HomeMy WebLinkAbout03-31-05 (2)
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
8UREAU OF INDIVIDUAL TAXES
DEPT 280601
HARRISBURG, PA 17128-0601
REV-1,62 EX(1'-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
FINK LEWIS R
269 STONEHOUSE RD
CARLISLE, PA 17013-9429
______u fold
ESTATE INFORMATION: SSN: 182-54-1011
FILE NUMBER: 2105-0255
DECEDENT NAME: FINK CLAUDINE T
DATE OF PAYMENT: 03/18/2005
POSTMARK DATE: 03/17/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 12/30/2004
NO. CD 005092
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $3,450.00
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TOTAL AMOUNT PAID:
$3,450.00
REMARKS:
CHECK# 5302
SEAL
INITIALS: JA
RECEIVED BY:
REGISTER OF WILLS
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as
Lllcal Registrar. The original certificate will he fllrwardcd to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
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Fee for this certificate. $2.00
DEe 30 200ft
Date
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Hl05.143 Rev,2J87
COMMONWEALTH OF PENNSYLVANIA 0 DEPARTMENT OF HEALTH 0 VITAL RECORDS
CERTIFICATE OF DEATH
TYPElPRINT
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PERMANENT
BLACK INK
88
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2,F6M.le
BIRTHPLACE (City and P
,~lIIle.O(Fo"'~nCounlry) HOSPITA,L
W~lJ.~QITlSROrt, 'np..o'" D
7. Ma lan'tl 8e.
FACILITY NAME (1Inotlnstltution,giveslr&ellll1d number)
STA,TEF'LENUMaER
SOCIAL SECURITY NUMBER
NAME Of' DECEDENT (Fits!, MklcIlfl, Laat)
1. Claudine T. Fink
AGE (Laal Birthday)
3. 182
54
101
DAT:EOFDEJllJ~;(Mooth. o.;y,l'urj'::
.. 12/30'!2004 i i ;
i..
DECEDENT'S USUAL OCCUPAT10N KIND OF BUSINESS I INDUSTRY
1~~i4".f:1.~o':.~t
11L Haranaker 11b. Her own hane
DECfDENT'S MAILING ADDRESS (Stmal, Cityfrown. Blata. Zip Cede) DECEDENT'S
ACTUAL
RESIDENCE
(Sealn.lnf<:tioos
onotherslde)
AS DECEDENT EVER IN
U.S. ARMED FORCES?
YesD rw[j
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11..Slet.. PA
MARITALSTATUS_Merrled.
NaverMarrled,WKIowed,
DNorced{Spedfy)
14. Wi(b,.,red
<./;
R..ld.nuD ~:~,D
RACE.Amencanlndian.Biack.Whiw,et.
{SpedfyJ
iiM1ite
SURVlVINGSPOUSE
(Ih''''.gi..._nnomol
..
COUNTY OF DEATH
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Cumberland
Carlisle Borc.
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11b. Counlv Cumberland
o.
dacedenl
ivelna
townal1ip?
i7c. kI Ye',decOO&<1tivedlr1
17d. D ~~I~:'~I\i~li: of
Dickinson
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city/boro
MOTHER'S NAME (FII'lJl, Mlddla. Maidan SumllITlll)
19. Willa V. Sliaron
~~~~~r~t6'ri~~~~{~~ ~'ty~rl!~reC~~A 17013
DATE" OF DISPOSITION PLACE OF DISPOSITION- Noma ofCematery, Cremetory LOCATION. Cityfrown. Slala, Zi!> Coda
l""mlh,cOj'.r"'1 or OtharPIaca
1/3/2005 ~rlana Valley Man. Grds. Z1d. Carlisle, PA
LICENSE NUM8ER
2Zb. FD 012633 L
Inc., Carlisle,
DAT SIGNED
{Monttl, Day, Yee.r)
PA
M n.
27. PART I' _.tI>odl....OI, 1"10_ "'o""'pll.....'"' wlll<ll .."".dlll'd..lPo, Do n"onlo.tI>o mod. o!<lylng, .".~... 1.0 '" "'.pl..k..)".....~ .~ook ..ho.ttfolur.
Ulh..)"..........nHolllI.... -1
A/V-{ .hu-~v / '[c{
NCEOF)'
".
: Awrwdmata
. Inlervalbelwoon
1 cnsel and death
Oth-ersignificantCOnditiOflsc:ontribu~n9todealh, but
notrll!lu~I~lnlhaundenyln9caulegivenlnPARTI.
SequentielyllltCOndll\on. b
ffeny,laadlngtolmmedlete ['
. CIIUSlI.EnlerUNDERLYlNG
CAUBE (DI.....e orln/Ury c.
.Ihol:lnhletedeven'-
resullingonde.Ih)LAST d.
WAS AN AUTOPSY WERE AUTOPSY FINDINGS
PERFORMED? AVAllABLl'. PRIOR TO
COMPlETION OF CAUSE
OF DEATH?
CUETO(
DLtE TO (OR
SEal'''
/
YMO No
YaaD
MANNER OF DEATH
Natural [H-- Homicide 0
_ent 0 Pending Inve'l4l'~on 0
Suldde 0 COlJldnot bedelennlnoo 0
DATEOFINJURV
(MunIll,Day,V..rl
TIMEOFINJURV
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~
28e. 28b.
CERTlFIER(CheckDl1tyone)
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PLACE OF INJURY
oolldlng.ot<;,ISpoc:ifI')
30..
30b. M. 30<:.
Alhoma.laom.8Intet.laclory.o/IIce
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*PRONOUNCING AND CERTlFYING PHYBlCIAN (Phyolcian both pronOllncing deeth end oartlfyl1g to cause of""elh)
Te tile bonl of my kn_ledge, deeth OCW....d IIIlh.II....., date, .nd p'_, aI'1d due to the cau...(.'.nd menner.. alated....
SIGNA
................D3i~
L1CEN
*MEDICAL EXAMINERfCORot.IER
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318,
REGISTRAR'S BlGttATURE AND NUMB
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