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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 �I� I� �����
Name: HARRY L.WYRICK,SR. File No: E
a/k/a; (Assigned by Register)
a/k/a:
a/k/a; Social Security No:
Date of Death: 12/30/2013 Age at death: 96
Decedent was domiciled at death in CUMBERLAND County, pp (Srare)with his/her last
principal residence at 59 WEST MAIN STREET WALNUT BOTTOM,PA 17266 SOUTH NEWTON CUMBERLAND
Street address,Post OfTce and Zip Cade City,Township or Barough County
Decedent died at CARLISLE REGIONAL MEDICAL CTR CARLISLE,CUMBERLAND PA 17015
Street address,Post Office and Zip Code City,Township or Borough County State
Estimate of value of decedent's property at death:
If domiciled in Pennsylvania............................ All personal property $ 25,000.00
If not damiciled in Pennsylvania. ....................... Personal property in Pennsylvania $
If not domiciled in Pennsylvania. ....................... Personal property in County $
Value of real estate in Pennsylvania......................................................... $ 50,000.00
TOTAL ESTIMATED VALUE. ... $ 75.000.00
Real estate in Pennsylvania situated at: 59 W.MAIN ST WALNUT BTM,PA 17266 S.NEWTON TWSHP.CUMBERLAND
(Attach additional sheets,if necessary.) Street address,Post Office and Zip Code City,Towns6ip or Boraugh County
� 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 NLY 14,2009 and Codicil(s)
thereto dated
State relevant circumstances(e.g.renunciatian,death of executoq 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(g),and did not have a child bom or
adopted;and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person.
O 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 lite,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(g)and was neither the victim of a killing nor ever adjudicated an incapacitated person.
�
Q NO EXCEPTIONS o EXCEPTIONS c'� �� �
—rn
Petitioner(s),after a proper search has/have ascertained that Decedent left no Will and was survivedby the followin�o�e(if any)�heir�{yt�h
additional sheets,if necessary): � � � � V� �
Name Relationshi Addres � � -.,y
t'ri �'1
"' U? .� C.? p
C'� '17 "ri "�1
p �C � � G7
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Form RW-02 rev.10/II/201/ Page 1 of 2
Oath of Personal Representative ofs��e�use o��y
COMMONWEALTH OF PENNSYLVANIA }
} SS:
COUNTY OF CUMBERLAND }
Petirioner(s)Printed Name Petitioner(s)Printed Address
JANET L.KUTZ 871 MT.ROCK RD. CARLISLE PA 17015
The Peritioner(s)above-named swear(s)or affirm(s)the statements in the foregoing Petition are true and conect to the best of the knowledge and belief
of Petitioner(s)and that,as Personal Representative(s)of the Decedent,the Petitioner(s)will well and truly administer the estate according to law.
Sworn to or affirmed a subscribed before � Gs�� � -�� Date!/ -/7- �`�
me i �day I ,tn �� � �J Date
$y — ,n, �'L Date
For the Register Date
BOND Required: Q YES �NO To the Register of Wills:
FEES• Please enter my appearance by my signature below:
Letters.. . . . . . . .. . . . . . . . . . . . . . $ ����� Attorney Signature:
( �l, )Short Certificate(s).. . . . . ��:.� �.,
( )Renunciation(s).. . . . . . . . C
( )Codicil(s). . . . . . . . . . . . .
( )Affidavit(s).. . . . . . . . . . .
Bond.. . . . . . . . . . . . . . . . . . . . . . . Printed Name: WILLIAM A.DUNCAN
Commission. . . . . . . . . . . . . . . . . . Supreme Court
Other . . . . . . . . ID Number: 22080
- �1 . . . . . . . .��
; ,Vl Y' , . . . , , . . " > Firm Name: DUNCAN&HARTMAN,PC rv
' . . . . . . . . � � • � Address: ONE IRVINE ROW C� '�-'_ � rn
. . . . . . . C'ARi,ISi,F,,PA 17013 � � �_��
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Phone: 717-349-7780 � �" � �"' S-n rn
. . . . . . . . � �� ��
Automation Fee. . . . . . . . . . . . . . . , � ' Fax: 717-249-7800 � C� � r_„ c�
JCS Fee. . . . . . . . . . . . . . . . . . . . . r . Email: ' '` "C7 .�'i "T'1
TOTAL. . . . . . . . . . . . . . . . . . . . . $ --$fJ6� c'� � -'rt :'� --
� ' � � F-� � R1
DECREE OF THE REGISTER � � U' ..�,�
Estate of HARRY L.WYRICK,SR. File No: ;�L�- �'1" - �J���7�
a/k/a:
AND NOW, � 5� l l,� L-� , '�i l � ,in consideration of the foregoing Petition,
satisfactory proof having been pr ente before me,IT IS DECREED that Letters TESTAMENTARY
are hereby granted to JANET L.KUTZ
in the above estate and(if applicable)that
the instrument(s)dated JULY 14 2009
described in the Petition be admitted to probate and filed of rec c�as the last Will(and Codicil(s)) of Decedent.
�C� � � �
egister of Wi s /�'' f, �'� ;�/'�1,/�1 �!�
gJ�' I (.
Form RW-Ol rev. 10//1/20// Page 2 f 2
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J LAST WILL AND TESTAMENT x �;, r;4 '~`� �� �
(Pour-Over Will) c� �..� " -�p `=� ..`�f.�
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HARRY L.WYRICK,SR. � z�i f-.� '" r'
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IDENTITY
I, HARRY L. WYRICK, SR., residing in the County of Cumberland, Commonwealth of
Pennsylvania, being of sound mind and memory, and not acting under duress or undue influence of any
person whomsoever, hereby declare this to be my Last Will and Testament, and I do hereby revoke all
other former Wills and Codicils to Wills heretofore made by me. My Social Security Number is 197-03-
5217.
I have the following children: Janet L. Kutz, born February 18, 1940,Sandra C. Morrison, born
February 9, 1946,Harry L. Wyrick,born August 27, 1948, and Jerry E. Wyrick,born May 1, 1952.
DEBTS,TAXES AND ADMINISTRATION EXPENSES
I have provided for the payment of all my debts, expenses of administration of property wherever
situated passing under this Will or otherwise, and estate, inheritance, transfer, and succession taxes, other
than any tax on a generation-skipping transfer that is not a liability of my Estate (including interest and
penalties, if any) that become due by reason of my death, under THE HARRY L. WYRICK, SR. AND
MILDRED E. WYRICK REVOCABLE LIVING TRUST executed on October 9. 2003 (the
,..��
"Revocable Trust"). If the Revocable Trust assets should be insufficient for these purposes, my Executor
shall pay any unpaid items from the residue of my Estate passing under this Will, wrt out any
apportionment or reimbursement. In the alternative, my Executor may demand in a writing addressed to
the Trustee of the Trust an amount necessary to pay all or part of these items, plus claims, pecuniary
legacies, and family allowances by court order. �
PERSONAL AND HOUSEHOLD EFFECTS
It is my intent that all my personal and household effects were transferred to the Revocable Trust
as a result of the Declaration of Intent signed on October 9, 2003 this date. If there are any questions
regarding the ownership or disposition of these assets, it is my desire that suc�► assets pour into the
Revocable Trust, signed by me on October 9, 2003 this date in accordance with the provisions of the
section titled"Residue of Estate."
RESIDUE OF ESTATE
I give, devise and bequeath all the rest, residue and remainder of my property of every kind and
description (including lapsed legacies and devices), wherever situated and whether acquired before or
after the execution of this Will, to the Trustee under that certain Trust executed by me on October 9,
2003. The Trustee shall add the property bequeathed and devised by this item to the corpus of the above
described Trust and shall hold, administer and distribute said property in accordance with the provisions
of the said Trust, including any amendments thereto made before my death.
POUR-OVER WILLS lL'�
Page 1 (Testator)
If for any reason the said Trust shall not be in existence at the time of death, or if for any reason a
court of competent jurisdiction shall declare the foregoing testamentary disposition to the Trustee under
�� said Trust as it exists at the time of my death to be invalid, then I give all of my Estate including the
residue and remainder thereof to that person who wouid have been the Trustee under the Trust, as Trustee,
and to their substitutes and successors under the Trust, described herein above, to be held, managed,
invested, reinvested and distributed by the Trustee upon the terms and conditions pertaining to the period
beginning with the date of my death as are constituted in the Trust as at present constituted giving effect
to amendments, if any, hereafter made and for that purpose I do hereby incorporate such Trust by
reference into this my Will.
EXECUTOR
I hereby nominate and appoint JANET L. KUTZ to serve without bond as my Executor of this
my Last Will and Testament.
In the event the first named Executor shall predecease me or is unable or unwilling to act as my
Executor for any reasons whatsoever, then and in that event, I hereby nominate and appoint JERRY E.
WYRICK to serve without bond as my Independent Executor.
Whenever the word "Executor" or any modifying or substituted pronoun therefore is used in this
my Will, such words and respective pronouns shall be held and taken to include both the singular and the
plural, the masculine, feminine and neuter gender thereof, and shall apply equally to the Executor named
herein and to any successor to substitute Executor acting hereunder, and such successor or substitute
Executor shall possess all the rights, powers, duties, authority, and responsibility conferred upon the
"��� Executor originally named herein.
EXECUTOR POWERS
By way of Illustration and not of limitation and in addition to any inherent, implied or statutory
powers granted to executors generally, my Executor is specifically authorized and empowered with
respect to any property, real or personal, at any time held under any provision of this my Will: to allot,
allocate between principal and income, assign, borrow, buy, care for, collect, compromise claims, contract
with respect to, continue any business of mine, convert, deal with, dispose of, enter into, exchange, hold,
improve, incorporate any business of mine, invest, lease, manage, mortgage, grant and exercise options
with respect to,take possession of, pledge, receive, release, repair, sell, sue for, make distributions in cash
or in kind of partly in each without regard to the income tax basis of such asset and in general, exercise all
of the powers in the management of my Estate which any individual could exercise in the management of
similar property owned in its own right upon such terms and conditions as to my Executor may seem best,
and execute and deliver any and all instruments and do all acts which my Executor may deem proper or
necessary to carry out the purpose of this my Will, without being limited in any way by the specific grants
or power made, and without the necessity of a court order.
My Executor shall have absolute discretion, but shall not be required, to make adjustments in the
rights of any Beneficiaries, or among the principal and income accounts to compensate for the
consequences of any tax decision or election, or of any investment or administrative decision, that my
executor believes has had the effect, directly or indirectly, of preferring one Beneficiary or group of
Beneficiaries over others. In determining the Federal Estate and Income Tax liabilities of my Estate, my
POUR-OVER WILLS
Page 2 (Testator)
Executor shall have discretion to select the valuation date and to determine whether any or all of the
._<��
allowable administration expenses in my Estate shall be used as Federal Estate Tax deductions or as
Federal Income Tax deductions.
CONTESTS AND SPECIFIC OMISSIONS
If any beneficiary under this will, singly or in conjunction with any other person or persons, directly or
indirectly:
1. contests in any court the validity of this will or, in any manner, attacks or seeks to impair or
invalidate any of its provisions;
2. contests in any court the validity of the Testator's Will or, in any manner, attacks or seeks to
impair or invalidate any of its provisions;
3. seeks to obtain an adjudication in any proceeding in any court that this trust or any of its
provisions or that Testator's Will or any of its provisions is void;
4. claims entitlement' by way of any written or oral contract to any portion of the Testator's estate,
whether in probate or under this instrument;
5. unsuccessfully challenges the appointment of any person named as Executor or successor
Executor of the Testator's Will;
6. objects in any manner to any action taken or proposed to be taken in good faith by the Executor
of the Testator's Will;
7. objects to, any construction or interpretation of this Will, or any provision of it, that is adopted or
is proposed in good faith by the Executor;
8. unsuccessfully seeks the removal of any person acting as the Executor of the Testator's Will;
9. files any creditor's claim in Testator's estate (without regard to its validity), whether the claim
`��° arose before or after the date of this instrument, but excepting claims for cash advanced or paid
for expenses of the Testator's last illness or funeral paid by said claimant;
10. attacks or seeks to invalidate any designation of beneficiaries for any life insurance policy on
Testator's life;
11. attacks or seeks to invalidate any designation of beneficiaries for any pension or IRA or other
form of qualified or non-qualified asset or deferred compensation account, agreement or
arrangement;
12. attacks or seeks to invalidate any will which Testator has created or may create during Testator's
lifetime, or any provision thereof, as well as any gift which Testator/Testatrix has made or will
made during Testator's lifetime,whether before or after the date of this instrument;
13. attacks or seeks to invalidate any transaction by which Testator sold any assets (whether to a
relative of Testator's or otherwise); or
14. refuses a request of Testator's, Executor or other fiduciary to assist in the defense against any of
the foregoing acts or proceedings,
then that person's right to take any interest given to him or her by this trust shall be determined as it
would have been determined if the person had predeceased the execution of this will instrument without
issue surviving.
The provisions in of the foregoing paragraph shall not apply to any disclaimer by any person of any
benefit under this wi1L In the event that any form of this provision is held to be invalid, void or illegal,
the same shall be deemed severable from the remainder of this provision and shall in no way affect,
impair or invalidate any other provision in this will; and if such provision shall be deemed invalid due to
POUR-OVER WILLS
Page 3 tator)
its scope ar breadth, such provision shall be deemed to exist to the extent of the scope ar breadth
permitted by law.
SIMULTANEOUS DEATH
If any Beneficiary should not survive me for sixty (60) days, then it shall be conclusively
presumed for the purpose of this my Will that said Beneficiary predeceased me.
ARRY L. CK,SR.
Testator
This instrument consists of 6 typewritten pages, including the Attestation Clause, Self-Proving
Clause, signature of Witnesses, and acknowledgment of officer. I have signed my name at the ttom of
each t e preceding pages. This instrument is being signed by me on this ��ay of
,
���
POUR-OVER WILLS ��
Page 4 (Testator)
_ ATTESTATION CLAUSE
The Testator whose name appears above declared to us, the undersigned, that the foregoing
instrument was his Last Will and Testament, and he requested us to act as witnesses to such instrument
and to his signature thereon. The Testator thereupon signed such instrument in our presence. At the
Testator's request, the undersigned then subscribed our names to the instrument in our own handwriting
in the presence of the Testator. The undersigned hereby declare, in the presence of each of us, that we
believe the Testator to be of sound and disposing mind and memory.
Signed by us on the same day and year as this Last Will and Testament was signed by the
Testator.
WITNESSES: ADDRESSES:
' �j�� �,�� ��(.�L 6/j ��
- LG� ���./�i�Gc.,� ��-�c�� ��. �?�
(Printed Name of Witnes )
�. C" �� O c��� �'�U r9.fc° s�'�
S�rvi�,e„� t� /I�r�,:rU� C<.�r l,�s�/� . �.�-/ �a i�—
(Printed Name of Witness)
POUR-OVER WILLS
Page 5 (Testator)
COMMONWEALTH OF PENNSYLVANIA
u�� COUNTY OF CUMBERLAND
SELF-PROVING CLAUSE
B FO�E ME,t e dersigned authority, on t is day personally ppeared HARRY L. WYRICK,
SR., �� ' and�tie%2��>��.�'�i� , known to me to
be the Testator and th tnesses, respectively, whose names are subscribed to the foregoing instrument
in their respective capacities, and all of them being by me duly sworn, HARRY L. WYRICK, SR.,
Testator, declared to me and to the witnesses, in my presence, that the instrument is his Will and that he
had willingly made and executed it as his free act and deed for the purposes therein expressed; and the
Witnesses, each on his ar her oath, stated to me in the presence and hearing of the Testator, that the
Testator had declared to them that the instrument is his Will and that he executed the same as such and
wanted each of them to sign it as a witness; and upon their oaths, each witness stated further that he did
the same as a witness in the presence of the Testator, and at his request and that he was at that time
eighteen (18)years of age or over and was of sound mind, and that each of the witnesses was then at least
fourteen (14)years of age.
ARRY L.WY CK,SR.
Testator
�,c�;�l�
Witness
al����� LI}�l i^!�C K
(Printed Name of Witn ss)
' ���/</'�l/'i.!/�� )
L�--- �
Witness
iJ..�-.7/r��,'rQ`��1�1`�S'd.'�
(Printed Name of Witness)
SUBSCRIBED AND ACKNOWLEDGED before me H R�R�' L. WYRIC �, SR., estator,
and subscribed and sworn to before me b .�iLo/�c� and
/LG! � ✓J�vvitnesses, this the � day of ,
COMMONWEALTH OF PENNSYLVANI
� tvotaria�Sea� ta ublic, Commo wealth of Pennsylvania
Kaye N.Failor,Notary Public
� Dickinson Twp.,Cumberland County
My Commission Expires Apr.23,2010
Member,Pennsylvania Association of Notaries
POUR-OVER WILLS
Page 6 e ator
..� �. . :�� ,; . .3 �,ro: . , ���<-:�����;e-�� ���..��..-,.��,_.,� �.�.� ��,�. ����.�< .-,�.�,�,,, �,�.�,>„-
H105.805 REV(9/11) � � � � � N �
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6A0 R E C 4 R D�D 0 F F�C E 0�` ,,,,,,,,,,,,,,,, This is to certify that the information here given is
REG�S�E�. �'� w��-L$ ���,,'��P`SH QF pE�;y__ correctly copied from an original Certificate of Death
���°o`b' _ ,`rL; duly filed with me as Local Registrar. The original
�� - certificate will be forwarded to the State Vital
101� ��� 1? P�i 1 `�� 2 0 -= Z;
;� � ' n� Records Office for permanent filing.
:* _ __ ��a`
� �. J � $ � � �"� CLEf,K OF =���,�9 , �.�'~''�,,` �A. �..!a�s.� ex�
PNAt�S COURT -.IMENTOE�; � {?F� 3 0/2013
n°
Certification Number ""���°"""� �� Local Registrar Date Issued
�/ CUMBERLAP�Q CO., PA �
�S Type/Print In COMMONWEALTH OF PENNSYLVANIA�DEPARTMENT OF HEALTH�VITAL RECORDS �
� Per�"a�e�t CERTIFICATE OF DEATH
Black Ink State File Number.
1.Oecedent's Legal Name(First,Middle,last,Suffix; 2.Sex 3.Social Se<urfty Number 4.Da(e of Death(MO/Day/Yr)(Spell Mo)
Har L. Wyric)c, Sr. Male 197 03 52'17 Dec�nber 30, 2013
Sa.Age-last Birthtlay(Yrs) Sb.Vntle�1 Yea� Sc.Under 1 Da 6.Date of Birth(MO/Day/Year)(Spell Month) 7a.Bj�[hpla (Clty d St te or Forelgn Country)
�l� � -... . Months � �.Days Hours Mlnutes .. � Yery�jr���.� �JA �� . . . .
°t 96
D�c�nber S. 19l 7 �b.s�.<na�a�e tco��M Dau h,in
8a.R651dence(StOYe or Foreign COUntry) � 8b.Resitlence(StreeT and Numb�cr-Include Apt No.) 9c.Did DecedCnt Live in a TownshipT
P3� . . � � �ves,de�ede.,c n..ea i., South Ncwtpn � � awP.
. ad.Resitlence(caun[y� � � . rj9 W. Mgj�y $t. � � � � � .
LL7Rl��0l`��EiT1C1 � �: ��� Se.Residence(Zip Code) �7�266 �No,decedent IHed wlthin Ilmits of �� � city/bo
9.Ever In US Armed Forces7 30.Marital Status at Time of Death �Marrletl Idowed 11.Surviving Spouse s Name(If wife,give n e prior to flrst marriage)
�Ves �NO 0 Vnkno 0 Divorcetl 0 Never Marrled �Vnkno am
12.FatheYs Name(First,Mltldle,Last,Suffix) W 13.Mother's Name Prb�to First Marrlage(First,Middle,Last)
Hariy Clinton Wyric)c Carrie Jane Holtry
14a.InformanYs Name 14b.Relatlonship to Decedeni 14c.InformanYs Mailing Address(Sfreet and Number,Ciry,State,.Zlp Gode)
o Janet L. Kutz Dau htar $7'I Mt. Roc}c Rd_ , Carlisle, PA 170"15
G �' ��� � isa c o� aac c ec o �� � � � � .. �
aIf D �th Occu�retl iO a H.o PIYaI' � �InPaiient y- ' ' - - - - � . n Yona ._ _ _ _ _ . . . .
. . ...: . . I lf Death O .ed 5 mewlfcre Other Thah Hosplial �Hosplce Facility,^� ��7 Deutlent's Hom'e
J � EmergenCy Raom/OUtpatlent � .Q Dead on Arrival � � N�� i g Ho. �/Lon Term Care Facil�ty� �Oiher(Specify) � � � �
0 15b.Facility NamC(If nof institutlon,g{va street and number) 15c.City ��TOwn,State,and Tip Codt+ � � 15d.County of��Death �
� Carlisle'<Ra ional 'Med. Genter Carlisle PA 'I 7015 CLmil�rland
�� 16a.Nlethod of Disposition $p��rial � Cremation 166.�ate of Disposlilon 16c.Plate of Dlsposicion(Name of cem�tery,crematory,o�other place)
.� p�Re oval from State. O Donation . � .. �. . �. �� �
� o Othcr($pe�ify) ��3�`LO14 Gtmibarland Va11ey MaTtiorial Gardens
� 164 tocatio..n Of DisppsittOn(City o�Town,Stafe,antl Zip) . . 17a.Signaiu�c O� al Service Licen Pe I�1 Gharge of Inferm.ent. 176.Utense�N.umbe�
� Carlisle, PA '17013 FD O'12633 L
E .17c N artd C pl te�Address of Funeral Facllity � � � K � .
3 �in Brothers �ineral H�, =nc. , 630 S. Hanover St_ , Carlisle PA '1'70'13
18.D d nYs Ed Hon-Gheck the box Yhat besi tlescrlbes the 19.Decede f f Hispanic Orlgin Check Che 20.Decedent's R e-Check ONE OR MORE races Yo indicaie what
� h�ghesi degree or level of schooi compleied at the time of tlea[h. box[hat best describes whether[he tlecedeni the decedent considered himself or herself[o be.
�8Sh grade or less 75 Spanlsh/Hispanlc/Latino. Check the"NO" �{�White � Korean
� No diploma,9th-12th grade box If decaden[Is nof Spanish/Hispanic/Latino. � Black or African Ame�ican � Vleinamese
� High school graduate or GED completed No,not Spanish/Hispanic/Latino �American Ind{an or Alaska NaTive � Other Asian
0 Some college c�edit,bui no degree �Ves,Mexican,Mexican American,Chicano �Asian Indian � NaSWe Hawailan
O Assoclate degrae(e.g.AA,A5) O Yes,Puerta Rican
O Bachelor's degree(e.g.BA,AB,B5) �Yes,Cuban O Chinese O Guama�ian or Chamorro _
� Filipino Q Samoan
� Maste�'s degree(e.g.MA,M5,MEng,MEd,MSW,MBA) �Yes,oCher Spanish/Hispanic/Latino �Japanese � Othcr Pacific Islandcr �
0 DocSOreSe(e.g.PhD,EdD)or Professional degree (Speclfy) � pther(Specify)
.MD DDS DVM �LB JD
21.D cedent's Single Race Self-OeslgnaHOn-Check ONLY ONE co intlicate what the deceticni consltlered himself o�herself to be. 22a.DeceOeni's Usual OccupaSton-Indicafe type of work
�Whlte �Japanese � Samoan done during most of working Iife. 00 NOT USE RETIRED.
� Black or A7rl�an American � Kore � Other Pacific Islander
q �Amerlcat�Indian or Alaska Nattve �Vietnamese � Don't Know/NOt Sure Caxpanter
7 �Aslan Indian �Other Asian O Refused 22b.Kind of Business/Industry
� � Chinese O Native Hawailan � Other(Speclfy)
a O Filipino 0 GuamaNanorChamorro PA .Railroad �
ITEMS 23a-23 M � E COMPLETEO 23�a.Date Pr ounced ead(MO Day r) 2 b.5 'gp i�re a Per.son PrOnouncin6 Deat (OnIY when aPPI c>ble) � 23c.License Numbe�
BV PERSON WNO PRONOUNCES OR ` / ,/
GERTtF1E pEATH � � (�� � 3 �/B6
�sd.oace Igned( o/Day/Yr) � 24.Tme of Death ���`y � . ��• � �. . M/�-
�2��'J U f. � � 25.Was Medical Examiner.orCOronerCOntacted? � Ves No �
� �� � � � � CAUSE OF DEATH� � � � �
� Approximate
26.Part 1. Enier the Cha(n of events-tliseases,InJuries,or compliwtions--that dfreCUy caused the death. 00 NOT enter terminal events such as cardtac arrest, � Interval:
respiratory arrest,or ventricular fibrillation wlthout showing the eHOlogy. DO NOT ABBREVIATE. Enter only one ca�se on a Iine. Atld addltional IIneS If necessary. 1 Onset to Death
L'oLJ ln i`1 �iQi� r �
IMMEDIATE CAVSE ---------------> a, /�5 A� ,���/' r
(Final disease or condiTion p���� �Ce fi
resulting i�tleath) � rqu� of):
. ... . � b. �.�? F/P-JrLGr 1P� ��.`-,Y('T_
Sequ�ntiaNy lisi conditlons,�� � � �� Due fo(or as a consequenc¢of): '
if any,Ieading So tf+e cause � . � � �
Ils[ed on 11�a.�.Ert[er�the . � � �
UNDERLYINfi GAVSE �� . � Due to o as a con � �
(tllsease Or Injury that � ( � sequence of): �
W �
Initlated the events resulting d. � � � �
� I.n death)LAST. Oue to(or as a<o�sequence of): 1
1
� .26.Pbtt 11. Enter�other 5' ifl t diti t ib tl t d th but not resulting in th tlerlying cause given in Part 1. 27.Was an autopsy pertormed?
. � .P/✓LC.L�./YJ v N(/f- i.- L�.�CCJ•��.iTipiy�ili✓�(� . . O Yes C3�No
m Ci►--sCyr� �G�Ct--/tif--+E- E'h� i0^' �---�2iY�y�iErls�J:' 28�oco�,neeecne��auseosdeatn�z
� .-. .. . A--L. IiL c� �.� n- _ � . O Yes C3�No
29.If Female: 3D.Did Tobacco U e Contribute to Oeath� 31.Manner of Death
o � Not pregnant within pas[year � Yes � Probably Q'�NaCUrai
� Homidde
� PregnanC a[time of tleath � No [a}'TJnknown Q Accitlent O Pending Investlgation
ad � Not pregnant,but pregnant wlthin 42 days of death p Suictde � Could not be tletermined
�. � Not pregnant,b�t pregnant 43 days to 1 year before death 32.Date of In u Mo�e Yr 5
� Unknown if pregnant withln fhe past yea� � ry( � Y� )( Pell Month)
33.Time of InJury
34.Place of Injury(e.g.home;construcNOn sife;farm;school) 35.Locatlon of in u
G J ry(Street and Number,Cliy,County,SLace,Zip Code)
36.Injury a!Work 37.If Transportatlon Inj�ry,Specify: 38.Describe How Injury Occurred:
� Ves Q Drtver/Operato� 0 Pedestrian �
� No O Passenger O Other(Specify)
.�)
39a.Certifier-physician,certified n e practitioner,medlcal e miner/co r(Check o 1
n y one):
��a rtlfying only-To ihe best of my knowledge,death occurred due to the cause(s)and manner stated.
�Pronouncing Sa Certifying-To the best of my knowledge,tleaih occurred at the tlme,date,and place and due to the c se(s)and manner stafed.
� 0 Medical Examiner/Coronar-On the basls of examination and/or Investigatlon,in my opinion,deat�hf woccu^rretl ai the Hme,date,and place,and due to tha�cya�use(s)antl pmanneLr stated.
$ignature Of Certif�g�: .---�V� Title of certifler: /�� , ) Lice�t5e Numbar:_;'•C�-��O�S�/
39b.Nartle,Addresa�antl Z7p Code of Person Completing Ca s of�eeih(Item 26) /Y 39c.Dat Signed o/DaY/�'r)� �
� ` �� e • � ^ �7� . Z � !J ��2�/� � .
40.R gf t�r's Disi�ict N4mbe� 41.Registrar's Signature 42.qsgiszrar File Date(MO�ay/Vr �
43.Amendments � �� �� �y_ ��� v�
O
�
Dlsposltion Permit No. d-L�O� `q H105-143
REV 07/2012