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HIUS_905 BEV.(ffiIll
`I~his 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 ~~~t~1, ~taµgtics ,I,~ o~r1953, as amended. ~ ~
~` ,f'_ `", ! !I~IARNING: It is illegal to duplicate this copy by photostat or photograph.
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Marina O'Reilly Matthew
State Registrar
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LOMMONW EAI TH OF PEN N$V LV ANIA- DEpA0.TM&NT OF HEALTH - VITgL ftECO RpS
CF RTIFICATF nF r]FOTH
(1R94SFi
], Decedent's Legal Name IFirzt, Mltldle, Last, Suffix) Z. Sex 3. Social SeCUritV Narrnbar - q. Daix of Oea[It (MO)Day/Yr) (Spell Mo)
Benjamin 5. Peters, Jr. M. 174-20-3706 September 26, 2012
Sa. Ag¢-LPS< birthday (Yr[) Sb. Untler 1 Year BC- Und¢f 1 De 6. Data OT Birth (MD/Day/V ear) (Spell MOn[h) 1a hplac0 fl~Ijy
aQtl Star 5y~ ForOlgn COUn[ry)
86 Months Days IlOUrz MIn Ut<5 l
~ ~l l ~H
.hme 10 1926 7b. mrthplare tcpl. myl C ber]_and
Ba. Residence f5tate Or Foreign Country) SB. RBZldence (Steep.[ antl Number- Include Ap[ No_) Bc. Did peceden[ LIVe in a Township)
Penns lvana RY [
n¢aetlent eyed it HarnDden
3814 Post Ln.
Rd. Ra~ldenea (<DUnty) 7-smP ,
[wp,
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Cumberland 8¢- Residence 12ip Coda) QNO, tlecedem IivcJ wlxhln Ilmita of _ cl[Y(bor0.
9 Ev¢r In US Armed FOr[esT 1D MdrIC01 Status at Tim¢ oT DeatM1 Q Married ~ WltlOw60 11. SurvIVInR $POUSe's Name (If wife, qiV¢ name Prlur to first mamlage)
Yes [] NO p V nknOwn Q Divorcptl [7 Never Married Q Unknnwrr
12. Fa[h¢r'S NBma (First, Midtlle, LasT, Sulflxl 13. MO[her's Nim< Prior Co Firzi MarrlOHe (First. Middle, Las[)
Benjamin S- Peters Catherine Ware
]4a- Informant's Nam< 1qh RelaCionahip [O Decedent lac. Informant's Mailing gddreas (5[re0[ and Number, CICV. S[aie, 21p COJe)
o Jennifer Good ear I~u titer 930 Dennis Circle Chambers Hill PA 17111
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__ __ ____ ______
~~ ~ a PI D afh ChOCk OnIY
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f Death pccurred In a Husplial; (-} Inpatient _ _ __ _____
~If DBatb Occufretl Somewhere
er Than a HOS ItY I: ~~~ "~~ HOS -ce Fac'lliy
0th p' c} p ~~~~~ d Decade tt s Home
EmGrg¢ncy ROOm/OrrtVa[i¢n[ ~ Dead On Arrlvel
~ Nursing HOm¢/Lpn H-Term Car¢ FaCiIItV ~ Other (Spacl(y)
]Sb. Facility Nim¢ (If not Inztitrr(iOn, glv0 G[ and number'. 15<. CitY or Tbwn, 5Ca[0, b Lip COd 15d. COUntY of Death
Golden Living-West Shore Cam Hill, PA 17011 C>_unberland
~, 16x. MBthod Of DispOSitinn [] Rurial LrematlOn 1tib. Date Of Dizposl[lon 16c. Place Of Dlspo Itmn (Name of cem¢xa N, crematory. Or Other place{
z
(j RemOVel lrom State 0 Donailon
-
~ (J Omer ($p¢clfy)_ 09/28/2012 Ha 11in er Crema.tory
1Bd. LOCa[lon Of DispOSitiOn (LI[y o(TOwn. 5t0Ce, and Zip) 1/a ature Of Funeral 5 Nlce Licensee Or per n Cha arT¢
~ 1/b. License Number
~ Mt _ Holly Springs , YA 17065 ..-~r.1
_~ ~ _ 014819
E 1~c. Name. and Compl¢t¢ Atldreas Of Funeral FBCIIILy
M ers-Harper Funeral Home inc. 1903 Market St_ Hi l1 PA 17011
18. Decedent's Education -Check ipe box that best Jezcrlbe8 the 19. Decedent of Hlapanlc Origin - Lh¢ck the 20. Decedent's Ra[e -Check ONE OR MORE rates [o indicate what
hieha Degree or level o[ school co rr Vleted at the time of deatfr. bo eM1at best de ribe whether [ha tleced¢nt the tlecetlent co nsider¢J himself or hersBlf t0 be.
t
~] g
[It gratle Or lass 5 Spanizh(HispanlCjlatlno. Check to<" ~rV Mlte Q Koran
I
Q Nc dl VIUmO, 9[n - 1Lth grade
box If tl¢ced¢nt iS no[ $Vanizh/Hlsptlnlc/Latino. Q Black Or AfflCan Anrrricart Q Vie Lna mes0
Q Hlgh zc12001 gradrrete ur GEV c mpleted ~ No, n r Spanish/HisPanlc/La[ina. ~ American Intllan Or AlazkB Nari.re Q tJ[her Asian
[] $onte college cr¢tli[, but n[a degree Q Y¢L, MORlcan, Maxicare American, L:hlcOnO Q Azlan Intllan [~ NaYivn H Wallan
Q A O iafe degree (rg. AA, AS) r] yes, Puerto Rican ~ Chlnacv ~ Gu9Tanian or CM1arnurr0
~' Bac F.elur'z degree (e.g. Bq, AB, BS) 0 Yes, Cuban Q FIIip Ina ~ SemOan
~ M zxer s degree le.g. MA, M5, MEng. MEd, MSW, M6A) [7 Ves, o[N¢r Spa nizh/Hispanic/Latino ~ Japanex ~ Other Yaclfic Isla nJ¢r
Doc[orat¢ le.g. PhD, EVD) or Prof esslOnal negrae (Specify) ~ Other (Specify) ~__. -
I¢.g.MO.D05 OVM LLB,JD)
L l.
D
ecedent's SInHI¢ Race Sclf-pesignation -Check ONLV ONE <O in Jirate what the decetl¢n[ [unslderect himself or Itars¢If t0 be. tLa, Decedent's Usual OccupOtlon - Indlcaie type of work
ra
~r
ly WYrI[¢ •] Japenp50 n Samoan Jun¢ tlurinR mOZ[ of wur king Ilf¢. DU NOY LISP RETIRED.
r~ Rlack ur African American Q KOr¢an Q Other Pacific Isla rider
Q A n Intllan ur Alaska N8[IVe Q Vle Q OOn't Knout/NO[ Sufc LBbOrer
V Azlarr Indian Q Other Asian Q Ref USetl 236. Kind Of guzlness/IntlustrV
~ Chin eze O Nati.re Hawaiian ~] Other (SpeclN)
Q Fllipl ru ~ Gu r Chanrurr
Museum
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ITEMS 23x
23d MVST DE COMPLETED 23x. Date
Pronoum:ed Oeatl {MO/pay)Yr) 336- Si eiu re Of Person Prunounclnq Oea[h (On y when applicable{ 23r. Licence Number
BY PERSON WHO PRUNOUNCE$ OR
CERTIFI[5 DEATH /] ~1 ~l
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33J. Da[0 Slgn ( ~~f)J y/Yr ~T 24. Tfine o~ DY oath ~
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_C/~~ I ate' L~ ~ 25. Was M¢dIC01 [xa
r Co r CO ed] FQ Y¢i
"erD cone nt
CAUSE OF DEATH
ApprBximam
16 a Enter m6 spa n Pf ¢ --di.eazea, m(nne:. rx mpneaupre--um nl.aaly a [¢a the daatb. no NOT enter cermir;al ¢ rich a ardiar a In r..al:
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resprrn[ory er r¢s or ventr
cula
r fibrllle[iun wish oui S
hOwing [hr- r•uology. DU NOT A
B
6REVIATE. Enier O
nly one' reuse On 3 Iln¢e Htltl ad JiJOnal linbz
i f
necezzary Ond¢t CO D¢a[h
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2
L
IMMEDIATE CALI ]E
--> a. ~ ~/'- L~/-"~C. /J -~ ~~ (C-/ / I 'j U.^J I /J
(F, al d rid-miDn Dna to (ter a[ a cDns¢qu once Df). -. -. - -_..
n~
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resu ming
n dea
l _ /~, _
Sequent1a11Y Ilzt cn.. d't Ou o (or as a conseq ~ pre of). -
On
if any, I¢edln et [FC c
uzt¢tl on one Dente. anee c. G- ~i" ~-
G~~ty~ll
_
UNDERLYING CAVSE Duo [o (Or dz a cans Oquence of): ~-
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(CI[Base or inf ury that /q ~ >' / r
In" areJ Lne events re.suhing n. ~- L l ~ - ~ _ /~v/ ~ ~' C~~- »-~- ~~H
In tl¢atnJ use. q ~ rice Dt) - -
Q 26. Part IL Enier nthee zi¢nlfltan[ coed t onz cOntr"bui n¢ to deeYF but not rezuliing In the undprl aus
Yin6 s B given rn Part I u
22. WOS an a Ynpsy p¢r(Ormed2
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f/ ~-- L~ ~ i f ~ / l ~ Y¢5 N
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28. Were autopsy findings a
vHllabla
to r0
I
SB [ne cause
A¢a[hi
m ~
Y
NO
a
E
r4 29. 1I Female 30. Did TObar[o Use Contribute to Dea[h3 3]. Manner Of Death
Q NO[ pr¢8nan[ wit icier pasx year ~ Y¢5 Q Pr c.ba bly ~ -Natural
~ plomlcidn
p Pregnant a[Jme Of death
-~NO r
U
~'-
k
/
f
n
nown
Accident
Q NO[ pregnant. but pregnant wlxFln 92 tlaya of death ~ ¢nding0l[ vestlgBtlon
_ ~ suicide ~ Coula pe tletermined
r] N[aI pregnant, but pregnant q3 davz to t year b¢fOra tleatlt 32. Date of Injury (MO/Day/Yr) (Spell Month)
Q I In known If pregnant within [It¢ past year 33. Time of In1Ury
34. Place of Injury (B. g. hDme: COnsirrrc[ron slt0; farm; school) 35. Location OT Injury (StrceC and Nu Tb¢r, City, SLa e. Zlp COtlcJ
35. Injury aC Work 3'J. If TranspoRitiOn In{ury, Specify; 38. D¢a[ribe HOw lrrjury OCCUrrctl; -
p Yes Q Driver/ape ator Q Pedesirlan
~ o (] pas. nge ~ Other (Spr_-cify)__ _
r
~
39x. Ce ~r IGheck OnIV onC1
~-•~ Ifying physician -TO [h0 besC of mY knnwl¢dge, death o rtd drrc t0 [h0 ca use(a) end n r r stated
ccur to me
Pronouncing B. CertifYmB Physician - To the best Of my knpwl¢OgO, tleath Occurreel a[ xh¢ time, tlaYe, end piece, antl tlue t0 [he r..rUZels) antl m nn [-
O
r
Q M¢dlca{ txa miner/('a.r asp er - Qn [h¢ basis pf
in
e.em
a[l
O
n, antl/Or inveztiga[iOn, In My Opinion, rleaLM1 ocCV reed a
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[F¢ tlrne, tlai0, antl Platt, arrrl
JUe
tO [he cause(s) anJ man er y[at¢b
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Sign.rr ore o/car[lirer: ~-•f ~~ / z- ~i.4F NJY-J Title of c6rtlfler:_ V/J//
u¢en[e N~mba,.~-/J cq ~'j. f F
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396, Name. AJdrezs antl Llp Coda of Person Com pl<ting Carrse O! OaatM1 (Item 26) ~~~`-- <-=y jp C.c~EE-~-- 6.!~~7 - 39c. Date Signed (Me/Day/Yrl
/y/i GCq' ~~ G v- ~2RC!/ G/7 -.c~9- fc~ ~~r- J - -Z.
4O. R¢Rlst Yaf's District Number q1. RBgistrar s
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q2. RBRistrar FIIG [e (MO Ddy Yr)
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Oiznczrnrsrr P¢rml[ ND. 075681.2
I I1 D5 143
RFV tli/JDII
LAW OFFICES OF
PANNEBAKER Cu MOHR, r.c.
JAMES B. PANNEBAKER* 4000 VINE STREET
email: jim@pannebakerlaw.com MIDDLETOWN, PA 17057
KENDRA A. MOHR Telephone: 717.944.1333
email: kendra@pannebakerlaw.com Fax: 717.944.4004
October 24, 2012
Register of Wills
Cumberland County Courthouse
1 Courthouse Square
Carlisle, PA 17013
Re: Estate of Benjamin S. Peters, Jr.
No. 2012-01101
Dear Sir or Madam:
The original death certificate we filed in the above-captioned Estate had the
incorrect social security number listed. We have received corrected death certificates. I
have enclosed an original death certificate for your records. Please send me four revised
short certificates. I have enclosed a check in the amount of $16.00 and aself-addressed
stamped envelope.
Thank you for your attention to this matter. If you have any questions, please do
not hesitate to contact me.
sincerely yours,
Kendra A. Mohr
Enclosures
*Of Counsel
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