HomeMy WebLinkAbout10-19-12COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128A801
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
STONER VESTA G/BARBARA SHELOW
5 ALLIANCE DR APT 104
CARLISLE, PA 17013
Bole
ESTATE INFORMATION: ssN: tst-is-coot
FILE NUMBER: 2112-1 132
DECEDENT NAME: STONER VESTA G
DATE OF PAYMENT: 10/19/2012
POSTMARK DATE: 10/19/2012
COUNTY: CUMBERLAND
DATE OF DEATH: 08/28/2012
REV-1162 EX(11-961
NO. CD 016670
ACN
ASSESSMENT AMOUNT
CONTROL
NUMBER
101 ~ 54,000.00
TOTAL AMOUNT PAID:
REMARKS: RECEIPT TO ATTY
SEAL
CHECK#1030
INITIALS: WZ
RECEIVED BY:
54,000.00
GLENDA EARNER STRASBAUGH
REGISTER OF WILLS
REGISTER OF WILLS
H l0iRD5 REV f9/I 11
i~-~~~a
LOCAL REGI CERTIFICATION OF DEATH
WARNING: It i this copy by photostat or photograph.
( `mil P s ~
IS (~. ~ 'Ji i J
Fee for this certificate, $6.00 ~~'2 flCj 19 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
~L~;;tf` certificate will be forwarded to the State Vital
~~un~' S Records Office for permanent filing.
~! ~"
P 18 6 2 8 0 0 9 ~~ L~~~t~.l,~,b.~c auk ~ o/to~2
Certification Number
n~
ryp•/Prim In
Permanent
Local Registrar _ Date Issued
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH VITAL RECORDS
/•'COTSCE~•ATC AC E'1CATM _. __
In l. D•c• ant s lN•1 Name (First, Middle. Left, Suffix) 2. Sex 3. Sgclal SecurlN Number 4. DK• W DN[h (MO D\Y Spell Mo)
Vesta G. Stoner females 191 18 3001 August 28, 2012
S _Aje-laK 91rthG•y (YM Sb. Undfr l Y••r Sc. Un er 1 D 6. O•h of Birth Me/Ory Nr) (Spell Month) iHO lrthf{lec• (Ctty en 'jt•b or For•ISn Country
ill S 1 a, PA
~
'
a. MonCM O•ys Heurf MlnVtef zjt]ly 12, 19
rJ(J ]sL
Z2
1 ib. BIKM1PIece (county) cwnber
{e. R•ald•nN Stec er Forf1{n Country) Bb. RNidence Street an Num er -Include Apt No.) Bc. Did Det•tlfm Live In • Tewnfhlpi
Plena vania 5 Alliance Dr. Apt. 104 Ov:, ae<ea.nt llwdln twp.
R.. •ns:• n ~arliale Borough
C rl B•. RNitlanc• (Zip COdf) r3NO. decedfn< Ilyfd wlthln limits p chy/bor0.
rm•d Fordsi 10. Marital Status at Tlme Of DNth Mercled W owe 11. Survivlry Spouse's Name (If wlh, {Na name prior to first mer,iNe)
9. Ewr In U
~
Q Yea NO Q Unknown Q Divorced Q NeV•r M•rcled Q Unknown
12. F•th•r s Namf Firrt, Mlddl•. Lest, SVMx) 13. MOth•r's Nam• Prior to First M\rrli{• IFint, Middle, Lart)
Hertttan 9hatto Mary Oolcer
14•. Inhmtent•a Neme 14b. Rel•[lonfhlp <o Deeed•nt 34<. Informant's Mellln{ Addr•as IStreet en Num CIN. State, 21P C 1
1
7015
stono Church Rd. Carlisle, PA
3helow Daughter 211
Barbaro L
q
.
11 W:tl,~OCwrcd In . Hpspttal: '~ Inpatient jlt Diith Occurred SOm•whereOther Then a Hospital: t~ Noapice Facility y O:C•e•ne's Nem. "'" ""
S Emf Room/O etl•nt Df•d M ArtNal Nunin Hom•/LOW Term Gre iscll Other (Sp.c
S •c11Ry Nem. I net Inrtlhl[Ien, {Nf ltrfe< an numbfr, lSC. CIN or Towh State, an Coda 15tl. Dgunty Of D•eLh
Carlisle Tonal Medical Canter Carlisle, PA 17015 Cumberland
, 16•. Mfehod o Dlapwltlon Buries Crwmatlon 16b. OeC• of DIfpNRlen 16e_ PIPte of QlspofRlen~ ((Nem• of amftfry, c in•tpry, pr otH•r piece
~ Q Remowl Trom Shh Q Danetlen 9Efptember l r and Valley I.Nemor n Gardena
O<Mr S )
16d. I.ecetlen a DlapOalROn ( IN or Town, Step, end 21p) Sia. u.e Funeral Ice Ugnse• or P•raen in CMr{e of InHrment lib. Ueens• Number
~ Carlisle, PA 17013 013144E
a tic. N•m• end Complf[f Addr•u Of Funeral Fec111N
HoYlman-Roth Planeral Hartle and Creme Inc. 219 N. Hanover st. Cariisie. PA 17013
JI i{. O\t• •nt'f E utetlen - Chfc [he bent •t Nt scN es the 19. Dec•d•M of Hispanic Onfln - Check the 30. Decedent's Race -Check ONF OR MOR6 aces <o Indlub whet
hl{tees! dgrN or bwl Of school completed •t M• time of death. box [hat heft dafcrlbes whether <hf depdent the decedent considered himself or hersNlto b•.
Q Btn {r•d• er Naf is SP•nish/NlsPanlc/Ladno. Check the "NO" ~ Whtte Q KorNn
Q No diploma, 9th - 13th {redo hex If tledd•nt If not Spanlfh/Hlspanlc/Le[Ino. Q Black or ATilc\n Amfriwn Q Vletnamfw
0 HI{h school graduate Or GED cemplKed ~ No, net Spenbh/Nlapanlc/L•Hno Q American Indian or AI•sk• Native Q Other Aslen
Q 50mf co11N• eMdit, but no d•{roe Q Wz, Meslcan, Mexican Amerion, Chlunq Q Aai•n Indian Q NKIw M\W\II\n
Q Assxlate dNree (e.{. AA, AS) Q Yes, Puerto Rlean Q Chlnefe Q 3u•menlen or chemorco
p Bachwmrv eNr.. le.{• BA. AB. B51 Q Yes, Cuban Q Filipino Q Semgen
Q M•atfr'f dNree (e.g. MA, M5, MEn4 MEd, MSW, MBA) Q Y•a, ether Spenlah/Hispanic/la[Ino ~ J•Panese Q Other PatlRc islander
Q Deetoratf (f.B. PhD, EdD) pr Prohasionel de{raw (Spaclryl O Other (Sp•cIN)
• . MO DDS DVM B lD
31. Df3f let's Single R•<• 5• -DNlgnadon - Gheck ONLY ONE tO lndlcKe whet the decedent wnfldered himself or hersel/[o be. 22e. vacadem'a Usual Occupetlpn - Indicate type p( work
Q White Q J•panaff Q Samgen - dons dodo{ moat o1 working IN•. DO NOT USE RETIRED.
Q Blaek or Afrlun Am•nc•n Q Kprfan Q Other Pacific Islander HOmema]eer
Q Amerlun Indian or Alaska Natve Q Vietnamese Q Don'[ Rnow/Not Sure
Q Aslen Intllan Q Other Aal•n Q Refused 22b. Kind o} Buslmas/Industry
Q ChiMae Q Native Hawaiian Q OMer (SPacIN) 17Wn HORIB
Q Filipino Q Gu•m•nl•n Or Chemerco
• -
NOUNC{S OR
PR roe Dea o sy
c d~ n naCU arson rnneuntin{ Deet On Y w en ePP a 23t. NRff Vm fr
BY -gRSON WifO
O
~ /~
E
~
~~ ~r 8/B6
~
z! n d Mo Day r) f Dee<h
26. Tlm
~ z5. WN Medlwl Exemlmr or Coroner Centact•di Yez No
CAUSE OF DEATH wpproxlmeh
Z6. -•R 1. Sneer tM chain o/fronts--dlf•as•s, Injuries, or comPll<eHOns-that directly caufed tM death. DO NOT enter tarminsl events fueh sf e•rdi•e •mrt, inbrv•I:
respiratory arrest, or wntricularflbrlllatlen wttheut showing Me etiology. DO NOT ABBREVIATE. EnCar only one cause on a Ilne. Add additlgnel Iinfs If nfcfsaary On»[ to Ofrth
IMMEDIATE GUSE - ------s ~ N A/V ~ T711 AP ~ vF YS
(iln•I disuse or condltien Due to (or as \ consequence pf):
risuttln{ In duM)
b.
Sequentially Ile[ cendl<lona, Due to (or ss a consequence of):
If env, krading to the cf uses
listed on Ilne e. Enter the c.
UNO{RLYINO GVSE Oue to for as a consequence ot):
(disease Or Injury that
Inltl•e•d the ewnH resul[Ine d'
of • con
in duth) LAST. Due to for sequence ef):
16. P•R 11. Enter other glgp)flunt cendltlena wn[dbu[Illl w duth but not resu [In{ In [he under yin{ taus. {Ivan in Part I 27. Wa an •u<opry p•rformedi
t 1'71
`I GlLE G'uC
7 No
..
11
G[-aJ+Tti, 111 Lt-KL. G 2B. Were autopry n Inp fwl
~?/K $Z/H1pNl~ to eompN[•eM C•uf•otdNeni
Yu No
39. If Female: 3D. Dld Tpbetco Usf Contribute to D•a[hi 31. Manner of Death
Not Pr•glvnt wlthln Peat Ys•r Q Yes Q Probably
N
U
k $ Neturel Q Nomiclde
)_] A
id
t Q Pa
di
I
ws[I
ftlen
~' Q Pro{n•n< et [Imo or duth
Q Net pre{Wan[, but prlgNnt wltltin 42 dfw of du<h o Q
n
nown
~ cc
en
n
n
{
ng
O Sulclde Q could no[ ba determined
Q No[ Prefnan<, but pr•Bnant 43 days to 1 y.ar baforw death 32. Data oT INV ry tMe D•y/Yr) (Spell Menlh)
Q Unkngwn If prw{nan<wl<hin the Pest war 33. Tlmf of lnlury
34. PI•ce Injury (e.{. ome, wnz[rVC[IPn slf•~ Term; school) 35. Loce[Ipn of Injury (Street antl Number. Ciry, State, Zip Code)
36. Injury et Work 3i. If TranapPlNtlon Injury, SpaelN: 38. Describe Now Injury Occurred:
Q YN Q Drlrwr/Operator Q Pwdeatrian
Q No Q Pefunger Q OtMr (SPecHy)
39e. uKI •r (c eck only one):
GKINInB pl,Vflclan - To th. b.st of my knowlwdB., death occurred due [p tl,• Ca Vs•(a) and manner iteted
Pronquncing 6 CeKiNing pRYflelen - To the belt of my knpwladp, death occurred et the time, dates, and place, antl des to the ooze(s) end manner sbted
Q Medical Examiner/Cyrgner - On th. basis urination, antl/er inwsti{•tlen, In my opinion, tlee[h occurred \[ the [Imo, dote, and place, antl tlue to M
f•YIt•~utf•(a) antl manner st•tfe
-{'
~a
SI{netVrf o1 c•rtifl Weis of cerdflar: ~~~ LI<ansf Numbfn,A-•A+QZ•ya~j
39b. Nome, AddrNS and 21p G Person Campletin{ Causes oT Death (Item 26) 39c. D•p 51 ed MOO V r)
D .sip /E.rY I.IiT3TN.v/v Ira o s J¢iAtaS ~~ r71vv7
9 e Krer f st c[ um er A •{ rt etYfe
~
~
~~ 4 r e• O ey r
c
° .30 ab\a
a3. Amendmenea
DIfPOSRIOn P•rmlt Nq. ~' 1qX Lei 1}- H1O5-140
Rev oi/zou