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HomeMy WebLinkAbout10-04-12.Reset PETITION 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: Edna Dorothy Pochatko a/k/a: a/k/a: a/k/a: Date of Death: July 8 2012 File No' ~~ " ~o~ ' ~~0 (Assigned by Register) Social Security No: Age at death: 100 Decedent was domiciled at death in Cumberland County, pA (stare) with his/her last principal residence at 1002 Crystal Creek Circle. Mechanicsbure. 17050. Hampden Township, Cumberland County Street address, Post Otiice and Zip Code City, Township or Borough County Decedent died at Golden Livine Center. 770 Poplar Church Road. 17011 Camp Hill Cumberland County PA Street address, Post Offtce sud Zip Code City, Township or Borough County State Estimate of value of decedents property at death: If domiciled in Pennsylvania ............................All personal property If not domiciled in Pennsylvania ........................Personal property in Pennsylvania If not domiciled in Pennsylvania ........................Personal property in County Value of real estate in Pennsylvania ........................................................ . TOTAL ESTIMATED VALUE... . Real estate in Pennsylvania situated at: 1002 Crystal Creek Circle, Mechanicsburg, 17050, Hampden Township C (Attach additional sheets, ijnecessary.) Street address, Post Ofnce and Zip Code City, Township or Borough ® 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 December 27 1990 thereto dated and Codicil(s) State relevant circumstances (eg. renunciation, 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(8), and did not have a child bom or adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. Q 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 life, durante absentia, durante 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(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, ifnecessary): ~ ~ Name Relationshi Address 's~ ~`' ~' c-7 C~ t~-i T ~ ~; ---i 'S ~:, ~? ~:a r - ~ r .~ ~~ c-!-t T C.: r~~ c~:a C~ ,!} ri ForrnRw-oz rev. 10/11/2011 Page 1 oft Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA } } SS: COUNTY OF C'.lSYY1bP,~I~ nd } (~ , ~ s~t:__ ~Cr~`~'`^, <,I is i',1~ M ~' "'2 OCT -4 Pi~i 3~ i 6 f.Ui Petitioner(s) Printed Name Petitioner(s) Printed Address',.• ; ;-< Daniel T McMahon 1002 C stal Creek Circle Mechanicsbur PA ~~ ~ C~l~:,t~t' The Petitioner(s) above-named swear(s) or afFmi(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 ecedent, the Pe,~ioner(s) will well and truly administer the estate according to law. Sworn to or affirmed a d ubscribed before !! ~~~~~ Date ~O - -Zo ~ y~ me t t day of , By: ur the Regtster BOND Required: Q YES (~ NO FEES: Letters ..................... . ( 3) Short Certificate(s)..... . ( )Renunciation(s)........ . ( )Codicil(s) ............ . ( )Affidavit(s)........... . Bond ........................ Commission ................. . Other ........ lll1 ~~ ........ $ 2 0.06 i 2 as ~~. o Automation Fee ............... ~• JCS Fee ..................... TOTAL ..................... $ 717 737 6400 717 737 5355 ~inaatlaw_nnm Firm Name Address: DECREE OF THE REGISTER Estate of Edna Dorothv Pochatko File No: 02 i - i oZ - ~o ~ 1 a/k/a: AND NOW, C~'(~-~A(~22r' ~ 2~l 2 , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters .`- ~~1~~._~1 ~_~~ are hereby granted to ~Ar16~ i ~~~(~ ~~`,t_ Y1(')1~ in the above estate and (if applicable) that the instrument(s) dated ~,Q( r described in the Petition be admitted to probate Forns RW-02 rev. 10/1//1011 Date Date Date To the Register of Wills: Please enter my appearance by my signature below: Attorney Signature: Printe sme: James A Supr a Court ID umber: 2 James A Miller Phone Fax: Email: filed of record as the last Will (and Codicil(s)) of Decedent. egister of Wills _ ~ `~y~=u-~~ ~YJp 1 ~ e2of2 W I nS..RnS RFV /0/t t s LOCAL REGI ERTIFICATION OF DEATH WARNING: It i~E t' 1..~ this copy by photostat or photograph. ~,.~` G. _ Fee for this certificate, $6.00 `~~~ OCT _~ This is to certify that the information here given is correctly copied from an original Certificate of Death duly filed with me as Local Registrar. The original ~~.'~~th. certificate will be forwarded to the State Vital 0~~~~2~ Records Office for per anent filing. CUM~RLANI P 1859353 Certification Number H!/PINT In cunt GC' ~~ ~~g~~~ Local Registrar Date Issued COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT Oi HEALTH • VRAI RECORDS CERTIFICATE nc ncnru 1. Dxetlent's Leal Name IFkSI, Middle, las4 SuAla 3. Sev 3. Social SxuNN Numberpp < d. Date of Death (MO/Dry/Yr) Isp<N Mol Edvla 1Darotl~ ~ hai-k oc o o - Sul F aal~ - Sa. N!-last BMhtlay (Ynl Sb. Undx l Year Sc. Under I 0 6. Date of Birth IMO/Day/Yearl 19pell MonMl ]a. Birth (Cky aM Nap w f n Country[ Months Day Naurs Minutes '+ p© ~ r. ~ a i i 9 i a ro. Mnngx• Ifpmryl Ba. ResMence Iitale w Forel{n Country) {b. ReNdenc< (Street and Number ~ Include Apt No.) e<. Old Deaden[ Live in a TownMlpi ' ' ( C G exed<Mlwedin HarrY ~Y<E e~r~i Bd R eal~<np<ICpNnNI r . OOa ~+~ ( X-2P~ , P twp C.u M Be.Rnldenu lzw caeel ~1 ^Np, exedent lNee wnhw BmlD Or cev/bprp. 9. Ever in U9 Armed Forces[ ]0 Marital Natus at ilme of Death Q Married WbwvM 11. SurvNln{ Spouu's Name III wile, {Ne name prior to Nrsl marrk{el ^Yn ENO ^Unknown ^Divprced ^Naver Married ^Unknow 11 Fatnei s Name INrd, MwMe, last, SufA 13. Mothai s Name PHOr to First MaMa{e IFlrsl, Middk, Lastl 0 Ida. Inlwmant's Name tlb. ReNtionshlp to Decedent 34<. inlwmanl's Mailin6 Address (Street and Number, Ciry, Spte, 21p fpdel - - od ~ as ~ c W ................................_ ..._._ 1 a aap at f pn< ............MP4y ............................................. ............................°A.k........ ~ ~ S ............................ ............................ .. ..................._............. H Death awnee m a Ho pl sry LJ Inpauenl II Death Occurred ]pmlwhere Otner Th<n a Hosplpt. y Hupke Fxility ^ 0<cedent's Nome ^Emer my ROOm/OUtpatiaM ^Ikadon Arrival NurslMHoma/LOn{-iarm CarefaciliN Otherl5pecilyl a 15b. FuRiN Name Ilr rwt ImNNtbn, Eiv<streel and number' 19c. City w Town, Step, antl Elp Cade 19tl. Cwnry of Dent L.d ~ D 11 P 16a. Methatl ill Dispositbn Q B ~ Cremation Ifib. Date d DNpp [ion 1 %xe dl Olspodtlon (Name of cemetery, cramxory, or other plea) 8 ^ Remwd nom N,le ^ Dpmnpn ~ ~ t o a i a m I N ~ri F ` Other IspxlN) D a K,Yy.~ a,, k~vv..YZa ~ ~~ - aw E 1fid. Lwation of aspwkbn Ivry or Town, zpte, and npl ]ice. si nature er wneral service Licensee r P<c in char 9 ie or interment ]ro.Licenp Npmber 5h', ens Ph i~a57 ~ / k-- of tic Name and Cmpkte Address pf Funeral faclllry ` ~ IB. nt'sEMatbn-C [Ae bov that best deudbu the 39.Oxetlent pf HHpan In-fnxFthe 20. Merit's Rea-CMck ONEO ORE rxes to lndk>[e what hi h d ert { gree a kvN of schpd complate0 at the time of death. Ooa tMl best dexrlbes whedrer the decedem the decedent compered himxlf or henell to be {Ih {radewless is Spanlsh/HlsWnk/latlnp. Check Me'NO' ~Whke QKwean ^NO dlpbma,9[h~11M {rade Yea if dxedent is nw SWnIM/Hlswnk/latinp. QBlxkorAMcan American QVktmmeu ^HI{h uhod{rMwte arGEDcompktM No, mtSpanish/HHpanic/lxinp ^Amerlcan lndlan or Naska Native ^O<her Asian Q Some cdlge credit, but rq de{ree ^Yes, Meakan, Medan Amerlcan, Chicano ^ Asian IMian ^ Natve Ipwallan ^ Assodate de{rce le.{. M, AS) Yes, Puertp Rican pfnlnese ^GUamanianprChampno ' Q ^B,rnekr aae{r.ea.{.BA,AB.BS) Yes,[uban ^ ^ Huw~ ^ sampan ^MUteisde{reela.{. MA, MS. MEM.MEd, MSW, MBAI ^Yes, other Spanish/Hispanic/Latinp Qlapaneu ^Other PadflclslaMer ^ Oactwale le.{. M0, Etl0) or Prokfslonal de{ree ISpxiNl ^ Other IswclNl e.. MD D05 OVM LLB 10 31. Decedent's Nn{le Rxe Self-DefpneUOn - CNxk ONLY ONE to IMWte what the dxedent considered Mmsell or herulf Ip be. 13s. Decedent's Uwal Ottuwtbn - IMiate ryp• of work pp wnlee ^ ],wnae ^ sampan epee did n{ mwt o(wohlM Ilk. 00 NOT USE RETIRED. ^Bkck orAM n A k w mer an QKwean ^OMer Pacinc Islander frtL Q Amerkan IMlan or Alaska NatNe ^ Vktmmeu ^ Don't Know/Nol sure ~TG~ CL ,Y ^ Asian Intllan ^ Other Asian ^ Reluue 12b. Kind of Business/Industry Chinese ^ Native Hawaiian ^ Other IipeciN) q ^ FNpino ^ Gwmanlan or Chamorro p ~l i G ~n Ls 0 p, TfEM53 - 33d MUST Bf COMPLETED 13a. Date Prpnoumed Dead IMO Day rl 236. Si{nxure of Pxspn Pronountin{ Deal IonN when applla el 13c liceme Number BY IFRSON WIN/ IRONOVNCES 00. CERTIi1ES pEATN - \ - 23d. Dap SynM (Me/DaY/yr) 21. Tlm<of Death c (L J/ R ~ G ,~ I y V ~ ~ (J ~ ~ V f G 25. Wu MMkalEnmine wCproner Centxtedl ^ Yas B' No CAUSE OF DEATH Approalmxe 16. Pad L Enter the chaN of events--0ISeases, injuries, or cempllations--that dlrcMy ausM the death. DO NOT enter terminal evenU each as ardlac arrest Interval . respiratory ames[, or ventricular AbrlMtion without showin{the etblgy. DO NOT ABBREVIATE. Enter onN one cause pnallm. Add Mdilional lines it necessary ~ Onutto Death ~s /1 ~~ IMMEDIATE fAUiE ...........--> a. 1_ {il.•G ~ ~l,S [/. ~jjc~ /,E, T'bt~/` C ~^'1 j 1~j~1/a'- (FNaI diuase w coMilipn Due Io Iw as a conse9wnce oN' ' resWtin{In dea[nl / / / )~ SepuentialN lid mMitions. Wet ppuence olp it any, leadiq Ip the nose Iis1M on line a. Fnlx the _ UNDERlY1N0 CAUSE Oue to (ore cas onsepuence oN Id4eau w iniury that F baled the eventsrnuluni d. in death) LAST Due [p for as a cpnse9uence prl. ' g S 16. Part II. En[!r other IeniR 1 INtl b •I [ d Lh but not resultin{ N me underNln{ cause Given in Part I 37. Was an aulogY pi I Yn 1{. w.rc aplop,r nMln{s.YanaMe 8 tilt pleletneappordealro o ~' 29. IS Female: 30 Did T b Q Yes No i . o xcp Up ContrMUte to Deaths 31. r of Death ~.Mptwananl within past yea. ^Yes ^ ProbabN Natural ^ Homkide ^ Prgnanl at [line of death ~ ~ ~aso Q Unknown ^ Accident ^ PeMln{InvesH{ahpn Q Not re nanl b t h . p { , u pre{mnt wk ln 01 day of death Q Suicide Q Coultl m[ be determined Na rc mnt b t 1 d p { , u pre{nant 3 ays to 1 year before death 32, Date pf Injury (MO/Day/Yrl (Spell Month) Q Unkrwwn 11 pre{nanl wlMln Me past year 33. Time ill Injury 3a. Place of Injury (e.g. hom<; constrvctbn site; farm; school) 35. LaaHOn of Inlury (Street and Number, [Iry, State, Zip CMeI 3fi. Inlury at Woh 37. If Transportatbn Inlury, SPxIN: 38. Deunbe How Inlury Wwrretl~ ^ Yes Q Driver/Operator ^ PedesNkn No ^ Pasxn{er ^ Other ISpKIry) ' 39a. Certifkr (Check onN pnel: Q Cartdyln{ physMan ~ To Me Out of my krlowlM{e, death ottumd due to the auselsl and manner stated @-Prormunclry 6 Cemrylry phyN k To the best of IM{e, dace acurrM a[ Me [kn<, date, and ppce, and due to the caupls) antl manner sptM ^ Medical Ewminer/COronx- n basis of epm , aM/w albn, In my pPnbn, death occurred al the lime, dale, and plea, and due to the uuplsl M manner silted si{nature m certnier ~ P L : rdle ill artmer'. e Dense Npmb<.:Gs~ -19rA7 ,r 3 94 Name, A Zip Code of Person complMn{ Caup of DeaM Ilte 1fi) 39c. Date Stoned IMp aY/Yrl ihY», l~ moo, r o./ ~a ~. d rlrv e z 0. Re{IStrcr's DHtHCt Number dl. nature d1. Rgis[pr FI Date Mo Day rl ~j•zi~ 7 ~~ t d 3. Am~ epla n ~ l i. ,~ 1Z,~ ~Q .Yk~r (~` 'S 1 ~~~( ~ {~`i~ ` $ ~. '_ 7 ~ ~ . ' T / {1 L~ N ~ ~,g u . ~ 'M v z ~ ~' V~t~ -1~(.I /N H109~1A3 Dkpwitbn Permit No ds _I 1 l1 REV 07/2011 __ _ _. __ a ~ ' ~ a - , ~~~fl~~'~~' ~I-Ffl~~ ~~GI FE:'~ r,;~ ,~w~~ ~ e BT WILL AND TEBTAMENT OF ~:~12 OCT -4 PM 3~ EDNA D. POCHATKO 4N'S r'(~~T „~ Pochatko, of Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding and considering the uncertainty of life, do therefore make, publish and declare this to be my Last Will and Testament, hereby revoking and making null and void any and all Wills and Testaments or writings in the nature thereof by me at any time heretofore made. FIRST: I direct the payment out of my estate of the expenses of my last illness if any, my funeral expenses, and my just debts, the same to be paid out of my estate by my Executor hereinafter named, as soon as conveniently may be after my demise. SECOND: I give, devise and bequeath all of the rest, residue and remainder of my estate and property, real, personal or mixed, of whatsoever nature and character and wheresoever situate, of which I may die seized or possessed, or to which I am in any way entitled at the time of my death, or over which I have any power of testamentary disposition unto my daughter, Katherine A. McMahon, if she survives me by thirty (30) days. THIRD: In the event my daughter, Katherine A. McMahon, predeceases me or does not survive me by thirty (30) days, I give, devise and bequeath all the rest, residue and remainder of my estate to the Trustee of that certain Trust Agreement established on October 30, 1990, by my said daughter and her husband, Daniel T. McMahon, with both being Settlor and Trustee, and with Berna Louise Colestock as Successor Trustee, regarding my grandson, Shawn P. 1 ~ ~~r ~~ I . . „ _, McMahon, for the uses and purposes and under the terms and conditions as therein set forth, if that Trust is in existence at the time of my death; and if that Trust is not in existence at the time of my death, then I give, devise and bequeath all the rest, residue and remainder of my estate unto my son-in-law, Daniel T. McMahon. FOIIRTH: I nominate, constitute and appoint my daughter, Katherine A. McMahon, to be the Executor of this my Last Will and Testament. In the event she should predecease me, or is unwilling or unable to serve as Executor for any reason, I nominate, constitute and appoint my son-in-law, Daniel T. McMahon, as Executor. FIFTH: I direct and request that any fiduciary under this my Last Will and Testament, shall not be required to enter bond or security of any nature whatsoever in any jurisdiction in which such fiduciary may act. IN WITNE88 IiHEREOF, I have hereunto set my name and affixed my seal to this myL~,a~st Will and Testament which consists of three (3) pages this ~ 7~"~ day of / -~ 1990. Edna D. Pochatko ( ) s.s.~ ~8v - ~v - ri.3 P 2 __ .. 1 *, _. . , .~ SIGNED, sealed, published and declared by the above-named Testator as and for the said Testator's Last Will and Testament in the presence of us who have hereunto subscribed our names at the Testator's request as witnesses thereto, in the presence of the said Testator and of each other. ~-~ C ;~ ; 3 10/9/2012 11:29 AM FROM: Great Road Settlemnt TO: 717-8930699 PAGE: 003 OF 003 Rcr-.,,~ __r ,,c ~~III I ~ ~l.~~Vi._:~ ~ i:~r_.ud ~0l2 OCT -4 PM 3~ t 6 '~'-~=`~'`' ~ TH OF SUBSCRIBING WITNESS(ES) QRPHA(~i`S C CUMBERLAND CO., PA REGISTER OF WILLS Cumberland COUNTY, PENNSYLVANIA Estate of Edna D. Pochatko Deceased Brenda L. Overmiller (each) a subscribing witness to (Print Namc+-"s) the ®Will ©Codicil(s) presented herewith, (each) being duly qualified according to law, depose(s) and say(s) that she / he /they was /were present and saw the above Testator /Testatrix sign the same and that she / he /they signed the same and that she / he /they signed as a witness at the request of the Testator /Testatrix in her /his presence and in the presence of each other. /.Srgnanvet (.SigKatureJ 48 S. Duke Street (Sweet Address) (Strut Address/ York, PA 17401 (Cint S'tote. lip/ Executed in Register's Office Sworn to or al~irmed and subscribed before me this day of , Deputy for Register of Wilis ICin~, State. Zip/ Executed out of Register's Offu-e Sworn to or affirmed and subscribed before me this '~-~~ day of _ ~ c Ten ~ I~Z Note ~ Pu My Conunission Expires: (Signature and Scal of Notary or other official qualified to administer oaths. Show date nfexpirazion of Notary's Cmmnission. } Nt)"lF: To lx taken by Officer authori~,~d to athninister Della. Ptrttsa hour present the origitut] or copy of instrtmtcnt(s j at time of notarisation. COMMONWEALTH OF PENNSYLVANIA Form RW-(13 rrr. 10.13.(kS NC~hA~1L 5`FAT, Nancy J. Bachyaski, Notary Public City of Yak, York Caurty oo~ieaion . F 25, 2015 10/04/2012 THU 11:40 [TX/T2X NO 9306] f~j003 10/9/2012 11:29 AM FROM: Great Road Settlemnt TO: 717-8930699 PAGE: 002 OF 003 ~:, RFCG~P;'~Er3 r~~~CE 0~ R~G~., ~r 4,_ ,t/~~I 1 c 4 ~D11 OCT -4 PM 3~ 16 .:...OATH OF SUBSCRIBING WITNESS{ES) ~~,~ ORPHraI`J'S COURT ERLAN() ~.~ ~ REGISTER OF WILLS Cumberland COUNTY, PENNSYLVANIA Estate of Edna D. Pochatko Deceased Bruce C. Bankenstein , (each) a subscribing witness to fP+int Nnmeis) the ®~'Vill ®Codicil(s) presented herewith, (each) being duly qualified according to law, deposes} and say(s) that she / he /they was /were present and saw the above Testator /Testatrix sign the same and that she / he /they signed the same and that she / he /they signed as a witness at the request of the Testator /Testatrix in her /his presence and in the presence of each other. /Siq,ratw-e/ 48 S. Duke Street York, PA 17401 (Cttr. Scare. Zip/ E.ecuted in Register's Office Sworn to or affirmed and subscribed before me this day of , lSignan+re/ (.S/reel Address% fCiry', Stale. Zip) Executed out of Register's Office Sworn to or affinned and subscribed before me this '`~'~~" day or ~ c~,•e ,, , ~ o ~ Deputy for Register of Wills Nota Pub t My Corrvnisslon Expires: (Signature and tieal of Notary or other official qualified to administer oaths. Show dote oCeapiration of Nutan• ~s Commission. ) NO"I't: fu br taken 6y Officer authorized w ndrninistar oaths. Plrttsc hove present the original or copy of instrument(s) at time of notarization- Fbrnr Rlf~=iJ.? ,•~~•. rri. r3.ars COMMONWEALTfI OF PENNSYLVANIA NOTARIAL SEAL Nancy J. Bachynski, Notary Public City of York, York Couaty cmnmi>uion F 25, 2015 10/04/2012 TAU 11:40 [T%/R% NO 9306) 1~j002 w.~ _ ___ ~ __ __ H105905 REV.(1 /11) - --- - -- 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. RFCORGE~' ~;~Fi~E OF ' ` .r1t'~gN(~~~gal to duplicate this copy by photostat or photograph. y~ 1~ ~~ 212 OCT -4 PM 3~ ! vL.~1~fi +,~~` ORP-IAN'S COURT' a1MBERLAND CO., P/~ 6016630 No. `1~«~ o. ~-~ `~ Marina O'Reilly Matthew Acting State Registrar FEB 2 2 2011 Date Ht0513~1'O~CORRECTED ITEM(S):8c COMMONWEALTH OF PENNSYLVANIA•DEPARTMENTOFHEALTH •VITALRECORDS 043465 TYPEIPRNT w PERMANENT PER: FD DATE:5-19-06 bas CERTIFICATE OF DEATH BLACK Mlx STATF FII F NI WnFR ~~ 0 ~.~ ueavan tram, moue, usl, sump 2 Sez 3. Saul Setudry NuMm /. Dated DeaMi (Mash, day, year) Katherine A McMahon . Female 212 - 42- 8864 April 21 2006 , S. As•I~YI Ikidmt tAdert 6. Dabdlalh 7. andstaka Ba. PlacedDealh am IknM D>ts Nan Acmes • 62 Ym. I 1 / 17/ 1943 Annapolis maryland ~ Hospice Horse ' tb. CanlydDeah &. ^bpa6mM ^ERlOumafmq ^DOA ^NumbgHarm ^Resdemx ~OMim~Speciy City, Boo, Twp. d Dean Bd. Fa3y Name (Mari idbYOn, Bile street and manlier) 9. Was Decedent d Hsparc Orgb? ®No ^ Yes 10 Race: American b6an, gark, While, ek. (M yes, sp¢dy Cuban, (Spxrry) Dl3r3phin SusquehatLna 'J'tap Carolyn Croxton Slag Residence Medcal.PimrbRican.ebl 4dtite tt. DecedaRS llaW dmah done mold LIe. Do m>t atab refired. 12. Wes Oecederdev«ndm 13. Deuderifs EducaMm lSPsok ~r9r•d•wngbled) 14. MadalSmha: tarred, Neva Monied, 15 Survrrig Spouse (M rile, gve nmden none) KiddlNak IGddBuplessfMdusby U.S AmmdFamesi . EenedayrSeoadmypFll) Cabpe(14a6.) MhOo•ed,Divacad(SpmXyJ Harseduties ^Y•~ I~~ Married Daniel T. McMahon • 16. DeoededsMaim3Ame.(SYed,dylbwn,spb.zgc~de( ,: 12 ~ 1002 Crystal Creek Dr. Ad~R na.Sale PA IAeea t7c.~ Yes,DxeeaMUvedb Hampden 142p. T•y, Mechanicsburg, PA 17050 +~~r fkmberland TON~'"D' na^No,DendeMLisedwiii AcAml trmils d ~.r~ 13. Fatlmis Name (Fist nwdde, last, sdk) 19. Motlefs Name (FMsI, midde, maiden surname) Thomas Pochatko Edna Pinkosh 20a. bfamanrs Name (Type I Print) 20b. bfamant's Maing Address (SeeeL d+Y I ben, stale, nP Lade) Daniel T McMahon . ]002 Crystal Creek Dr. Mechanicsburg, PA 17050 21a MelbddCeposition ®CremaYon ^pmafpi (e ~s 21b. DaladDeposifm (Abnlh, day. year) 2tc. Raredfieposil0n (Naredc«reery,umnalayadhm Pl•ce) 11d. lacatlon (CMy/ben, sloe, zipwdel ' ^Biaial ^Rlmeval from stab ; M/-fir wa CrmlWlonal3lnaMan Aubacd ^aha-soar .brlle4calEunYarrl:aramA ®Y„^s, April 26, 2006 Holl' r Cremato Mt. Holly Springs, PA 17065 ~ 21a SipmluredFlnral . (aperwrtarJwgassuch) 27D. lioeneeNumha 22c. Name adAddreMdFa3ry ~ ~ FD 0]2714-L Richardson 1'1u>eral Home Inc. 29 S. Enola Dr. Enola, PA 17025 Canpleb Moro 23ac Men oerYlNrg 23a To h d my lobabdge, deaf owared at vb inm, aab and place stabd. (S9na6•• and ise) 23b. Licame NunMer phyidanendaraiabbatimeddedlb 23c DaleSgned(Madh.~P.Y•a) caMy caseddealh. • Mems 2426 must be cmGeled M person ""° "°`~'""~ dam"` 24. Tare d Death 2S. Dab Prabunced Dead ~MaMh, day. year) 26. Was Case RNmred b Medical Eaamimr I Caana fa a Reason Other tlmri Genmtion a Danabn? 12 :10 P M April 21, 2006 ^ y, ~ rro CAUSE OF DEATH (See hg6uetiona and •:ampNa) Appodmale ekvval: Pal II: Ener otlmr ~ 2B. Did Tobacco Use Cadrbub b Deaf? Mom 27. PART 1: Edm the ~M'B.d44!>!#-deeasea, ryuies.acaryicafms-MaldMycauN Mie deaMi.DO NOTeda kmeWevena such as cadiac amrst. ; OrodbDealh but not mslltir e Me udml vi i eP g ) g came g sen ms all. ^ Yes ^Probady H~y onset a rmMipiar M 7ri pf P m w R aW ahoai g tl ra e6obgy. List ady ae ausean exh ile. 1( F~ ~ { ' ~ ~ p ~ s T ~ cordMbn ending a dearil~ a. 1 N` I '~S l/ I 1 r L M/L~s ^~ ~nluNwn /.r~~0/-1 ~ 23 M . Fyanale: Dim m la r • amequaw ary U Nd pregnait aihn PSI l~ 6toaldian,Many, b. bmefsbdmima ^Prepmm al Yneddeah ~ Duenl«ua00naequercs oQ. INDEILLTMIG CAUSE (dieeaeeai~eytulieSaedthe c, ^ Ndgegnanlbdpregnaardlinl2days • evade msuliig n deaLi I LASE. d d~ Due 101« as a 0a0seouen0s M. but Ivegnanl43days b 1 year • n ^ dl 30a. Was an Aubpsy 336. Were Adapsy FMags 31. MamerdDeadt ^ UNCrown'd pepmm dhn Mmpa,t y,a 31a Ddedbpay(AImIA,day.yeaQ 32b. Desabelbw ' Owned: P f d? ~ er ame Avaia6b Prior b Candelen 32c. Place d bjuy: Hans, Fam, Sheet, Fatsory, acameaoeam? ^NaNral ^ttomicee olkeBuidng,elc.ISOedM ^ Yes ~No ^ Yes ^ No ^ Atrded ^ ~9 ~ 31d. Tined bµy 32e. bjuy al Work? 321. MTrampataEOn 6yury (SpecJy) 713. l.aa6m d 6MrY (Sheet. sly r ben. steel ^Sukide ^CouU Not he Dekrneed ^Ye9 ^No ^DmrerlOpembr ^Passenga ^Pedeseian M. ^OMmr-SpaaTy 33a CwtlMrldmdcodyene) 33b. SignaaeandTNed ' ~~WIM (nMpai urYyig cane d death dial amlMmr physipan fix prauabed deaN ad wnpbled Mem 23) Totlm bwsdnry bsomledga,daMaceurrad 4mroMla cmmyq and malaNraahLSA-------------------------------- ~ ~ Yy)r~ ~ ~ia~ - 0•~uhMrbS1~Y~~P~ndo9adc~M~Sbwuseddeaml To1MbpldmyMnoldedga,deMhocarmdallMtlela,Me,mdplw,tadAmbtlmearaaalmdmannxpelalp~_____________ __~, ~. IN1~ 33d.Dak ~ ~. .year) al 9 ~ ~ ~ ~ r Md ~Np~ ~ y ,y a o-6 b ia aaaMrorinratl 10 atlon Mm 'a Ydo daM M p ~ l p aaur A altMBm4dW,rMPhca~andMlablMallayalydmnmerraM~,_~ d N a as Cm~e1 CauaedDeaS~IMem27) iypelPmt 35. RegistalsSgmMVeandD's6idMmber 36. DabFfed ,day year) r'~'/s~+n /~j'yMy/~/j;ti~/S] /Iq~ ~~ I fT O ~ dl ~ id ~ ~ 3 yr ° i ~ ~ y~4~ ~ m P e ~ ~ , ;.t ,f, lase InsTnrcLlons and examples on reversal