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HomeMy WebLinkAbout10-09-12PETITION 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: BENJAMIN_S._PETERS. JR. _____ a/k/a: a/k/a: a/k/a: - __- _ _ -- Date of Death: 9/26/2012 File No: ~ ~~-{ ~ ~ _ _ (Assigned by Register) Social Security No: 174-20-0238. _-_ _ Age at death: 86-_ __ ____ Decedent was domiciled at death in Cumberland County, Pennsylvania __ ___-- (State) with his/her last principal residence at 3814. Lamp Post Ln. Camp Hill 17011 Hampden Twp _ ___ Cumberland-- ___ _ Street address, Post Office and Zip Code City, Township or Borough County N~1\ Decedent died at 770 Poplar Church Rd Camp 17011 Camp Hill Boro ___. __________ Cumberland- - PA _ Street address, Post Office and Zip Code City, Township or Borough County State Estimate of value of decedent's property at death: Ifdomiciled in Pennsylvania ................................All personal property $ ~ Q0,_~QO•~0 If not domiciled in Pennsylvania .............................Personal property in Pennsylvania $ 7f not domiciled in Pennsylvania .............................Personal property in County $ Value of real estate in Pennsylvania .............................................................. $ 200,000.00 TOTAL ESTIMATED VALUE.... $ ___ _ 300,000,OQ Real estate in Pennsylvania situated at: 3814 Lamp,Post Ln Camp Hill 17011 Hampden Twp __ -_____._ Cumberland- _____ (Attach additional sheets, ifnecessary.) 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 8/16/2012 _ _ and Codicil(s) thereto dated no named._ExecutoLtwo named beneficiaries, Jennie Good~Ce~r_and Steven l3or_dnnr. ~~v_en_Bordner ded_10/3/2012 leaving Jennie Goodyear (aka Jennifer Goodyear) as sole surviving-heir. '~ , _ __..._.re--y _.__- .._ _ -_._ State relevant circumstances (e.g. renunciation, death of executor, ere) ~ r~ © ~ _ ~ ""'' ~ t7 Except as follows: after the execution of the instrument(s) offered for probate Decedent did not marry, was not divorc not a party'lb a pe{s~iing divorce roceedin wherein the ounds for divorce had been established as defined in 23 Pa. C.S. 3323 ~ p g gr § (g), and did ~iylyk~Cyea child born or `.',r._ ._,.y adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. y`~, ~=F t G.. ` ' ' ® NO EXCEPTIONS ^ EXCEPTIONS - ~'_~~ . -_~_ __ ` ~_~ f ® B. Petition for Grant of Letters of Administration (tf applicable) C.T.A. rJ ~T, '-" - Q _ ` " _{ r-rt c. t. a., d.b.n., d. b. n. c. t. a., pendente lite, durante~5sentia, durante minott~tb?eC~ 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-Will and was survived by the following spouse (if any) and heir attach additional sheets, if necessary): i~ Name Relationship Address _ - -_ 930 DENNIS CIR ', IJENNIE GOODYEAR Beneficia of Will HARRISBURG PA 17111 ~~ '' STEVEN BORDNER (died 10/3/1 L_ Form RW-02 rev. 10/11/2011 Beneficiary of Will Oath of Personal Representative official use only COMMONWEALTH OF PENNSYLVANIA } ~, } SS: COUNTY OF CUMBERLAND _ } Petitioner(s) Printed Name Petitioner(s) Printed Address - --- - --- 930 DENNIS CIR ~IJennie Good~ea_r_~ka Jennifer Goodyear HARRISBURG _ ___ PA__ 17111-_ - - L-- -- ---- --- - - --- ---- 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 lrnowledge and belief of Petitioner(s) aid that, as Personal Representative(s) of the Decedent, the Petitioner(s) will well and truly administer the estate according to law. Sworn ±o affirmed an su sc 'bed befo e <. ~,~-:._ 1" -„~~G~2'.7~9 -_ __- Date ~ ~~?~/ Z"' me -~~"'- day of ~ ' ~ ~ Date - -- - - $y. ---- -- Date -_ - For the Register Date - - -. BOND Required: ^ YES ®NO FEES: ~.~r Letters ....................... $ ' _ ~ C' • L,! L (10 )Short Certificates(s) ...... ~' • 'L' __ ( )Renunciation(s) ......... . ( )Codicil(s) ............. . ( )Affidavit(s) ............ . Bond ......................... Commission ................... . Other _ ........ . To the Register of Wills: Please enter my appearance by my signature below: Attorney Signature: Printed Name: KENDRA A. MOHR Supreme Court ID Number: 200829 ___ - Firm Name: PANNEBAKER & MOHR. P.C. -__ _ Address: 4000 VINE STREET__ _ --- ---- - --- --- --- --- ......... MIDDLETOWN - _ PA 17057-- ~, __-__ _____ ......... Phone: 717-944-1333 C7 _ - - --_ - ......... Fax: 717-944-4004 -~ ~ t-~'., ~~ ~i ~ -~ Automation Fee ................. ~~~ '~ ~~ C7 r';~ Email: kendra@pannebakerl.~!m . JCS Fee ....................... ~ . ~~ _. - -„+ r:--~. - p ~ .; DECREE OF THE REGISTER U < ~ - r - -= ~; •..__ :. ~ =:., 'C? (..:: tit Estate of BENJAM_I_N S_ PETERS, JR. File No: ~ ~ ~ ~~_~~~ ~~ ~ ~" ~~ ~ _ es- -- a/k/a: - -- ---- // AND NOW, ~i~3 ~ ~`_ ~'~ ~ ~' d~C" ~ ~ ~ ~`" , in o ideration of thel foregoin Petition, satisfactory proof having been presented before me,IT IS DECREEI}~ltat Letters "~° ' ~~1~~_' "` j _ - -- are hereby granted to ,~-~-.L-l-~ ''~ _ __________ in the ab a estate and (if applicable) ±hat the instrument(s) dated ___- _.- '~ described in the Petition be admitted to robate and filed of record as the last Will (and Codicil(s)) Qf Decedent. T r ;, ' r'C-2 c ~ Register of Wily ,1 ,P (i' / 'ti E ~~1. )~~ ~, t_ 1 ~')L~ ~ ~;~-' ~'' Form RW-02 rev. /0////20!/ ~`- Page 2 of 2 N ~0 O ~ "*'1 t'r'1 ~'Q _,._ ~ 4_a l m T ~ . .~ i_ n _ 7 '~ -_ ~p cn ~~:`! ~:~ D ~,, ,, 7~- f, _~~ ~ ~ _ 0 ~- 7~'' -- `n v / "" /~ ~©/ ~'0 v' 1 ~ ~ V+ ~' Lt/ ((j ~ 1 ~ ~ ~~ ~ ~~ ~j ,~ J ~ ~` ~~ ~. Y PETSRS JR , SEIdJAl4IN S 8 6 M SUR 06/10/1926 CARDINALE JOSEPH 056835 056835 08/14/12 43134659 HLD1 Camp Hill, PA 17011.2288 OATH OF NON-SUBSCRIBING WITNESS(ES) REGISTER OF WILLS CUMBERLAND COUNTY, PENNSYLVANIA Estate of BENJAMIN S. PETERS JR. ,Deceased JENNIFER GOODYEAR and TERRY GOODYEAR , (each) being duly qualified according to law, depose(s) and says(s) that she / he /they was /were well- acquainted with BENJAMIN S. PETERS. JR. and am/are familiar with the handwriting and signature of the decedent, and that the signature of BENJAMIN S. PETERS. JR. to the foregoing instrument purporting to be the Last Will and Testament/Codicil of BENJAMIN S. PETERS. JR. is in his/her own proper handwriting. fa f e (Si re) X30 DENNIS CIR (Street Address) (Signature) 930 DENNIS CIR (Street Address) HARRISBURG PA 17111 (City, State, Zip) HARRISBURG PA 17111 (City, State, Zip) Executed in Register's Office Sworn to or affirm and subscribed before me thris ,, ,~ ~ day of f~Y ,~fc~-. c Deputy for Regis of Wi is ~..~ o rn .- y~ 4 r:. ~ ...~ ~-.-, , (~ ~ l ~.~ t-..-? 'T's C ~ D 0 c~ ~.d en Form RW-04 rev. 10.13.06 Continuation of Petition for Grant of Letters BENJAMIN S. PETERS, JR. 174-20-0238 Decedent Name Page 1 Social Security Number Real Estate in PA 3025 Columbia Ave Camp Hill 17011 Camp Hill Boro Cumberland Street address, Poet OtRce and Zip Cade City, Towne6ip or Boroag6 County ,ti~ n.,~ c=a ~ ~ ~ ~ r r•l G, t G_ ~'} C~ ~ ~ ~,~F1'3 -~ ~ 1 _.- ~ i _ "_.` '~ 0 ~ ~ L~ C~ COPY FAIR OF LAST WILL AND TESTAMENT OF BENJAMIN S. PETERS, JR. "Aug. 16, 2012" "If I don't survive this all goes to Jennie Goodyear and Steven Bordner." /s/Benjamin S. Peters, Jr. ,., ~ ~ ~ ~ ~~~ ~ r ~ r~i ~ ._. D ~ r--, , = f O ~' 3 ~i ;=? C~ .J H105.805 REV (9/I I) LO~;"1~AR'S CERTIFICATION OF DEATH WA~ ~. to duplicate this copy by photostat or photograph. Fee fvr this certificate, $6.OQ ~~~~ ~CT 'a9 ~M.~' ~'6 This is to certify that the information here given is correctly copied from an_ariginal Certificate of Death :, duly. filed with me as Local Registrar. The original ~"`'," ` : i certificate wilt be forwarded to the State Vital ~~ ~ ~~~ Records Office fvr permanent filing. ~~ ~.. P 18800.886 ~~~ ~ 2 ~ Certification Number _ 1/9c~1_Reg~strar_ Date Issued Type/Print In COMMONWEALTH OF PENNSYLVANIA .DEPARTMENT OF HEALTH .VITAL RECORDS °e""'"e"t CERTIFICATE OF dEATH ~~ ~~ a 1. nt s Lepl lhme (ilrst, MWdh, last, SufTlx) 2. Sex 3. Soelal Security Number 4. Data of Wath (Me r) ( N Mo) Benjamin S. Peters Jr. M. 174-20-0238 S tsnber 26 2012 Sa. Aia-Lest Birtfidp (Yni) Sb. Under 1 Year 3e. Under 1 6. Date of Blr[h (MO/Day/Yeer) (Spell MOnM) 7a.. rthp/aea Staff pr Foralin Country 86 Months DAYS Hours Minutes _ YA V Jt~iie 10 1326 7b. i1rn,Pt.~e (cpunq.) ia. ResMenu(Stete or F -orelgn Country] . Residence (Street and Number -Include Apt No. 8c. Did Decadent.LNe In a Township? P ~ V 8t ~lYaa> decedent Ned m H9[[7DdeL1 t„„y- fa X814 L P t Ln ~ os . amp sd. ^ ~, t ~ a ~+aafta+~. iYaafcs : : ie. Residence (21p Code) Ej NO, d•eed•M INed withM limits of c{tyfberp. 9. Ever in VS ArmW Feroea7 10. Marital SMUS at Time of Death Married ow 11. SurvMng Spouse's Name (N wife, ^hie name prbr to first merclye) Q Yes QNO QUnknown Q Divorced Q Never Mauled QUnknow 12. F is Name Flrat, Midd a, Last, Suffix) 13. Mother's Nima PHOr to Flrst Mattis{! (Flrst, Mkld e, last Ben amin S. Peters Catherine Ware 14a. In Name 14b. Relationship to Decedent 14c. Informant's Maiiing Address (Street and Number, City, Stab, 21p Code Je=mifer Good ear D,s ter 930 1?enn3:s Circle C~aambers Hill PA 17111. - .--......... ..... ........ ......... ............. .... N With Occurred iiM a NospRal: ~ InPatMnt ~ ...... a ci o i On y one _ ......... ........ .e °..-... If Owatl~ OccNrred.50 hers~Otfier Thin a Hospita I '.. •••••~ 1•IOSPici FacNity n... a.J ~D~CaNiare[ i ltom. • .. E u ', ;.Wad on ArrNSI - Nurikn Home tan Term Care:Facili OtMr (S 1 1Sb. ndt htstltutbn~ (tNe strait a nuMber; Go I,~vi -West Shore i5c. C ty or Town State, and ZIP ode H£~.l PA 17011 SSd. County d Death' C~erland ~, IN Methotl Ispos BuNi1 CremaNOn 1fib. Date of DhposKlon iEe. Place of OlsposRlon (Nama e1 umebry, crematory, or otl.er place) Q Rarnuv.I stem Stw>. Q Donation other -. 9/2 812 0 1 2 Eiolli er Cremator 1 d.:LOeatlPn OhpOfitton ih, or Town, State, and 21p) ::. 27 : efure Of FuM lee Ucansee or Pe In Cha' brmeht 17 ,'Ucani! VM r Mt . Ek'sll s PA 17065 014819 17C:. Nante~itd..GOSt.pjeq Add of FuMral RsclBty era-fiatrner mineral Home Ina. 1903 Market St. Hill PA 17011' ~ 3 's E ck tM that best descn of the 19. Decadent rsf Hispsnlc OriNn -Check the 30. Wcedent's Rau -Check NE OR MORE taus to in Irate at hlsFtest degree or fevN of srfiool comphted st the time of deKh. box Mat bert describes whether the decadent the decedent eonsklered MmseH or herself to ba- Q Sth trade Or Nis Is Spenlsh/HlsPanlc/LaHno. Cheek the ^Ne^ ~1/hib Q KpMan Q No dipbma, 9th - 12th trade box I7 deceden[ b not SPanish/Hispan/4LaHno. Q Bieck or African American Q Vietnamese [] Nigh school graduate of GEO completed ~ NO, not Spanhh/Hispanle/Letlno Q American Indian or Alaska Natfv! Q Other Asian Q Soma collye credit, but no dpree Q Yea, Mexican, Mexican American, CMcano Q Asian Ind/an Q Native HawaBan Assotlatf delta! (a.g• AA, AS) Q Yes, Puerto Rican Q Chinese Q Guemanlan or Chsmorro iachNOr's degree (e.g• lA AB BS) Q yea Cuban Q FIIIPino S , , . Q amoan Mister's degree (e.l. MA, MS, MEng, MEd, MSW, MBA) Q yes, other Spanish/Hhpanie/LaHno Q Japanese Q Other PaNflc Islander Q DxWreb le.i• PhD, EdD) or Professional decree (Specify) Q Other (Spe<ify) MD VM J 21. Decedent's Slnlle Race SeN-WfignatiOn -Check ONLY ONE to indicate what the decedent conaidercd himsMf or herself to be. 22a. Wca ant's Usual Occupation - Indicab type of WhRa Q Japanese Q Samoan done dunng most of working Ilfe. DO NOT llSE RETIRED. Q Bisck or African Amenun Q Korean Q OtMr Paclflc Islsnder Q American Indian or Alaska Native Q Vietnamese Q Don't Knew/Not Sure Laborer Q Asian Indian Q Other Asbn Q Refused 22b. KI of Business/Industry Q Chinese Q Native Hawaiian Q Other (Specify) Q FlBpirto Q Guemanlan or Chamorro Museim :. b ronoun o eY 23b. Si care o Person ronour.t ng n w .n aP G 23c. - canes r BY PMSpN 1II/M0 PItOF/OUNCEi OR. ~8 24. nme Death O z . D.te ( ~ 1 _ 25.. Was McWtel E Iner Or Coroner Contacted? yes No CAUSE OF DEATH - Approfimsb 26. Part 1. Enter Me chin of events-diseases, Injuries, Or complleations-that directly caused the death. 00 NOT enter terminal events such as cardiac arrest, Interval: respiratory arrest, or venMeular flbr111etion without showini the etwlegy. DO NOT ABBREVIATE. Enter o nly one cause on a Ilne. Add additbnal Tines If neussary ~ Onset to Wath G IMMEDIATE CAUSE ---> f/4f ~~`AI C ~~~5^ ~/ r t ~®'~4 /A. (Final disease or wndhbn Due to (or as s consequence of): resulting M death) b. ~i ~ - ~~ ,,c a: ~~s .--.•-~ „~-~ -~ -~~ rlvf' Imo' Z SequentlNW list sonsllMone. Due to (a ss a consequent. of): Harry, Nsding w tM cause ~ /_1~ f/ listed on Ilne e. EntettM c !7 !' UNDERLYIFq cAlJSC Due to (o as consequence of):. -- . (disease ar Injury that ~j ~ ~~ ` ~ G_ ~~L /1 ~L ~ LL ~ r? I ltl d h Ri d ) n ag t e events rew ng . A i In death) LAST. .Due to ores a conseque ca of) 26. Part 1(. Enter other. but not resulting In the vntlerlying twee given In Part i 2 :. Wif an autopsy pits 7 yy ~ ~//~.~ i. N i lr ~ - ~ ' a _ /~~~ ~ ~ /lam ~ ~ ~'-~ ~to'~ plats m. ta.tse of a ht7 yyy .. ~: ~ _ Yes NO FemaN: 30. Did Tobacco Use GontNDuie to Death? 31. Manner of Death Q No[ prelMnt wRMn past year Q Pr nant at tim f d th Q Yes Q Probably N U Natural Q Hemitlde ~ ~• eg e o ea Q Not pregnant, but prgnant wlehln 42 days of death ~ O Q nknown Attldent Q Pending Investigatbn .Q Sulckie Q Wuld not be determined (7 Not pregnant, but pregnant 43 days to 1 year bebre death 32. Data of Injury (MO Day/Yr (Spell Month) Q Unkrgwn H pregnant within tM pest year 33. Time of Injury 34. au of m ury e.i. home; wnstrucHOn site; rm, school) 35. Location o/ Inlury (3ereet and Number, City, State, ZtP Code) 36. Injury at Work 37. / TransporMlon Inlury, Specify: 3i. Wxnbe Now Inlury Otturced: Q Yes Q DrWer/Operator Q Pedestrian Q No Q Passenger Q Other (Specify) 39a. only one): rtMyfng physiclM - To tM best o(my knowledge, death occurred due m she cause(s) arM manner stabd Q Pronouncing 8 Certifying physlWn - To the best of my knowledge, death oceurced N the time, date, and place, and due to the cause(s) and manner sbted Q Medical Examiner/GOroner - On tM bash Of axamMatbn, and/er Investlgatbn, in my opinion, death occurred at the time, data, end pier , arM dw to the cause(s) antl manner stateE Signature d urtMar: ~J Title of cpreMhr. /'YZ ~~ Llunsf. NumlePr:~_~ !r/A/~~ 3%. Nasni ': rap a 2IP Person Completing Cause of Death (Item 26) ~ ~- G../ // <4,/ 39c. Wt! Sigsied: ( F) G ~ ~ -: ~ R aE G-! f ere Num !r 1. Reglstra s re firr 1+•~ a/Le 49. Amendments DlsposlNOn Permit No. 0756812 HSOS-163 REV 07/2011 L'~A~li~~~: ~~ is i31eg~~E t~ ~l~:~~;e.tyx~ -~i :~ ~:~~~.a~. ~~ ~0~~~fi=~):ir ~.t i ::~; ~, y . ~ ~ ~ 4: ~ ~ ~+ ~, P 188~1~s72 '- -~. ; _ t ,. - ~ ,~. . ~ --~ If -air . ;~.~)'~i:~ Type/Print In COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF HEALTH VITAL RECORDS Permanent CERTIFICATE OF DEATH 2~ L C. O ~~ C d Q/ C~ v 1 E 1. Decedent's Legal Name (First, Middle, Last, Suffix) 2. 5¢x 3. Social Secu rfty Number 4. Dace of Death (MO/Day/Yr) (Spell Mo) Steven Bordner Sr Male 174-46-7125 October 3 2012 Sa- Age-Last Birthday (Vrs) 6b. Under 1 Vear Sc. Under 1 Da 6. Date of Birth (MO/Day/Near) (Spell Month) 7a. Btrth~pl ~ace `City nd Stac e r Foreign Country) l l ~ MonThs Days Hours Minutes McCY"lanlCSbt„- Pa 57 Se tember 22 1955 7b. Birthplace (County) 8a. Residence (6Tate or Foreign Country) 86. Residence (Street and Number -Include Apt No.) Sc. Did Decedent Ltye in a Township? Q Ves, decedent lived in Fairview twp Sd. Residence (County) '251 la ' 11 08 . 8e. Residence (Zip Code) Q No, decedent lived within limits of city/boro. 9. Ever in US((~~ff ed Forces? 30. Marital Status at Time of Death Q Married Widowed 11. Surviving Spouse's Name (If wife, give name prior to first marriage) Q Yes OCNO Q Unknown Q Divorced Q Never Married Q Unknow 12. Father's Name (First, Middle, Last, Suffix) 13. Mother's Name Prior to First Marriage (First, Middle, Last) 14a. Informant's Name 146. Relationship to Decedent 14c. Informant's Mailing Address (Street antl Number, City, Stale, Zip Code; 17070 0 251 S a ler's Mill Road New Cumberland Pa Ci c ........................................................... .......................................... f h d l ~ ........ 16a. P ace.o Death C ec only one _ ............ ....... ~......o....................... ................................_.... __ _ __ _ _ f th ~~-+~++.. ~ ~ ~ ~~~ ~ ~~~~ ~ ~~~~ ' ` - ° I Deat Occurre in a Hospita : Inpatient 5 Q Emergency Room/OUf patient Q Dead on Arrival • Dea 1 Occurred Somewhere Other Than a H pita l: [ f Hos Ice Facili P ty TJ Decedent's Home Q Nursing Home/Long-Term Care Facllitys Other (Specify) oat SSb. Facility Name (If not institution, give street and number; 15c. City or Town, State, and Zip Code 16d. County of Death Hol irit Hos ital '1 1 36a. Method of Disposition Burial ~ Cremation 166. Date of Disposition 16c. Place of Disposition (Name of cemetery, crematory, or ocher place) m Q Removal from 6tate Q Oonatlon ~ tuber 5 2012 H lli Other (Specify) o n er Cremator ~ 16d. Location of Disposition (City or Town, State, and Zip) gna u ral Service Lic rson in Char ge of Interment 17b. License Number t a 17c. Name and Complete Address of Funeral Facility M ers-Hamer Funeral Home Inc 1903 Market Street H ill Pa 17011 $a' 18. Decedent's EducaCion -Check the box that best describes the 19. Decedent of Hispanic Origin -Check the 20. Decedent's Rac¢ -Check ONE OR MORE ra s to indicate what r- highest degree or level of school completed at the time of death. box that best describes whether the decedent the decedent considered himself or herself to be. Q 8Th grade or less is Spanish/Hispa plc/Latino. Check the "N O" ~ White Q Korean Q No diploma, 9th - 12th grade box If decedent is not Spanish/Hispanic/Latino. Q Black or African American Q Vietnamese Q High school graduate or GED completed ~NO, not Spanish/Hispanic/Latino Q American Indian or Alaska Native Q Other Asian Some college credit, but no degree i r AA A t d ( A6) Yes, Mexican, Mexican American, Chicano P t Ri Q V Q Asian Indian Q Native Hawaiian , ssoc a e eg ee e.g. Q Bachelor's degree (e.g. BA, AB, BS) es, uer o can Q Yes, Cuban Q Chinese Q Guamanian or Cha mono Q FIIIPino Q Samoan Q Master's degree (e.g. MA, M6, MEng, MEd, MSW, MBA) Q Ves, other Spanish/Hispanic/Latino Q Japanese O Other Pacific Islander Q Doctorate (e. g. PhD, Ed D) or Professional degree (Specify) Q Other 5 I ( pee fy) . 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 Ja pahese Q Samoan done during most of working life. DO NOT USE RETIRED- Q Black or African American 0 Korean Q Other Pacific Islander Q American Indian or Alaska Native Q Vietnamese Q Don't Know/NOT Sure Auto McCtianlc ~ Asian Indian Q Other Asian Q Refused 22 b. Kind of Business/Industry Q Chinese Q Native Hawaiian Q Other (Specify) Q Filipino Q Guamanian or Chamorro 1 ITEMS 23a - 23d MUST BE COMPLETED 23a. Date Pro o ed Dead (MO Day Yr) 236. Signature of Per pouncing D ath (Only when applica blej 23c. License Number ro BY PERSON WHO PRONOUNCES OR n~ ~ 2_ CERTIFIES DEATH - ~ Q ~ 3 I N /\,t r-1 / _ / ~ p / (7 ~ ~ ~ / ""id 3~ T 23d. Date Sign d (M /Day/Vr) 24. Time of Oeath / P(~-.- ~ 25. Was Medical Examfner or Coroner Contacted? Q Yes No CAUSE OF DEATH Approximate 26. Part 1. Enter the chain of a ents--diseases, InJurles, or compllca Tlons--that directly caused the death. DO NOT enter term inai events such as cardiac arrest Interval: respiratory arrest, or ventricular fibrillation without show i n g the et iology. DO NOT ABBREVIAT Enter only one cause on a line. Add additional Ilnes if necessary Onset to Death + i ~ / ~ IMMEDIATE CAUSE ---------------> a. f '~ i'11 C~ Y~?~I~TM -~1 I`~ rQ ` ' (Final disease o ndition Due to ( a consequen a of): s resulting In death) 9q l b. t~~ /~ T L i ~' Vt UC_~-- Sequentlally Ilst conditions, Due to (or as a consequence of): if any, leading to the cause ~ - C~1 e~t; ~ ~ listed on line a. Enter the l ~ /- t UNDERLYING CAUSE Due to (or as a consequence of): (disease or injury that initiated The events resulting d. in death) LAST. - Due to (or as a consequence of): cj 26. Par! il. Enter other si niflc nt condition ntributin ih but not resulting in the underlying cause given in Part 1 27. Was an autopsy pertormed? ° Q Yes No 28. Were autopsy findings available to complete the c of death? ~ O Yes 29. If Female: 30. Did Tobacco Use Contribute fo Death7 31. Manner of Death E c°u Q Not pregnant within past year t tim f d Q Pr t th Q Ves Q P obabiy U t~•Natural Q Homicide e o_ egnan a ea Q Nof pregnant, but pregnant within 42 days of death Q No ~ nknown Q Accident Q Pending Investigation Q Suicide Q Could not be determined ~ Q Not pregnant, but pregnant 43 days to 1 year before death 32. Date of Injury (MO/Day/Yr) (Spell Month) Q Unknown if pregna nG within the past year 33. Time of Injury 34. Place of In)ury (e.g. home; construction site; farm; school) 35. Location of Injury (Street and Number, City, State, 21p Code) 36. Injury at Work 37. If Transportation Injury, Specify: 38. Describe How Injury Occurred: Q Yes Q Driver/Operator ~ Pedestrian ~NO Q Passenger Q Other (Specify) 39a. Certifier (Check only one): Q Certifying physician - To the best of my knowledge, death occurred due to the cause(s) and m r stated Pronouncing 8< Certifying physician - To the best of my k owledge, death occurred at the time, date, and place, and due 20 She cause(s) and m r stated Q Medical Examiner/Coroner - On the of examinatl and/or Investigation, in my opinion, deat h o ccu rred at the time, date, and place, and due to the cause(s) and m Hoer stated ,~ t ~ f Signature Pf certifier: ~ Title of certifier: f -, n License Number ~-O ~r ~ '2-Z4 ,~ 396. Name, Address and Zip Code of Person Comple g Cause of Death (Item 26) SQ 3 O.'- oft) S'~ ST, 39c. Date Signed (MO/DaY/Yr) ~r-en S S .~ os c „-, t// i9 i7o11 O- - l 40. Registrar's District Num *~' 41. Registr s 51 ty~ 42. Registrar File Dal Mor~ay/Yr 43. Amendments SHOULD READ Disposition Permit No.~/(~//J ~~/ H105-143 REV 07/2011