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Home My WebLink About14-2982 r IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: NAME CHANGE OF : File No. SURVIVING SPOUSE NOTICE TO RESUME PRIOR SURNAME (PLEASE PRINT OR TYPE) Notice . is hereby given t�h/at the above named Petitioner, P n �v,.nn•� A �a.A V iii na , residing at, 3 a- • f(�� S - Cu r(i S(c- �11� 3 ,being a surviving spouse as of—A- AA 6L 1, Ls � , hereby intends to resume and hereafter use the previous name of 2 O kc, (C and gives this -� written notice avowing his / her intention pursuant to the provisions of 54 Fl.S-9 = _-- 704.1. A Certified copy of the Certificate of Death for the decedent is attached.-Zr- Date: S Signature of Petitioner E C -F >� :' C,`s �a rr, Signature of name being resumed - COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND On the 10 day of 2004 before me, the Prothonotary or the notary public, personally appeared the above affiant known to me to be the person whose name is subscribed to the within document and acknowledged that he/she executed the foregoing for the purpose therein contained. In Witness Whereof, I have hereunto set my and and o ti OtaIv-1'lib�l( a� ai ryY y - �,• _ (Note: This notice must be accompanied by an original cei E kcat"ti of death for -the decedent) `" y ICC Prothonotary,ltumUMand county,GWate•w► r 3 My Cmmndssion Expires the First Monday of.Jan.2018 H105.805 REV(9/11) rt LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $6.00 I„jlJi "'"'--- This is to certify that the information here given is correctly copied from an original Certificate of Death duly filed with me as Local Registrar. The original o 'P-1% certificate will be forwarded to the State Vital v yam' a Records Office for permanent filing. P 20327736 `�°'��` "-9lMENT OFA Ill '^ ��^ foe c` JM 17/2014 Certification Number """"""'")III Local Registrar Date Issued Type/Print In - COMMONWEALTH OF PENNSYLVANIA•DEPARTMENT OF HEALTH•VITAL RECORDS Permanent CERTIFICATE OF DEATH Black Ink State File Number. 1.Decedent's legal Name(FI rsT,Middle,last,Suffix) 2.Sex 13.Social Security Number 4.Date of Death(Mo/Day/Yr)(Spell Mo) Amy M_ Vezina Femal 002-70-8289 January 16, 2014 Sa.Age-Last Birthday(Yrs) Sb.Under 1 Year Sc.Under 1 Da 6.Date of Birth(Mo/Day/Year)(Spell Month) 7a.Birthplace(City and Stale 1 Foreign Country) 36 Months Days Hours Minvte, Oct 1, 1977 Wo £ebro lo , NH 7b.Birthplace(County) Sa.Residence(State or Foreign Country) 86.Residence(Street and Number-Include Apt No.) 8c.Dld Decedent Live Ina Township? PA 302 South Pitt Street O Yes, Stlecedenf lived In twP d.Residence(County) 1 nd 8e.Residence(Zip Code) 17013 No,decedent lived within limits of Carlisle city/born. 9.Ever in U med Forces, 10.Marital Status at Time of Death Married Cl Widowed 11.Surviving Spouse's Name(If wife,give name prior to first marriage) 0 yes No 0 Unknown 0 Divorced 0 Never Married 0 Unknow Benjamin S_ Vezina 12.Father's Name(First,Middle,Oast,Suffix) 13.MOThe is Name P for to First Marriage(First,Middle,Last) Roger L_ Vezina Marie f _ Lareau 14,.Inforrjlant's.Name 146.Relationship o Dec.deny 14 I is Ilin ljddress Sreet and Numb CI Stat Zip Co Ben]amin S. Vezina husband O°L rSout�li hitt treet, C�ar`_.SIg 7 � 17013 C _ _ _ _ _ _ _ _ lsa.P ace o_Deat c .a_on y_one _ _ _ _ s if Death Occurred in H a ospital_ i$ Inpatient - 1If Death Occurred Somewhere Other Than a Hospital_ Hospice Facility []Detede nt's'Home 0 Emergency Room/Outpatient Cl Dead on Arrival I 0 Nursing Nome/Long-Term'Care Facility 0 Other(Specify) iSb.Facllit Name(If not Institution,give street and number) 1S-Cit or Town,State,and Zi Code lSd.Coun f Deat M.S. �lershey Medical Center F�ershey, Pa. 1P7033 �aup�in 16-Method of Disposition 0 Burial Cremation 16b.Date of Disposition 16c.Place of Dispose Tion(Name of cemete story,or other place) o Ramoval from State o Donation Jan 17, 2014 Ho££man-Roth FuneraryllrH. & Crematory o Othat(Specify) 16d.Location of Disposition(City or Town,State,and Zip) - 17. 1 atur.of Fn:erent vbL u`eral I LI on in C Carlisle, PA 17013 g.pf . 011Numb, 932Lr rv�n 17c.Name and Complete Address of Funeral Facility Hc) Erna n-Roth Funeral Home & Cremato 12 H219 North Hanover Street, Carlisle, PA 17013 m 38,Decedent's Education-Check the box that best describes the 19.Decedent of Hispanic Origin-Check the 20.Decedent's Race-Check ONE OR MORE races to indicate what F- highest degree or level of school completed at the time of death. box that best describes whether the decedent the decedent considered himself or herself to be. 0 8th grade or less is Spanish/Hispanic/Latino. Check the"No" 0 No diploma,9th-12th grade box if decedent is not 5 i,h/HIs �Whit¢ 0 Korean O High school graduate or GED completed 04 No,not S Ish Hlspan panic/Latino. 0 Black or African American 0 OtherVietnmese 0 Some colle credit,but no de pan / panic/Latino no 0 American Indian or Alaska Native 0 Other Aslan Be c gree 0 Yes,Mexican,Mexican American,Chicano 0 Aslan Indian D Native Hawaiian 0 Associate degree(e.g.AA,AS) 0 yes,Puerto RI<an )1Q Bachelor's degree(e.g.BA,AB,BS) 0 Yes,Cuban 0 Chinese 0 Guamanian or Chamorro Filipino 0 Samoan O Master's degree(e.g.MA,MS,MEng,MEd,MSW,MBA) 0 yes,other Spanish/Hispanic/Latino 0 Japanese 0 Other Pacific Islander 0 Doctorate(e.g.PhD,EtlD)or Professional degree (Specify) 0 Other(Specify) .MD ODS DVM LLB,JO 21.Decedent's Single Race Self-Designation-Check ONLY ONE to Indicate what the decedent considered himself or herself to be. 22a.Decedent's Usual Occupation-Indicate type of work White 0 Japanese O Samoan done during most of working life. DO NOT USE RETIRED. Black or African American 0 er Korean 0 Other Pacific Islander Homemak 0 American Indian or Alaska Native 0 Vietnamese 0 Don't Know/Not Sure W 0 Aslan Indlan 0 Other Asian 0 Refused 22b.Kind of Business/Industry 0 Chinese 0 Native Hawaiian 0 Other(Specify) 0 Filipino 0 Gua manlan or Chamorro Own Home ITEMS Z3.-23d MUST BE UNCES OR COMPLETED 23a.Date Prono n ed Dead(Mo/Oay/Yr) 23b.Signature of Person Pronouncing Death(Only when applicable) 231.License Number BY PERSON WHO PRONO CERTIFIES DEATH i It b 'L-1 23d.Date Signed(Mo/Day/Yr) 24.Time of Death 25.Was Medical Examiner or Coroner Contacted? 0-Yes V9 No CAUSE OF DEATH 26.Part 1 'Approximate . Enter the chain of events--diseases,injuries,or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest, , I roxi : respiratory arrest,or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary. 1 Onset to Death IMMEDIATE CAUSE --------------> a. 12 (Final disease or condition Due to(vL�s a consequence of): resulting in death) b. MQ-�-cLSl-zs �lr L Gx X"f O YVt ri/- . Sequentially list conditions, Due to(or as a consequence of): If any,leading to the cause I listed on line a. Enter the I UNDERLYING CAUSE Due to(or as a consequence of): (disease or Injury that I Initiated the events resulting d. , in death)LAST. Due to(or as a consequence of): I 1 S 26.Part 11. Enter other significant condition,contributing to death but not resulting In the underlying cause given In Part I. 27.Was an autopsy pertormed? O Ves No 28.Were autopsy findings-liable to compl.te the cause of death? pO Yes No o w 29.I[Female: 30.Did Tobacco Use Contribute to Death? 31.Manner of Death Not pregnant within past year 0 Yes 0 Probably ® Natural 0 Homicide Pregnant at time of death 0 No Unknown 0 Accident O Pending Investigation m p Not pregnant,but pregnane within 42 days of death E3 Suicide 0 Could not be determined t- O Not pregnant,but pregnant 43 days to 1 year before death 32.Date of Injury(Mo/Day/Yr)(Spell Month) 0 Unknown if pregnant within the past year 33.Time of Injury 34.Place of Injury(e.g,home;construction site;farm;school) 35.Location of Injury(Street and Number,City,County,State,Zip Code) 36.Injury at Work 137.If Transportation Injury,specify: 36.Describe Haw Injury Occurred: O Yes 0 Driver/Operator 0 Pedestrian 0 No 0 Passenger 0 Other(Specify) 398.Certifier-physician,certified n e practitioner,medical examiner/co er(Check only one): D Certifying only-To the best of my knowledge,death occurred due to the cause(s)and manne,stated. N 0 Pronouncing✓3<Certifying-To the best of knowledge,death occurred at the time,data,and place,and due to the ca use(s)and manner stated- 0 Medical Examiner/Co o O base Hellon and/ estigation,in my opinion,death occurred at the time,date,and place,and due to the cause(,)and m r stated. Signature of certifier: r o e v Title of certifier: uW--' License Number: 4vl 1 Z�a�ne 396.Nam Address and Zip Code of Person Completing Cause of Dea (Item 26) 39c.Date signed(Mo/Day/Yr) GSA-� M.S. Hershe Medical Center Hershey, Pa.17033 LCp i 40.Registrar's District Number 41.Reglstra is Signature 42.Registrar Flle Date!A./Day/Yr) 43.Amendments O_ H105-143 Disposition Permit No. REVEV 07/2012