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IN THE COURT OF COMMON PLEASE OF CUMBERLAND COUNTY,
PENNSYLVANIA
IN RE: Pe66V ANN Q U dKk ei 4-
NAME CHANGE OF File No. /-? - LI?2 ?o-2-
SURVIVING SPOUSE
NOTICE TO RESUME PRIOR SURNAME
(PLEASE PRINT OR TYPE)
Notice is hereby given that the above named Petitioner,
PF-6-56 Y A NU ke-i t , rending at,
/70.11 ,being a
Surviving spouse as of A prj L- 1 22-
hereby intends to resume and hereafter use the previous name of
and gives this
written notice avowing his /her intention pursuant to the provisions of 54 Pa.C.S. § 704.1. A Certified c?)py of
the Certificate of Death for the decedent is attached.
Date: _ BTU 1 j q ?0 4
Signature of etiti
Signature bfname being resumed
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
,;,
On the ? day of before me, the Prothonotary or the notary public,
personally appeared the abov affiant known to me to be the person whose name is subscribed to the wit
document and acknowledged that he / she executed the forgoing for the purpose therein contained.
In Witness Whereof, I have hereunto set my hand and official seal.
Notary Public
D
(Note: This notice must be accompanied by an original certificate of death for the deceden
;11"p x 1?,
JUL. - 9 Pm ("
FItEN #SYt VANIA
r?
k* At --? 2 2 ;? --5°!`
This is to certify that this is a true copy of the record, which is on file in the Pennsylvania. Department of Health, in acc3rdance with
the Vital Statistics Law of 1953, as amended.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Marina O'Reilly Matthew
State Registrar
6805666
No.
Type/Print In
Permanent
JUN () 4 2012
[,late
(07
r?J(
I:-
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
IP'c QTil rid-AkTc AC f1C/LTL.a
1. Decedent's Legal Na, m(First, Middle, Last, 51ffi1) 2. Sex 3. Social Security Nu mber?t N4. Dace !1h ( o/Oay/Yr) (Spell Mo)
Robert L_ Buckhelt I. 209-46-1711 A r.\ 02 ac'1 oZ
Sa. Age-Last Birthday (Yr.) 5b. Under 1 Year 15- Under 1 Da 6. Data of Birth (M./pay/Year) (Spell Month) ]a. Birthplace (City and State or Foralgn Co ntry)
55 Month. Day. H„r. February 7
1957
, ]b. Birthplace (County)
8a. Residence (State or Foreign Country) 8b. Residence (Street and Number - Include Apt No.
DDeredent Liv. in a Township?
1 1 O Kral l CT ... d, I-
Bd. me
t
C) r K Residence (Zip Code) 1 -dent li-d
witnln hmi<a city/born.
9. Ever In US Armed Forces? 10. Marl[al Status at Tlme of Death i d 0 Wldowetl 13. Surviving Spouse's Na (If wife, give name prior to fi
rr s marriage)
Q Yes E3 No Unknown E3 Divorced Q Never Marled
QUnknown Peggy Marseano
12. Father's Name (First, Middle, Las[, Suffix) 13. Mother's Name Prior to First Marriage (First, Mddle
Last)
,
John P_ Buckheit m
-
a
In
14a. forman<'s Name 141b. Resat unship Dee 14c. Informant's Mailing Address (Street and Number, City
State
Zip ',del
ffi ,
.
PeggY Buckheit 11
Wi a 110 Krell Ct
G
g ................................................
oeac ec on y on!
....-.. ......................................,.. } a. v ace o
......................
nT -"--"'--.................. ---
It OeaM occurred In a NosPital: -}n
tl
d
-
^
e
If
Pa
each Occurre
S,mewhere Other Than a Hospital: ?(
HOSpf
acllity
E - -----
rodent's Home
mer ency Room/Outpatle t Dead on Arrival _ Nursing Home/Long-Term Cara Faclliry Other (Specify)
F
35b
ilit
.
ac
y Nam! (I/ not Instltutlon, give street and number; 1 c. CiTy or Town, State, and Zip Cotle 151. County of Death
Ycr
tto Kc??\ C?. c11y
16a. Method of Disposition 3ILX Burial CJ ci,-a IOn 1 b. Data of Disposition 16c. Place of Disposition (Name of cemetery, crematory
or other lace)
,
C3 Removal frofpSeCite pDOnatl,n 4/30/12 Tncliantown Gap NEk t. tonal c
Ocher 5 fy)
y
meter
Z _
Sbtl. Location of Disposition (City or Town, State, and Zlp) 1 a. Signature of Funeral 5 rvlce Licen a or Person In Charge of Interment 1]b. License Num b
a e
Ann%r111e, PA
0118 5-L
1]c. N d Com late
oT Funeral Facility
Siayon?
s H 206 Ma le A%,e _ Mar sv lle PA 1 7
053
4-
2
,
. Decedent's Education eck he box that best describes the 19. ecedent of Hispanic Origin - Check the 2D. Decedent's Rare - Cher k ONE OR MORE r ad t
i
di
,-
highest degree or level of school completed at the time of death. box hat best describes whether the decedent the decedent co-dd himself ,r herself to o
n
-
cate what
E3 Rh grade or less Is 5 nish/Hispanic/Latino. ('.heck the "NO" hit. 0 Kor an
E3 No diploma, 9th - 12th grade box decedent I. not Spanish/Hispanic/Latino. E3 Black or African American E3
r3 High school graduate or GEO tom pletetl not Spanish/Nispanic% Latino C3 American Indian or Alaska N-1- E3
S Asa
[]
ome ge credit, but no Mexican, Mexican E3 Asian Indian []
A
i Hwallan
C3
ssoc
ate degre(gAA, AS) Puerto Rican
E3 Chnese []
B
h
l
'
;
.oor Chamorro
e
`
[]
ac
e
or
s degree (e.g. A, AB. BS) Yes, Cuban
t] E3 Filipino
' -
}Master
s degree (e.g. MA, M5, MEng, MEd, MSW, MBA) Ve sther panish/Hispanic/Latino [] Japan¢se []
h 1%
.
f,
Islander
C] Uoctorste (e.g. PhD, Edo) or Professional degree (Specif
) E3
y
Other (Specify)
. MD DDS OVM LLB JU --
21. Decedent's Single Race Self-Designation - Check ONLY ONE to Indicate what the decedent considered himself or herself to be
22a
D
d
t'
.
.
.ce
a n
s Usua10,, F.t..n -
M White E3 Japan E3 Samoan d
d
i
s• Indicate type of work
one
ur
ng most of working Ilfe.
E3 Black or African Amer;- C3 Korean
E3 Other Pacific Islander O NOT USE RETIRED.
Bu s J. ne s s
E3 American Indian or Al.- Native E3 Vietnamese E3 Don't K aw/Not sure Wne
)3 Asian Indian E] Oth
A
i
er
s
an C3 Refused 22b. Kind of Business/Industry
E3 Chin- E3--Hawauan E3Other (sp-1Y)__ Janit
i
l
or
a
S
C3 Filipino C] Guamanian or Chamorro rviees
MS - 2Sd MUST SE COMPLETED 23a. Date Pronounced Deatl (MO Day r) 23b. Signature at Person Pronpuncl g Dea[ (Only when apPlica hie!) 23c. Li
oY PERSON WHO PRONOUNCES OR A (-t a a a o t a
//
N.Y..
'] ! se Number
SIR-
.y
`i
/
23d. at.
Signed (MO Day/Yr) 24. Time of Death
°
f oZ G l a S -. L4 7 /?t
- 25. W a Madical Examiner nor Contacted?
Y Q Nq
CAUSE OF DEATH
26. Part 1. Enter the chaln of everlts--diseases, Injuries, or complications--that directly caused the death. DO NOT enter terminal e s such as tardier ii
[ Approximate
i
as
,
re.Pi, -- arrest, or ventricular fibrl 11- ion without showing the etiology. DO NOT ARBREVIATE Enter only one cause on a hne. Add additional linos If
{ nterval:
O
necaasa
IMMEDIATE
CA
USE y
nset to DestM1
.1
(Final disea
se
o
r r
co
ndihon Due to (o as a consequ nc of):
--_-- '-- -
resultinB In deatM1) ??\\
Sequa
list condltlons, Due to (or as a consequence of):
I
if any. loading to the "U"
n
listed on Ilne a. Enter the
VNDERLYING CAUSE --
Due to (or as a consequ encr of):
--------
(tllseaze or injury that
_
LL vitiated the .vents resulting d.
l
i
¢ in deatM1) LAST. _----...__-
Oue to (or quanta of) -.
s
S 26. Part II. Enter o<M1er sign'/'ca onditions c [rebut o tla:r<h but not rasul[Ing in <M1e
u nd¢rlying cause given In Part 1 27. Was an a t psy perfor-.tl?
f O Yes No
26. W top
r y findin
gs available
mplete
to complete he
cause of tleath?
29. If Female: 3 Yes N,
t
3
[] Nat pregnant within past year
Q Pre
nant
t time
f d
h 30. Did Tobacco Use Contribute to Death?
C3 Yes C) Probably 31. Manner of Death
C] Natural Homicide
m
2 g
a
o
eat
Not pre n nt, bu
[] H inane within 4[ da
t pre ys of death No Cj Unknown
8 gccitlent Pentlin
t? 8 1
(] Suicide Could
f
vestigatlon
d
. t
C3 N ot pregnant, b u Preg n 43 days to
1 year before tleath
E3 Unknown if pregnant within the past year
32. Date of Injury (MO/Day/Yr) (Spell Month 1 o
C3 a
atermin.d
Ap?;1 as OZU(? 33.TIm¢oflurY
.
34. Place of Injury hom
(¢.g. e; consu uchon site; farm, school) 35. Locaflon of Injury
(Street and Number, City
State
Zip Code)
,
.
N°"'?' 1(o kctct\? R? D;l\yb.?f-?; 1°A 1 -Ip?
36. Injury at Work if Tra nspor<atlon Injury, specify: 38. Des<rlb¢ Mow Injury Occurred: -
(-3 Yes C3 Driver/Operator 0 Pedean J ll l `` `` t
stri
,
<A
1
S
'
`'4 (\
?
c
r
<.
#
a`rS 1i Ylatl?G? .i
?"
MNO E3 Passenger C3 Other
ISpetity)
39a. Certl
r (Check only one): .?
Z
[] Certifying Physician - To the best of my knowledge, death occurred due to the cause(s) and manner stated
E3 Prpnouncing. Certifying physician - To the best of my knti-dga, death occurred at the time, date, and place, and due to the cause(s) and rnanner s[ tad
EXMedlcal Examiner/Coroner - O
a basi
f
e
p
s o
exam
n Ion, and/o Investigation, In my opinion, dea1JthO aY C; or vdfv,&the. time, date, and place, ,arid du. to the cause(
on Cr ) and manner stated
signature of ce rtlfl., Title of certifier:
Licen.e Numbs r:
3913 e'?`?7634$i'@f P`ISSS, ?§ ?f8'.t'tlff?d6j York, PA 17402
3
9c. are SlBned IMO DaY/Yr)
40
Re
istrar's Dl
t
l
f N
b l as amt
.
g
s
r
c
um
er 41. Re s Signature --
-5-10. 4 egistra FI a Dat Mo Day
43. Amendments
Dlsposl[lan Permit No. l/ / ???
-105-143
REV 07/2011
2012 JUL -9 PM 12.26,
CUMURLANU WiN
DENNSYLVANIA