Loading...
HomeMy WebLinkAbout07-25-12PETITION FOR GRANT OF LETTERS REGISTER OF WILLS OF ~,~ 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 respectfitlly request(s) the grant of Letters in the appropriate form: Decedent's Infor, ati n ~, Name: L~ //~ ~JC-'~.~...~ File No: ~~-'~ ~~~~ a/k/a: (Assigned by Register) a/k/a: L _ _ a/k/a: Social Security No: S ~ ~ ~~ ' ~ ;~ ~3 Date of Death: ~ ~ / ~/7 Age at death: ~'~'~ Decedent was domiciled at death in C ~~t'~ ~,F!/~/.t~ {~ County, ~ ~_ (Srate) with his/her last principal residence at / LL?l~CS,tJ~~ - 1..~ ,~ ~ ~' ~,CG/J% ~ /~~ ~-?L~x~,Q~G•.~C~/S Street address, ost Ott"ice and Zip Code /'~ City, Township or Borough Count Decedent died at / ~/iLC, ~'~tX?,L /= ~.4- ~ ( ~~ !c)l " ~`'~.~~f~c.~e..~ f~ Street address, Post O tce 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 $ ~, yU~l I/'ttot domiciled in Pennsylvania ........................ Personal property in Pennsylvania $ If not domiciled in Pennsy!vania ........................ Personal property in County $ value of real estate in Pennsylvania ......................................................... $ - _ TOTAL ESTIMATED VALUE.... $_~, [J~ () Real estate in Pennsylvania situated at: (Attnch additional sheets, if necessary.) Street address, Post Office and Zip Code City, Township or Borough County ~J A. Petition for Probate and Grant of Letters Testamentary / .,q ~ \ Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated ~ ~~%( l y < (c: and Codicil(s) thereto dated State relevant circumstances (e.g. renunciatiar, death of executor, etc.) Except as follows: afer 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(8), 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. u., d.b.n., d.b.n.c.t.a., pendente life, durance absentia, durante minaritate If Administration, c.t.a. ord. 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(8) 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 additional sheets, iJ'necessary): Name Relationshi Address .--..~ ~ © r,:~: xi~~~,-, ` r- ~: c~^ -' ~ e ® _ _ ~ _ Fnrnt <zw-nz ~~~~. lnitliznll ~7 ~~ ~'~ C...~ ,''; ' ,_-~ CO `__ ~ ~~ ' r -- "ti ~ge 1 0~` Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA } } SS: COUNTY OF (l/t'f~~~ _ t~K,© } Petitioner(s) Printed Name Tlie Petitioner(s) above-named swear(s) or affirm(s) the statement the foregoing Petition are true and correct to the best of Petitioner(s) and that, as Personal Representative(s) of the D e nt, the Petitione s) well and truly administer the Sworn to or a_f_f~r~ed cribed bef~~ ~.. me th' fi"ay ofi () By: N Cam. iTj fi' rte"' ~'. _ fV - Petitioner(s) PrintednAddress ~ : , CJ ~ lli~ \"~ ~ .,. ~ ~ ~. ~/ x- ~'~ t /b J~ Re„ister BOND Required: AYES ~NO FEES: b (~ Let rs ...................... $ ( `/~ )Short Certificate(s)..... . ( )Renunciation(s)........ . ( )Codicil(s) ............ . ( )Affidavit(s)........... . Bond .................. ...... Commission ................. . O her Automation Fee ............... .©~ JCS Fee . .................... TOTAL ..................... $ •, of the knowledge and belief estate according to law. Date 7L 2 ~ ~L Date Date Date 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 Q /1 s~ Q File No: ~ ~~ ~ ~ ' ~ !~ a/k/a: AND NOW, ~~~/~~~ , in consi ati n of the fore oing Petition, satisfactory proof having een presented before tne, IT I ECREED t Lett ~ are hereby granted to ! ~ - In the above estate and (if applicable) that the instrument(s) dated /,~~ /J, 5 described in the Petition be admit ed to probate and filed of re~grd~s the last Wil; (and Codicil(s)) of edent. Register of Wills Form RW-02 ,•ev. t0~t t~znl ~ G' Page 2 of ('\ 5 r LAST WILL AND TESTAMENT mho ~~+ w ~Y ~ ~J i ~.. 7 -1-1, ... ~ f..' -'~ G, - CT r ; ~ Cam, HELENA. SCHAD G ' ' ~ '_ ~y e j ~, _. °= I, HELEN A. SCHAD, a resident of Bucks County, Pennsylvania do make, p~t'blish and.- `" ~ declare this to be my last Will, hereby revoking all Wills and Codicils previously made by me. FIRST: IDENTITY OF TESTATOR'S FAMILY I declare that I am a widow. I have four (4) children, now living, whose names and birth dates are: Name Birth Date Michael 2-22-47 Dennis 8-28-50 Stephen 12-10-54 Timothy 1-24-56 I have no deceased children. All references in the Will to "my children" are references to them. SECOND: PROPERTY BEING DISPOSED It is my intention by this Will to dispose of all of the property which I may own. However, I hereby elect not to exercise any power of appointment exercisable by a Will which I may now have or which may hereafter be conferred on me; no provisions of this Will shall be construed as an exercise in whole or in part of any such power. THIRD: EXPENSE OF FUNERAL AND LAST ILLNESS I direct the payment of the expenses of my last illness and funeral. 1 FOURTH: RESIDUE I devise and bequeath the residue of my estate of every nature and wherever situate in equal shares to such of my children as survive me by thirty (30) days; provided that if any such child fails so to survive me, but is survived by a spouse who so survive me, such spouse shall receive the share such deceased child would have received had he so survived me; provided further that if any such child fails so to survive me and is not survived by a spouse who so survives me, but is represented by descendants who so survive me, such descendants shall receive, per stirpes, the share such deceased child would have received had he so survived me. In the event there is no one living who is entitled to receive the residue of my estate under the foregoing provisions, I give the residue of my estate to the Red Cloud Indian School, Pine Ridge, South Dakota 57770-9710. FIFTH: CONTINGENT RESIDUARY TRUSTS Whenever pursuant to the provisions of this Will all or any part of a distributive share of my residuary estate shall be payable to any beneficiary before such beneficiary shall have reached his or her twenty-second year, or to any beneficiary when he or she maybe subject to any other disability, then and in that event, I give devise and bequeath the shares to which such beneficiary maybe entitled under my Will, said share to be determined as of the time of my death, unto my Trustee hereinafter named, IN TRUST NEVERTHELESS, for the following uses and purposes to wit: To hold each share which shall vest in a beneficiary during his or her minority or during a time that any beneficiary by reason of illness, age, incapacity or otherwise shall in the opinion of the Trustee be unable properly to receive and disburse the same, in trust and invest the same in property authorized by this instrument and apply income and principal as necessary for maintenance, education, comfort and support of such beneficiary, accumulate and invest as aforesaid income not needed for 2 such purposes and pay over and distribute all remaining principal and accumulated income to such beneficiary at his or her twenty-second year or at the termination of his or her incapacity or to the estate of such beneficiary at his or her death prior thereto. I direct that such payment shall be made without the intervention of a guardian and the receipt of such person as may be selected by my Trustee to disburse the same shall be sufficient acquittance. SIXTH: ALIENATION AND ATTACI-IlVIENT OF BENEFICIARY' S INTEREST No beneficiary of an interest hereunder shall have any right to alienate, encumber, or hypothecate his or her interest in the principal or income in any manner, nor shall any interest of any beneficiary or remainderman be subject to claims of his or her creditors for liable to attachment, execution, or other process of law. SEVENTH: GENERAL ADMINISTRATIVE POWERS OF TRUSTEE In order to carry out the purposes of any trust established by this Will, the Trustee, in addition to all other powers granted by this Will or by law, without court approval, shall have the following powers over the estate, subject to any limitations specified elsewhere in this Will. 1. To accept in kind and retain any property which I may own at my death, without regard to any principle of diversification, and to invest in or purchase any form of property, without restriction to legal investments for fiduciaries. 2. To register property in the name of a nominee or to hold property unregistered. 3. To compromise claims. 4. To manage, control, repair, and improve all trust property. 5. To sell, for cash or on terms, and to exchange any trust property. 3 6. To lease any property for terms within or beyond the duration of the Trust for any purpose which the Trustee in his discretion may deem advisable in accordance with law, with or without an option to purchase, and to make such improvements or effect such repairs or replacements to any real estate subject to this Trust, and to insure such real estate against fire or any other risks, and to charge the expense therefore to principal or income or part thereof to each as the Trustee may deem proper, and to develop such property, to subdivide it, dedicate it to public use, or grant easements therein as the Trustee may consider advisable; and any lease or agreement made with respect thereto shall be binding for the full term thereof even though it may extend beyond the duration of the Trust. 7. To borrow money and to mortgage or pledge or otherwise encumber or hypothecate trust assets as the Trustee may, in his discretion, deem advisable either from himself individually or from others. 8. On any division or distribution of the trust estate, in the discretion of the Trustee, to divide and distribute property of the trust estate in money or in kind, including undivided interests, or partly in money and partly in kind, including undivided interests; to exercise such powers, herein conferred, after the termination of the trust estate until final distribution of the trust assets. 9.. To employ any attorney, investment advisor, accountant, broker, tax specialist, or any other agent deemed necessary by my Trustee; and to pay from my estate reasonable compensation for all services performed by all of them. 4 EIGHTH: OPERATIONAL PROVISIONS Trustee 1. I appoint my son, Dennis Schad, Trustee hereunder. In the event of his death, resignation, renunciation, or inability to act in that capacity, then I appoint my son Timothy Schad, as Trustee in his place and stead. Determination of Income and Principal 2. The Trustee shall determine what is income and what is principal of the Trust established under the Will, and what expenses, costs, taxes, and charges of any kind whatsoever shall be charged against income and what shall be charged against principal in accordance with the applicable law of the Commonwealth of Pennsylvania as they now exist and may from time to time be enacted, amended, or repealed. Waiver of Trustee's Bond 3. No bond shall be required of any Trustee appointed in this Will. Choice of Law 4. The validity and administration of the Trust established under this Will and all questions relating to the construction or interpretation of the Trust shall be governed by the laws of the Commonwealth of Pennsylvania. NINTH: EXECUTOR Appointment 1. I appoint my son, Dennis Schad, as the Executor of this Will. In the event of his death, resignation, renunciation, or inability to act in that capacity, then I appoint my son, Timothy Schad, 5 as Executor of this Will in his place and stead. My Executor, whether original, substitute, or successor, is referred to herein as my "Executor". No Bond Required 2. No bond or other security shall be required of any Executor appointed in this Will. Powers 3. My Executor shall have, in extension and not in limitation of the powers given by law or by other provisions of this Will, the following powers with respect to the settlement and administration of my estate. Same Powers as Trustee (a) To exercise with regard to the probate estate all of the powers and authority conferred by this Will on the Trustee over the trust estate. Distribution of Estate (b) When paying legacies or dividing or distributing my estate, to make such payments, division, or distribution wholly or partly in kind by allotting and transferring specific securities or other personal or real properties or undivided interests therein as part of the whole of any one or more payments or shares at current values in the manner deemed advisable by my Executor. (c) My executor shall exercise any options available in determining and paying death taxes on my estate in such a way as my executor reasonably believes may be expected to achieve the greatest overall tax savings for my family. These decisions shall be made without regard to any effect upon the size of any beneficiary's interest or the size of any trust and without requiring adjustments between income and principal. 6 TENTH: EXERCISE OF POWERS WITHOUT COURT APPROVAL All of the powers granted herein or by law may be exercised, except as otherwise provided by law, from time to time in the discretion of my Trustee and Executor without further court order or license. ELEVENTH: TAX PRORATION All federal, state, and other death taxes payable because of my death, with respect to the property forming my gross estate for tax purposes, whether or not passing under this will, and any interest or penalty imposed in connection with such tax, shall be considered a part of the expense of the administration of my estate and shall be paid out of the principal of my probate estate so that the burden thereof falls on my residuary estate, and none of those taxes shall be charged against any beneficiary or any outside fund. TWELFTH: GENERAL Effects of Inoperative Invalid, or Illegal Provisions I . If any provision of this Will or any Codicil thereto is held to be inoperative, invalid, or illegal, it is my intention that all of the remaining provisions thereof shall continue to be fully operative and effective so far as is possible and reasonable. Headings 2. The headings above the various provisions of this Will have been included only in order to make it easier to locate the subject covered by each provision and are not to be used in construing this Will or in ascertaining my intentions. 7 IN WITNESS WHEREOF, I, HELEN A. SCHAD, hereby set my hand to this last Will, which has been signed by me on this .~ ~ ~ date of % , 1996 at ~,.~`~-c-,~-~ ~-^-' ,Pennsylvania. HELEN A. SCHAD In our presence the above named Testatrix signed this and declared it to be her Will, and now at her request, in her presence and in the presence of each other, we sign as witnesses. ~, , ,/°' ~ COMMONWEALTH OF PENNSYLVANIA COUNTY OF BUCKS I, HELEN A. SCHAD, testatrix whose name is signed to the attached instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament; that I signed it willingly and that I signed it as my free and voluntary act for the purposes therein expressed. ~~. ~~ ~. HELEN A. SCHAD Sworn or affirmed to and acknowledged before me, by HELEN A. SCHAD, the testatrix, this ,j v n day of ~~J , 1996. _-____ i (SEAL) / / '~" Notary~Fu~bIic~/ ~~ ~! We, ~v~.L~ ~~ ~~~~ and , ~ <<. ,~ i 1 ~ r ~z. ;~L~ , - ~- , - ~ , > ,the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law do depose and say that we were present and saw testatrix sign and execute her Last Will and Testament; that she signed willingly and that she executed it as her free and voluntary act for the purposes herein expressed; that each of us in the hearing and the sight of the testatrix signed the will as witnesses; and that to the best of our knowledge the testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. _..~-.--~ /~ ~ ,..;; ,~ .. Sworn or affirmed to and subscribed to before me by l~ _~ 1; _ ~ ' ; ~, r,_ . ~ ~-- ' % ~ - ~,~ And ;~ , ~ r; . ~~ r ,, : , ~~ ;;- ,witnesses, this -- <` `day of ~ ;r~-, ,' .. , r , 1996. (SEAL) _-- ;' Notary Public ,UpTA.RIAL Sc,4L NANC'~ ,RRa ~ 'U9P2T4' ~ubliC Soy rr~,, ,rc ,_,.:,s UounPy „~ 'J OS NrIi NI-~ "7'i I i LOCAL RE~.~~;1;;~~ RTIFICATION OF DEATH WARNING: It is sa c~t~p this copy by photostat or photograph. f~4':. ;, i~ee for this certificate. ?~6.U0 ~~~~ JU~ 25 C fS V, P 18~01,2~2 Certification [Number Type/Print In Permanent B ry~' 1 Wti~~t~ vunnpC~c.r'v Y` ,'~:~~ )( _:•)~ali~ ghat th.. (nl~urmal( _ _~ ~ti~r r~,u, .~,},icci frln~~ ate ~.)ri~~linal CL ~,~. ;., .~ I)c ,1ud~~ ;ilr(i ~aitE~ nu a~ i_Itcai R~_isL:(r ~i°,, Sri<,i cc(-titicatc ~~il! he fur~~ar(IL~(! )1; ilu~ St.~!: V }Zero ~ Otfir~~ i~)r ~~erm~aie(n ri(in~~. ~~ ~ -__ -- -_ _ --__~1 i~.~- COMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF HEALTH ~ VITAL RECORDS rFRT~F~rATF AF DEATH lack Ink ~~ _ -~ - - - Sex 3. Soelal Security Number 4. Data of Death (MO/Day/Yr) (Spell Mo) 2 1 . . Daudent's Ugal Name (First, Mlddla, Last, SuMx) Female 507-16-9593 July 11 2012 S Helen Artis Schad a. Age-Last Birthday (Vrs) Sb. Under 1 Year Sc. Under 1 Da 6. Date o1 Birth (MO Day/Year) (Spell Month) 7a. Birthplace (City and State or Foreign Country) Months Oays Hours Minutes 91 May 6 , 1921 7b. Birthplace (County) B a. Realdenee (state or Foreign Country) Bb. Residence (Street and Number -Include Apt No.) 8c. Did Decadent Live in a TownshlpT tr 1 Longdor f Way QYef, decadent Ilvatl In twp. B d. Residence (County) ®Ne, decedent Iivetl within limits of C rl t e _ city/born. Cumberland Be. Residence (Zip Code) Surviving Spouse's Name (17 wife, give name prior to first marriage) d Widows il 9 . Ever In Vs Armed Forces? 10. Mari Q Ves ®No Q Unknown Q Di . tal Status at Time of Death Q Marrie vorced Q Never Married Q Unknown 1 33. Mother's Name Prior to First Marriage (First, Middle, Last) 2. Father's Name (First, Middle, Last; $uHix) Blanche P. Mast Arthur Teeters Relationship to Decedent 14c. Informant's Malling Address (Street and Number, City, State, Zip Code? 14b ' . s Nama 34a. Informant Shatto Drive Carlisle PA 17013 Son 310 n _ _ _ a. ace o eat e< o y one _ __ ital: ~ Floapice Facility ~ Decedent's Home Th H ' ' ~ 3 I an a osp ~If Death Occurred Somewhere Other [,~ Inpatlent f Death Occurred In a Hospital: rs Ter Emer envy Room/Outpatient ~ Dead on Arrival u Ini Home/tAn - m Gre Facility Ocher (Specify) County of Death lSd . 15b. Facility Name (If not institution, glue street antl number; lSC. City or Town, State, and Zip Code lisle PA 17013 Cumberland C ar Nursin Home lga. Method o1 Disposition Q Burial Cremation 16b. Date of Disposition lBc. Place of Disposition (Name of cemetery, crematory, or other place) Q Removal from State Q Donation other lspaeiry) 7-13 12 Cremation Soci ty of Pennsylvania Vicense Number nt 17b f I t . n erme a ee 16d. Location of Dispositien (City or Town, State, and Zip) 17a. Sign t of Fune rvlce LI or Pen n Charge o c E'D-013376-L Harriabur PA 17109 17c. Name and Complete Addrefi of Funeral Facility 4100 Jonesto ad Harriabur PA 17109 Auer C emation Services of Penns lvani nc. dent of Hlfpanlc Origin -Cheek tM 20. Deudent's Race -Check ONE OR MORE taus to Intllute what h 1 .~ ca e 1g. Decedent's Edueatlon -Check the box that best describef t t describes whether the decadent the decedent considered hlmseN or herself to be. t b b es o highest degree or level of school completed at the time of death. "NO" ®White Q Korean k th K l L i ~ c/ at no. e, _ /HI3Den Q 8th grade or less Is 5 Q Black or African American Q Vietnamese /Latino . Q No diploma, 9th - 12th grade box H:., dint is no[ s~ ~ Q American Intllan or Alaska Native Q Other Asian i no Q Hlgh school graduate or GED compleietl ®NO. nlsh/Hasp( Lat Q Asian Indian Q Native Hawaiian Chi n i "jR ' ean, cano i sr Q Some college crodit, but no tlegree Q Vas, , MaKI Q Chinese Q Guamanian or Chamorro _ ~~ Q Associate tlegree (e.g. AA, AS) Q Y - Q Flllpl^° Q Samoan ® Bachelor's tlegree (e.g. BA, AB, BS) Q Yes, Othdr Sp /Hispanic/Latino Q Japanese Q Other Pacific Islander MBA) Q yes MSW Ed ' , , , s degree (a.g. MA, MS, MEng, M Q Master Q Doctorate (e.g. PhD, EOD) or Professional degree (Specify) Q Other (specify) .MD DDS DVMe LLB JD nt considered himself or herself to be. 22a. Decedent's Usual Occupation -Indicate type of work d h h d ece e at t e 21. Decedent's Single Race Self-Designation -Check ONLY ONE to Indicate w done tluring most of working Ilfa. DO NOT VSE RETIRED. W White Q Japanese Q Samoan Q Black or AfNCan American Q Korean Q Other Paclflc Islander Cle rlc Q American Intllan or Alaska Native Q Vietnamese Q Don't Know/Not Sure Kind of Business/Industry 22b . Q Asian Indian Q Other Asian Q Refused Q Chinese Q Native Hawaiian Q Other (SPecity) Q Flliplnq Q Guamanian or Chamorro IRS • - 3 MUST B C MP D 23a. Date Pronounce Dea Mo Day 23b. Signature o anon ronoun<InL Deat On y w en app lu a 2 c. License Num er ITEM _ CERTIFIES DEANTFI PRONOVNClS OR 7 N..3~ yfo ~L 23d. Data SIg ed ( o/Day/Yr) 24. Time of •ath 25. Was Medlul Examiner or er Cpnbcted7 Q Yes ~TIO ~ CAUSE OF DEATH Approximate i juries, or compllcatlons-that directly caused the death. DO NOT enter terminal events such as cardiac arrest Interval: n chain of wants--diseases t to Death th E t O 1 , n er e nse 26. Part . respiratory arrest, or ventricular fibrilla[ Ithout showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ilna. Add additional Ilnes If necessary //f~'°l//~. ~ /J P~B jC ~~ r~~C~ C4 Cdr/ JK.Q^ ctJe•!' ~C H~`t IMMEDIATE CAUSE - a. / 1 ' of): ' Due to (or as a consequence (Final disease or condition resulting In death) b. Sequentlaliy Ilst conditions, Due to (or as a consequence of): if .nv, leading to the uufe listed on Ilne e. Enter the f): VNDERLVING CAUSE Due to (or as a consequence o (disease or injury [hat Ini[lated the events resulting d. as s con In death) LAST. Due to (or sequence of): Enter other h but not resulting in the underlying cause given in Part I 27. Was an autopsy performed? Part 11 26 . . Ves Ciu V Q w rt r ~ /`t 28. Were autopsy /indings wallable to complete the cause of death? . ~ 'y(pA {~w j ~ lf `' 1 Yes No ~t+^ e•-,r eH ~ ` ~ a j 4 If Fe le: 30. Dld Tobacco U Contribute to Death? 31. Mafj~ r of Death 29 l Q Hemlcida N . atura ~o[ Pregnant within Past Year Q Ves Probably [[jJ// t Q Pending Investigation id A en cc nant at time o1 death Q No ~(/nknown Q ld not be determined Pre C ~' Q g ou Q Not pregnant, but pregnant within 42 tlays of death Q Suicide Q Date of Injury (MO/Day/Yrj (Spell Month) th 32 d . ea Q Not pregnant, but pregnant 43 tlays to 1 year before 33. Time of Injury Q Unknown If pregnant within the past year 34. Place of Injury (e.g. home; construction site; farm; school) 35. Location of Injury (Street antl Number, City, State, Zlp Code) 36. Injury at Work 37. N Transportation Injury, specify: 38. Describe How Injury Occurred: Q Vas Q Driver/Operator Q Pedestrian Q No Q Passenger Q Other (Speclry) 39a. ~,lrtifler (Cheek only one): death occurred due to the cause(s) and manner stated k l d f now e ge, my [g GrtNying physlc4n - To the best o and place, and due to the cause(s) and manner staled date rred at the time th d d , , occu ge, ea Q Pronouncing a CertiTyi physician - To the beat of my knowle Se(s) and manner stated a u e c antl place, and due to [h date red at the time h d , , occur eat Q Medical Examiner/CO - the basis of x jrJayen, and/ vestlgatlon, In my opinion, / J ~ ~J n r .. Y / A ~ I mber/"ter, iOd ~~ ~ ~~~ r / ~ ~ / ) Li N ~ 1 U /` l l /` ri ~ .' ~ it ( cense u Signature of eertifler~ a of certifier: Z Y/Yr) d 21 Code f arson Completing Gus~p1 Death (Ice 26) 39c. DaterfSig 3 N Addre' y ~ ~ ame, ~ (I ~3f' ( ~ttfAwl J,/~f tC"f~QU ~(rn /uv1 ~ 2-t %k/~i~~~""'[W GCff4Jv4/+'+ ~~ ~7 3L(- / 42. Registrar F e Date MP Day i gnature 40. Registrar's D strict Num ar 41. Registrar s S 5 43. Amendments Disposition Permit No. ~ ~ 25 lV I ~ lS/ REV 07/2011