Doctorate (<.g. PhD, Ed D) or Professional degree (Specify) L7 Other (Specify)
. MD, DDS DVM LLB, JD
21. Decedent's Single Race Self-Designation -Check ONLY ONE to indicate what The decedent considered himself or herself to be. 22a. Decedent's Usual Occupation -Indicate type of work
White Q Japanese Q Samoan done during most of working life. DO NOT USE RETIRED.
0 Black or African American Q Korean Q Other Pacific Islander
Q American Indian or Alaska Native Q Vietnamese Q Don't Know/Not Sure MRNRG62
0 Asian Indian Q Other Asian [~ Refused 22b. Kind of Business/Industry
Q Chinese Q Nafiye Hawaiian [] Other (Specify)
O
Q Filipino Q Guamanian or Chamorro pOp/C S"r'oac
ITEMS 23a - 23d MUST BE COMPLETED 23a. Date Pronounced Dead (MO Day/Yr) 23 b. SignaTUre of Person Pronouncing Death (Only when applicable) 23c. License Number
BV PERSON WHO PRONOUNCES OR O ~~ Q L `-T.. ~. /J _ ~f `x~Aj ~ ~ ~ ~ $ 3 ~~, ~L-
CERTIFIES DEATH
-,
C
C'-~'L
i
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-
~
23d. OaU Si ned Mo/Oay/Vr) 24. Time of Oea
LO Q ~ Q ~ Q 25. Was Medical Examiner or Coroner Contactetl7 Yes ~ No
CAUSE OF DEATH Approximate
YY
26. Part 1. Enter the chain of eyepts--diseases, injur mplications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest Interval:
SO
D
eath
respiratory arrest, or v¢ntrictllar fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary Onset
.
`
>
IMMEDIATE CAUSE --------------o> a. ~ SL'~1 ~ ~ V ~ ~V ~~~~
(F nal m:ease or condition ~ Due to (or as a consequence Of):
resulting in death)
b.
Sequentially list condiTlons, Due to (or as a consequence of):
if any, loading to the cause
listed on Tine a. Enter the
UNDERLYING CAUSE Due to (or as a consequence of):
(disease or injury that
c Initiated the events resulting d.
In death) LAST. Due to (or as a consequence of):
~
S b
T noT resulting in the underlying cause given in Part I
26. Part 11. Enter other significant conditions c iributing to
d
ea
t h
u 27. Was an autopsy performed?
'
c
~
'IC
~
)N>
~~
~
4 ~
(~l~c
S No
Q
~
, \
(
~
.
~
, 28. Were
a u<o PSV findin
ilable
gs ova
as to complete the cause of deaths
[7 Yes O No
29. If Female: 30. Did Tobacco Use Contribute to Death? 31. Manner of Deaih
o Q Not pregnant within past year Q Yes Q Probably ~ Natural Q Homicide
Q Pregnant at time of death Q No ~} Unknown Q Accident Q Pending Investlgatlon
°~ Q Not pregnant, but pregnant within 42 days of death Q Suicide Q Gould not be determined
~ Q Not pregnant, but pregnant 43 days to 1 year before death 32. Date of Injury (MO/Day/Vr) (Spell Month)
Unknown if pregnant within the past year 33. Time of Injury
34. Place of Injury (e.g. home; construttion 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:
(] Ves Q Driver/Operator Q Pedestrian
Q No Q Pass¢nger Q Other (Specify)
39a. Certifier (Chock only one):
Certifying physician - To the best of my knowledge, death occurred due to the cause(s) and m r stated
Q Pronouncing 6 Certifying physician - To The bast of my knowledge, death occurred at the-time, date, and place, and due to the cause(s) and m rated
r
to the cause(s) and manner stated ''
[] Medical Examiner/Coroner - On the basis of examination, and/or Iny¢stigation, in my opln ion, death occurred at the time, date, and place, and due
fT T O L 4 ~ Y L ~
~~ ~3 ~3 i ~ ~" ~
~
License Number:
Title of certifier:
Signature of certifier:
39b. Name, Address and ZI Code of Person Completing Cause of Death (Item 26)
-L '7
~ 39c. Date 5 ned Mo/Day/Vr)
Lvt~So-. ~ ~'Wc ~~~^r~i\. P A
G C a n c.
- ~ n2 .~ S cv •'7-~ 8 •-~ mlr~ L t ~ 1 ~
40. Registrar's District Number 41. istra is Signature 42. Registrar Files Date (MO Day/Yr)
~3 alic/ - ./ -cam/Z
43. end menu
Disposition Permit No. O - / (/ ~ ~J 1 H305-143
REV 07/2011
LAST WILL AND TESTAMENT OF PAUL WINDSOR AUSTIN
I, Paul Windsor Austin, of Camp Hill, Cumberland County,
Pennsylvania, being of sound mind and memory, do make, publish and declare
this my Last Will and Testament, hereby revoking any and all Wills by me
heretofore made.
FIRST: I direct that my funeral be conducted in a manner
corresponding with my estate and situation in life, and that all my just debts
and funeral expenses be paid and satisfied by my Executor hereinafter named,
as soon as conveniently may be after my decease.
SECOND: I give, devise and bequeath to Train Collector Association
of Strasburg, Pennsylvania, my model train collection, including all related
equipment.
THIRD: I give, devise and bequeath all of the rest, residue and
remainder of my estate, both real, personal and mixed, of whatsoever kind and
wheresoever situate, to Gaylord Ralph Wine; providing however, that said
devisee survives me.
FOURTH: If my aforesaid residuary estate cannot be distributed
under the preceding paragraph, I then devise the same to Roger Anderson of
Minneapolis, Minnisota.
FIFTH: I hereby nominate, constitute and appoint Gaylord Ralph
Wine, to be the Executor of this my Last Will and Testament. If the said
Gaylord Ralph Wine, is unable or unwilling to serve as such, I then appoint
Roger Anderson to serve in such capacity. I direct that my personal
representative be excused from entering and/or filing any bond to assure the
proper performance of his duties.
r
~ ~ ~
~ ~~ ~
PAGE 1 OF 2 PAGES
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IN WITNESS WHEREOF, I have hereunto set my hand and seal this
day of October, 2004.
~~ESTATOR ,,~
i ~ /f
~~ ~ , (SEAL)
J PA L WINDSOR AUSTIN
WIT ~SSED:
~ ~' ~_ ~; ADDRESS f ~~4-~f~l~~ ~'Y~~f ~~ ~ C C~./LC>,/77/~ T/r /rL'//
~`.~+ ~f ADDRESSr-~i~~~~7~'T~~" ~~~L~'~ (.~,LG~9..~ !~I/~ ~/`I /~t~'~
c
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF Cumberland
~§
Paul Windsor Austin, the Testator, and the above witnesses, whose
names are signed to the foregoing instrument, being first duly sworn, each
hereby declares to the undersigned authority that the Testator signed and
executed the instrument as his Last will and Testament in the presence of the
witnesses and that he had signed willingly, and that he executed it as his
free and voluntary act for the purposes therein expressed, and that each of
the witnesses, in the presence and hearing of the Testator, signed the Will as
witness and that to the best of their knowledge the Testator was at the time
eighteen years of age or older, of sound mind and under no constraint or undue
influence.
Subscribed, sworn to and acknowledged before me by the Testator and
the witnesses, this ~2°"day of October, 2004.
.~
NOTARY PUBLIC
Notarial Seal My Commission Expires
Norman M. Yoffie, Notary Public
Camp Iiili 13oro, Cu;riberland County
My Commission Expires Aug. 26, 2005
PAGE 2 OF 2 PAGES
P.W. .
austin\will.pwa
H 105905 RFV.(8/I I)
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.
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WARNING: It is illegal to duplicate this copy by photostat or photograph.
c?,= Or
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~~ .~ Marina O'Reilly Matthew
" ~ ~ State Registrar
OTC ~
6 119 8 :~ ~ ~ ~~ ~
No.
Date
Type/Print In COMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF HEALTH ~ VITAL RECORDS 002 944
Permane"` CERTIFICATE OF DEATH
Black Ink State File Number:
1. Decede nT's legal Name (FirsS, Middle, Last, Suffix) 2. Sex 3. Social Security Number 4. Daie of Death (Mo/Day/Yr) (Spell Mo)
Ga lord Rat h Wine Male 264-52-2430 January 14, 2012
6a. Age-Last Birthday (Vrs) 6b. Untler 1 Year Sc. Under 1 Da 6. Date of Birth (MO/Day/Vear) (Spell Month) 7a. Birt place (City and Sta r Foreign Country)
~
~~
Months Days Hours Minutes licago, 2
C
74 Feb ~ 1 6, l 937 Yb. Birthplace (co„nty) Cook
8a. Residence (Slate or Foreign Country) 8b. Residence (Street and Number -Include Apt Nn_) Sc. Did Decedent Live in a Township?
PA 21 23 Wentworttl Dr fives, decedent lived In Lower Allen twp.
8d. Residence (County)
Cumberlant3 8e. Residence (Zip Code) 1 701 1 ~ NO, decedent lived within limits of city/boro.
9. Ever in US Armed Forces? 10. Marital STatus of Time of Death C] Married C] Widowed 11. Surviving Spouse's Name (If wife, give name prior to first marriage)
Yes Q No ~ Unknown D Divorced Never Married O Unknow
12. Father's Name (First, Middle, Last, 6uf£x) 13. Mother's Name Prior to First Marriage (First, Middle, Lasx)
Paul G_ Wine unavailable
14a. Informant's Name 14b. Relationship to Decedent 14c. Informant's Mailing Address (Street and Number, CITY. State, Zip Code)
0
Paul Austin Executor
2123 WentwortPl Dr Cam Hi11, PA 17011
......_
....
......_..-....-.-............-.-.......-
......
................. ............ 15 a. Place of Death Ch k I _ _
_
...-. .-..-.....-.-.--..-.-.-.-.-_ ec nn y pne......................-.........--
_
.
.
.
.
in a Hos ital- ~] In tient ~
If Death Occurretl p pa _ _
____ __ _
If Death Occurred Somewhere Other Than a Hos tai: (] Hos Fa cilli ~J Decedent's Home
pi pice y
~{$ Emergency ftppm/Outpatient Q Dead on Arrival -_ Q Nursing Home/Long-Term Care Facility ~ Other (specify)
ad 156. Facility Name (If not institution, give street and number; I6c. City or Town, State, and Zip Code 15 d. County of Deaih
1 i 11 1 7 1 1 L1.imberland
16a. Method of DisposlTlon Burial ~ Cremation 16b. Daie of Disposition 16c. Place of Disposition (Name of ce mefery, crematory, or other place)
Removal from States Q Donation
1 2
/2
ti
l C
t
S
di
t
G
N
p otner(spe"Ify) 1 /24
0 own
ona
eme
ery
n
an
ap
a
16d. Location of Disposltlon (City or Town, State, and Zip) 17a. Sign atur % u sal se ¢ Li or Person in Charge of Interment 1?b- License Number
Annville, PA 17003 ~/ E"D 013239 L
E 1?c. Name and Complete Address of Funeral Facility
Neill Funeral Home Inc 3401 Market 8"t_ Hi11 PA 17011
18. Decedent's Education -Check the box Shat besT describes The 19. Decede nT of Hispanic Origin -Check the 2D. Decedent's Race -Check ONE OR MORE races to indicate what
m highest degree or level of school completed ai the time of death. box that best describes whethe the de ede t
n the de etlent considered himself or herself to be.
~ 8th grade or less s Spanish/Hispanic/Latino. Check the' No" ® White ~ Korean
~ No diploma, 9th - 12th grade box if de ede t Spanish/Hispanic/Latino. Q Black or African American ~ Vietnamese
Q High school gratl uate or GED c mpleted ~ No, n I Spanish/Hispanic/Latino Q American Indian or Alaska Native ~ Other Asian
~ Some college credit, but no degree ~ Yes, Mexican, Mexican America ,Chicano Q Asi n Indian ~ e Ha
Q Associate degree (e.g. AA, AS) Q Yes, Puerto Rican Q Chinese Q Gue manlan o aChamorro
`g] Bachelor's degree (e.g. 0A, A6, H6) Q Ves, Cuban ~ Filipino 0 Samoan
~ Master's degree (e.g. MA, M6, MEng, MEd, M6W, MBA) ~ Ves, other Spanish/Hispanic/Latino Q Japanese ~ Other Pacific Islander
~ Doctorate (e.g. PhD, Ed D) or Professional degree (Specify) C] Other (specify)
(e. MD, DOS, DVM, LLB, JD)
21. Decedent's Single Race Self-Designation -Check ONLV ONE to indicate what the decedent considered himself or herself fo be. 22a. Decedent's Usual Occu pafion -Indicate type of work
White Q Japanese Q Samoan done during m of working life. DO NOT USE RETIRED.
0 61ack or African American Q Korean ~ Other Pacific Islander ACCOUtant
Q American Indian or Alaska Native ~ V ~ pon't Know/Not Sure
Asian Indian ~ OShe aA ~ Refused 22 b. Kind of 0usiness/Industry
p Chinese Q Native Hawaiian ~ OTher (Specify)
ln'tPl"na t1Ona1 SY11pp1ng
Filipino Q Guamanian or Cha mono
ITEMS 23a -23d MUST BE COMPLETED 23 a. Date Pronou ncetl Dead (MO/Day/Yr) 236. Signature of Person Pronouncing Death (Dnly when applicable) 23c. License Number
BY PERSON WHO PRONOUNCES OR
CERTIFIES DEATH
1 /1 4/201 2
23d. Date signetl (MO/Day/Yr) 24. Time of Death
4 ~ 2rj A31[ 25. Was Medical Exa miner or Coroner Contacted? ~ Yes Q No
CAUSE OF DEATH Approximate
26. Part 1. Enter the chain of events--diseases, injuries, or com plicatlons--that directly caused the death. DO NOT enter terminal events such as ca rdlac arrest, Interval:
a
th
showing the tiolpgY~ DO NO
T
ABBREVIATE. Enter only one cause on a line. Add additional lines iF necessary Onset to De
respiratory arresT, or ventricular fib rillaiion without
\
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~~
\
~.
IMMEDIATE CAUSE ---------------> a. ~ f ~ ~~y 1 C V wl// 1 ~i t" ~ Y I I 1!~~~ {~/11 /) //~F'J
(Final disease or condition Due o (or quence of):
resul[Ing In death) b SV S~-C ~ t ~~asa~~~l/~- - / ~~
sequentially Iisx conditions, Due to (or as a consequence of):
if any, leading io the cause
listed on Ilne a
Enter the
.
_
UNDERLV ING CAUSE Due to (or as a consequence of): _
(disease or Injury that
'n lciated the ev nts resulting d.
e
in death) LA6T.
Due io (or as a consequence of):
S 26. Part II- Enter other sieniflca nt conditions c tributine to death but not resulTing in the underlying cause given in Part I 27. Was an autopsy Perfo med?
O Yes No
~ 28. Were a opsy findings a aila ble
m to mpleie <he cause of death?
cq
0 Yes O No
29. If Female: 3O. Dld Tobacco Use Coniribufe xo Death? 31
M
a
n her of Death
o ~ Not pregnant within past year ~ Ves Q Probably ,-
~.
't
~ lV atu sal ~ Homicide
~ Pregn n[ a me of death
i ~~IVO ~ Unknown ~ Accide nx Q Pending Investigation
~ Not pregn ant
, but pregnant within 42 days of death ~ Suicide ~ Could not be determined
~ ~ Not pregnant, but pregnant 43 days to 1 year before death 32. Date of Injury (MO/Day/Vr) (Spell Month)
~ Unknown if pregna nT within xhe prix 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 Tra nsportation Injury, Specify: 38. Describe How Injury Occurred:
0 Ves O Driver/Ope ator O Pedestrian
r
Q No Q Other (Specify)
~ Passenger
39a. ertifier (Check only qne): '
Certifying physician - To the best of mY knowledge, death occurred due to the cause(s) antl m r stated
a
e
nd place, and duet the c e(s) and m ed
da
a
~ Pronouncing ~ Certi ng physicla - To the b of my kn wledge, death o red a( the t
s i
o
t
the ca (s) and mann
ed
at
nd/or Investigations In my opinio ~ d
h
urred at the tim eod ate, and place, and du
e
~ edical Examiner/ tuner - On the basis
in
ati
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n
o
c
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License NuTrtbe
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Title of c rtifie _
slg
of certifier. ~"
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e
A tlress and de of Per n Completi Cause of Deaih (Item 26)
) ~
p. Name 9c. signe (MO/Day/Yr)
4D. Registrar's Dis r tt Number
t ` 41. Re Signature 42. RegisTrar File Date (Mo/Day/V r)
a ,
- ~ ~ ~ ~ ,.. .t , s l a~-1 ~
43. Amendments
r,~~....~~ri.... Pnrmir nin ~ ~ ti .?~-f H10S-143
/ J~t/ REV D-i/enJJ