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HomeMy WebLinkAbout03-05-13 REGISTER OF WILLS CUMBERLAND COUNTY PENNSYLVANIA SMALL ESTATES AFFIDAVIT For Insurance Proceeds NOT to be used for Settlement of Small Estates under 20 Pa. C.S.A. U102 (Original Death Certificate Must Accompany this Form) Deceased J W Case No. also known as Social Security No. l?*****.*.30,01 . Before the Register of Wills of said County personally came Lil7~ e p . 6-~, who resides . l p ~ at ~J ......~c7I P: vI r _.1,J I. 0_a.._!".~ f being duly sworn, deposes and says that age a resident of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . day of o°1b0 in said County, departed this life, at ......l~r..........._C11~....7 on the A.D. 20 o'clock 4M M., ptssessed of personal 1l,, property estimated to be of the value of $ ~.4 t5 h 0 1W ra, and possessed of real estate, the estimated value and the location of which is as follows: 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 p -e does not exceed $11,000 and 60 days have elapsed since the death of the insured. The undersigned agrees payment cannot be made under this Affidavit if a written claim for same has been made by a Personal Representative of the estate and no other heir(s) having preference exist or have released their benefits to the undersigned. / That said decedent left a spouse - whose name and residence is J d h .C . . and the following as next of kin: NAMES RELATIONSHIP RESIDENCE i r 1 v S I/?6.` S~ Je. e+ 7-1 © r Ca c~ ' C"i° F 1 That the above named are the spouse & and all the known next of kin of said decedent, to thek3st 6Rhy knowledge and belief. 1 Your Petitioner avers there are NO KNOWN PROBATABLE ASSETS that would regtke`o estate ca proceeding. Therefore, NO ESTATE WILL BE RAIS AND LETTERS ARE NOT `-PSSARY. Fro Signed c- Cn By: Sworn and subscribed to before me this ~PLIN day of ....1 , 20 13 Register of Wills: Kindly enter appearance in the above case this day of , 20 . I.D. No. Attorney BE IT REMEMBERED, that as of the J day of AAA1y01- , A.D. 2013 There has been NO ESTATE PROCEEDING RAISED FOR THIS DECEDENT AND NO LETTERS HAVE BEEN ISSUED BY THIS COURT. i . . . . . . . . . . . . . . . 9 .'vC'... . . . . . . . . . . Regi ter Glenda Farner Strasbaugh Register of Wills & Clerk of Orphans' Court My Commission Expires First Monday, January, 2014 ii in, 11), I<1S rl; LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate.b.OO This is to certify that the information he cii'n ~~~p~ZN Of pE correctly copied from an original Certificate of Beath duly filed with me as Local Registrar Tlro on iiml certiticate will be forwarded to the State Vita Records Office for permanent tiling. P 13745512 UGl3 u pooh Cer-trlrcatron Nunlher urlllrrtrtt Loral Registrar l)att, kstl,:d 01 C w = rn W 01 C7 rn C-> :0y.r- -6 r 2 rn rr$ rTl C-> C) ~CZ: c3 F--a fi7 H105-143 REV 112006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS TYPE / PRINT IN PERMANENT BLACK INK CERTIFICATE OF DEATH (See Instructions and examples on reverse) STATE FILE NUMBER 1. Name of Decoders (First, middle, last, suffix) 2. Sex 3. Social Secuny Number 4. Data of Deem (Month, day, year) Maurice S. White M 179 - 30 - 3176 Aug. 29, 2007 5. Age (Last Birthday) Under 1 year Under 1 day B Date of Btrm (Month, day, year) 7. Blnhplace (Clry and slate or foreign country) Bs. Place of Death (Check on one) Me,s a Days Hour M.- Hospital: 1Other 70 rm. 112/2/1936 Carlisle PA ❑Inpatlent ❑ER/Oupatent ❑DOA ❑NursingHOme r2Residence ❑Omer-Spaay: ab. County of Death 8c. City, Bom, Twp. of Death Bd. Facility Name (If not instiMon, gin street and number) 9. Was Deoetlenl of Hispanic Origin? ® No ❑ Yes 10. Race: American Indian, Black, While, at. W Qf yes, specify Cuban, (spew Cumberland South Middleton Ttkirp, 68 Fairview St. Mexican, Puerto Rican, etc.) its 11. Decedent's Usual Occu fion Kind of work done du' most of sninkint; life. Do no( s ate req 12. Was Decedent or in the 13. Decedent's Education (Sir iy only, highest fired, completed 14. Medtel Status: Monied, Never Marred, 15. Su v v ng Spouse (If refs, give maiden name) Kind of Wrok Kind of Business / Intlushy U.S. Armed Forces? Elementary / Secondary (0.12) College (1-4 w 5+) Wdowed• Drvwced (Spec//}~ intenance Su rvis. CPS Reeves 6r7Ye= ❑Na 12 Married Connie F. Guise 16. Decedent's Melling Address (Street, city / torn, state, zip code) Decedent PA Did Decedent South Middleton Actual Residence 17a. State Live in a 17c. ® Yes, Decedent Uved in Twp, 68 Fairview St. 17b. County 7mt'v=rl nd Tow rah p7 17d.❑ No, Decedent lived wmin Carlisle PA 17015 Actual Lima of city /Bom 1B. Father's Name (First, mkltlle, lest, sums) 19. Mother's Name (First, middle, msiden surname) Charles W. White Blanche - Stei leman 20a. informant's Name (Type / Print) 20b. Informants Mailing Address (Street, city / town, state, zip code) Connie F. White 68 Fairview St., Carlisle, PA 17015 21 a. Method of Disposition ❑ Cremation ❑ Donation 21b. Date of Disposition (Month, day, year) 21c. Place of Disposition Name of Gamete ( rye crematory or on- plaza) 21 d. Location (City /town, slate, zip code) Burial El Removal from Slate Was Cremation or Donadon Authorized ❑ Other- byMealealExamin.r/coroner? ❑Ya:❑Nm 9/1/2007 Clunberland Valley Manorial Gar S Carlisle, PA 22a. Sprature of F Low. (or person as h) 22b.DLicense Number 22c. Name and Address of Facility ► 012633 L Frain Brothers Funeral How, Inc., Carlisle, PA 17013 orripm items 23aa on" when candying 23a. To the my atlge, tla edat he time, date and place stated. (Sign duns and this) 23b. Ucense Number 23c. Data Stoned (Month, day, year) physician is not available at time of death to certify cause of deem. -F-0 _lgrL ftIC44,0- Z'3 2Zi~vl • hems 24.26 must be completed by person 24. Time of Death 25. Data Pronounced Dead (Month, day, year) 28. Was Case Rafe to Medical Examiner /Crooner for a Reason Omer than Cremation ro Donation? who prrowmxm death. M. ❑Yes No CAUSE OF DEATH (See InatruMion. en examples) r Appmxedide Interval: Pan Il: Ernst other slanifinl corrdllros c!~•Lrih!akw to dear 28. Did Tabazco Use Contribute to Death? hem 27. Pan I: Enter the chain of ,vt eo- damears, injuries, or complications- mat drechy caused the death. DO NOT enter lerminal events such M cardiac arrest, Chase to Death but not resulting in ere underlying cause given in Pan I. ❑ Yes ❑ Pft" respiratory arrest or ventricular fibdhabon without showing the etiology. List only one muse on each line, n ❑ No ❑ Unkr- IMMEDIATE CAUSE /Final disease or cordilwn resrxtkg In deem) _10 a. 1 . _ tue, 91%o r 29. If Femaio: yy (or a consequence.Q: ( ❑ Not fxegnent within past year e ` ~ngb tls ease Ikteds, 9 ~ a* th r1 1 I /y~ I• j ❑ Pregnam at lime of death az X Emw the UNDERLYING CAUSE Due to (or as a consequence of); r death ,but pregnant wtlhin OZ Jaya (disease or injury met inillated the r ❑ Not evens rear. If m deem) IT c' r of death Due to (w as a consequence oQ: ❑ Not pregnant, but Prepare 43 days to 1 year d. r before dpm r ❑ Unknown If pregnant Whin the peer year 30a. Was an Autopsy 30b. Were Auopsy Flndings 31. Manner of Death 32a. Date of Injury (Month, day, year) 32b. Describe How Injury Doomed 32c. Plea of Injury: Home, Farm, Street, Factory, Performed? Available Prior to Completion Office Building etc (Simmyy/ of Cause of Death? Nelurel ❑ Homicide L ❑Yes No ❑Yes E] No E] Accident E] Pending Investigation 32d. Time of Injury 32e. Injury a1 Work? r~f TrenspoInj32g. Location of Injury (Street, city / Mm, state) ❑ Suicide ❑ Could Not ho Determined M Yes ❑ No Ddren /or ssenger her-spec/y 33a. Cerhrsr (check only one) lure TNe of Ceniher • Certifying physician (Physician certifying cause of death when another physician has pronounced death and competed Ram 23) To the beat of my kno ledge, death occurred due to the cause(.) antl manner u stated- _ _ _ _ _ - sJ'- • Pronouncing and certifying physician (Phyaidan both pronoun ihng death and ortiying to cause of death) 33c. License Number 33d. Data aido (Month, y, year) o To the beet of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner as stated------------------ El ~^v ' p}~yy I l Medical Examiner / Coroner V `V w On the basin of examination and / or investigation, In my opinion, death occurred at the done, date, and place, and due to the cause(s) and memrer as slated- ❑ to 'I 2 _ ' 0 33 NAame and Address of 1 n pilled Cause of Dea Item T ,LyV1 0 35. na nalbre and m `,Q. G' r `SS' M t D Jk04 .1 ate Fled (Month, day, year) ~ -1 I ► l l l a l I l O l - 660`1 1 Disposition Permit No.