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REGISTER OF WILLS
CUMBERLAND COUNTY PENNSYLVANIA
SMALL ESTATES AFFIDAVIT
For Insurance Proceeds C> :73 M
c M C'
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NOT to be used for Settlement of Small Estates under ZO Pd~€: 4. 6318 '
(Original Death Certificate Must Accompany this Forte p cz7 s' ti
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Deceased C4 wee/ #V e . C1.7 re/Z Case No. r ~ , ~ •
also known as Social Security No
Before the Register of Wills of said County personally came f m L,„ ~p/2/t w who fesJdes&)
at o A7ea,1,., . 6L-1W 00~7 lC ! ? a being duly fworn, d
deposes and says that r cA Igoe YL , a resident of
Chi r Oi.v ur sL.W fi~ '770 S, L^1ANuvPr 5L C°A.►L/ S 4 / 7 C / 3 ,
In fiald County, departed t s life, at r/ S u ,d ,Gs (s /4 on the 01,&/- day of
Fz/~~o rs. z A.D. 20 p; 1 o'clock M., possessed of personal
property estimated to be of the value of $ IrlO V6 7 ,oq and possessed of real estate, the estimated value
and the location of which is as follows: ,41.o Ov e-
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after
execution of any testamentary writings whether or not offered for probate; was not the victim of a killing,
was never adjudicated an incapacitated person, and was not a party to a pending divorce proceeding at the
time of death wherein grounds for divorce had been established as defined in 23 PA C.S. section
3323(g):
The total amount of insurance proceeds payable by A-Aw p e4 4A. .1r%4 does not exceed $11,000
and 60 days have elapsed since the death of the insured. The tndersigned agrees payment cannot be made
under this Affidavit if a written claim for same has been made by a Personal Representative of the estate and
no other heir(s) having preference exist or have released their benefits to the undersigned.
That said decedent left a spouse - whose name and residence is
and the following as next of kin:
NAMES RELATIONSHIP RESIDENCE
A&4Q4e W,
C II •c✓ V.-t. g, !L ~r °Y3+~w /`x 7733%
ps c e,`.-e- /.j- O f 2 7 v
/51/. 4~Aoy c B-,- ZS70 /+o s, a~`.see /i'd Se'e, !'c3/
That the above named are the spouse & and all the known next of kin of said decedent, to the best of my
knowledge and belief. _
Your Petitioner avers there are N N PROBATARL E A that would require an estate
proceeding. Therefore, ESTATE WILL E RAISED. D R NOT NECESSARY
Signed
By.
Sworn ands scribed to before me this
day of -V Q , 20 Register of Wills:
Oht I -!)fi I Kindly enter appearance in the above case this
Ui day of , 20
J LD. No.
~
Attorney
BE IT REMEMBERED, that as of the ~Tl ay of u lu ( (t'`Z cd- , A.D. 20 /1--3
There has been NO ESTATE PROCEEDING RAISE FOR THIS DECEDENT AND NO LETTERS HAVE
BEEN ISSUED BY THIS COURT.
r
r
Glenda Farmer Strasbaugh
Register of Wills & Clerk of Orphans' Court
My Commission Expires First Monday, January, 2014
C> c a rn Ca
M C.1 Z~ try ;n
r --1 'I u7 C.3 4
H101 80, Rev iOH071
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, 56.00 T, r D
RECQ tug This is to certify that the information here omen is
o I „ t ~ f , , ~ p~1H O~F p
dt~: correctly copied from an original Certificate of Death
REGISTER Or
~a o duly filed with me as Local Registrar. The original
7V 4- certificate will he forwarded to the State Vital
l 8
u'i11i
t
3
Records Office for permanent filing.
P 15147281 C L E RK 0z
Certification 1Vumbcr ORPHANS. CSR ~`l!HENirOE„~'''
Local Registrar Date Issued
CUMBERLAND CO., PA
H105-143 REV 112006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH a VITAL RECORDS
TYPE / PRINT IN
PEBLARMANENT
CK INK CERTIFICATE OF DEATH
(See Instructions and examples on reverse)
STATE FILE NUMBER
1. Name of Decedent (FrsL We, bd, suPu) 2. Sex 3. Said Seceriy Number 4. Data of Death (Month, day, year)
Catherine V. Carr Female 178 - 07 -5683 2/21/2009
5. Age (last Birthday) Under 1 year U dar 1 6. Dab d Birth (Month, day. year) I T S rtlglece (City and stab «1«eign cdvary) ga. Place of Death (Check one)
wino neyx Mows Mixxm PA ~ ~
92 Yrs' 12/16/1916 llfton Hel h 3 ❑Irgatlerd ❑FA /ougabent ❑DOA XIN.-VI-Iome ❑R.W- ❑Dlner-Specify
gb. County of Death Be. City, Bone, Tsp. of Death ga. Facifily Name (t not oslilueon, give street and meroet) 9. was Decedent elFtispank Ong i? CH No ❑ Yes 10. Ram: Anwrican Indian. Bock, WNb, eo.
Cumberland Carlisle IN yea. specify Cuban, (Spec*
~i Chapel Pointe Nursing Home Mexicat,PuelroRcarlat.)
11. Decedents Usual eon Kind d eork done moat d We. Do not state refired) 12. Was deceden eve into 13. Decedents Edrmtion (Specify only Ng" gram oom W.M 14. Mau W Satin: Monad. Nevar Married. 15. Surviving Spouse (11 09., give ma rten name)
KIntl of Work Kxb d Busksss / IiMatry U.S. Amed Forms? Elementary IS Jary (0.12) Co" (1-4 «5t) w • Disarced (SP«d1Y)
Exec. Secretor ranufacturin ❑yesl5dNo 12 0 Never Married None
16. Decedent's MabkgAckma, (Shred, city / town, stale. zp cede) Decedents
A&wtnaw- m.Sale Pennsylvania LiveDa~ 17c.0 Yes, Decedent UM in Tvp
20 Meadow Drive 17bC,,,~ Cumberland Township?
17d.K1 No. Demden Uwe wean
Adud Lhib. of CamB Hill Cilr/B-
III Feiner'. Name (Frst midde, Iad, sufh) 19. Mother a Name (FNSt. n Me, maiden sumeme)
Edward Carr Eunice Unknown
20a. IMohnn r. Narre (Type / Print) 2M. Inbmants WON Address (Stied, dry / town, -few, to code)
John Carr 20 Meadow Drive, Cam Hill, PA 17011
21 a. Method of Disposition i ❑Cnernabon ❑ Dcratbn 21b. Date of Disposition (Mordh, day, year) 21c. Placed
e ❑ Bunal ❑ Removal hom ' Wes Cre-don or Donation AuM«Imtl 13sposdon (Name d cemetery, cnernatonY «otlar Place) 21d. Location (City /town. stab. nP code)
by rtledical Bxemlr«/ Caron? ❑ Yes ❑ N4- lHoly Cross em a Lansdowne. PA 19050
of Funeral as suit) 226. License Numbar m Name and Address of Facility 33 W. Baltimore Ave.
xb r mebeda - - illiams-Lombardo Funeral Home
orgy when irlifton HpiffhfQ- P 8
my IP10wkd9e, death ocarrted at the Ism, cote and place stated. (Signature and Mb) M. License Number 23c. Data Signed (Month, day, Year)
s not avaitada at fine of death to
cause of death.
Irons 24-28 mat be mnplated by same 24. Thee of Daam 25. Dab day, 7 26. Was Cam Roland ~ ~ 'Ti`er / C- M Re~oOther rMaann're n ~ Donation'
/
.h.prar««mms death. O 9 / :5 , 9 M. 4-"77/ 70 ❑yes ONp
CAUSE OF DEATH (S- inabuctone end examploa) , ;Wg nnate Interval' Pan II: Enter other . - 28. Did Tobago Use Contribute Death?
Item 27. Pad I. Enter dw Cerred. «venlriprmr _ dseaess spurs. or mmpoatioos-drat drachy mussy the ding,. DO NOT 4-n« terminal events such as mrdac arrest, r Onset to Death but not in the .
respiratory NoI sdhgrehexirg the ebdow List orgy am musemeach hot. r rewhing under" muse q.. in Pan I. ❑rtes ❑
A~esd~mgn)"seese« ~p L^❑ No
SL ' V 29. It Fermk:
ore b es a oq. ❑ Not pregnant xitldn pant year
Est mndtiaa, it b_
b cause tided on Fro a. ❑ Preyam at Nos of death
Enter UNDERLYING CAUSE Due to for as a consequence d):
(dssb res«iafug~lyn 1. LAST c. ❑ Not Vagrant, but pregnant wilhiri 42 days
of seam
Due ro as a consequatoe oQ.
E] d Not pregnant, but Pregnant 4-3 Oat's to 1 year
- ; helaeeedn
❑ Unknosm it pregant within the past year
304-. Was an Autopsy 30b. WereAMOpsy FMegs 31. Death 324- Dote of Injury (Month, day, year) 32b. Desmhe How InjuryOcciured 32c. Pam of Injury: Name, Fan. Sued, Factory,
P-hon"a ! Avmlable Prior to Cmpsbwt
of Cause of Death? Name ❑ Honkdde Once Bubdi g etc. (SP o y)
El Tea El Yes ❑ No ❑ Accident E] Pending Investigation 32d. Time of injury 132. Irgury at woe? 321. If Trenspodation injury (spedTy) 32g. Location of
Suicide ❑ Dnnar / Operator Pa Pedestrian Infury Street, city /town. sole)
❑ ❑coda Not be De -t had M ❑yes ❑No ❑
33a. Certifier (dock «by one) - ~r
e wr
• Signet.
Certifying pnysid. (Physidan -dying mum a death eh. another
pharmhas pored---------------------------------
Pronouncing and -Item 23) ► O
To the had of my loowbdge,dmth xttwreddm to the muss(s)and meamsr as sbMend certifying physician (Physician both pranouncM death and cedying to cause of death) 33o License 33d Date Sigurd (Month, day. year)
To the best of my knowbtlge, death amurred at ft One, dab, and pace, and dm to the causet and rhannar as stated------------------ V N1 r . Medical Examiner /Coroner L• ( I S L
On the basis of examination and/ on investigation, in my opinion, death occurred at the bin, dale, end place, and de to the muse(s) and rhas-r as dsrod_ ❑
34 . Name and Address of Person Who Completed Cause of Death them 27) Type /Print
0 35. R 's &gsnuns and District Number 3g. Data Inky (Month, day, yea
► I ~I .~I 04 I cl I .Q
Disposition Permit No. 0 3 0 4 4 7 0