HomeMy WebLinkAbout04-06-05
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Register of Wills ofCurnberland County
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
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COUNTY OF CUMBERLAND
The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are true and
correct to the best of the knowledge and belief ofpetitioner(s) and that as personal representative(s) of the above
decedent petitioner(s) will well and truly administer the estate accord~ to law/? .---,1
Sworn to or affirmed ~ubscribed {X ~ ;:, ~ J
Before me this 1.0 day of
~~ ,2005
~~"-~C\AI'\.\lA. "~~i:>~1.......-
~~~ter \
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No. ~ 1-05 .;lOd.-
Estateol~~ Q..,pc.,,,l ,Deceased
GRANT OF LETTERS OF ADMINISTRATION
AND NOW \\ 0"~ J.. lo 2005, in consideration of the petition on there;verse"Cc:.
side hereof, satisfactorY~Of having been presented before me,
IT IS DECREED that l~llc-\ \ ~ ThY-. 0 "-
is/are entitled to LeU s of Administration, and in accord with such finding, Letters of Administration
are hereby granted to . r
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~A''''^ ~ 6' ~n v-r\
in the estate of
FEES
Probate, Letters, Etc. ............. $
Will................................. $
Renunciation....................... $
Short Certificates ( )............ $
~P.. $
Automation Fee................... $
Bond........ .................. ....... $
Total $
Filed L.j Ill> ~ 20 05
1-\5.0:)
kI1Pn1.a Jff1AflOA c:MWJl~!tL ~
v Registe~ofWills .Qu4-f. . ~
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Attorney (Sup. Ct. T.D. No.)
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Address
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('1 1t)"2.'1 (' -'lb~Q
Phone
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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 certificate will be forwarded 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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"""'''''''''''''''1111/11111
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Local Registrar .
Fce tor this certifIcate. $6.00
115~~.G8
nl-\.K ~ 8 2005
No.
Date
ITEM II
SJ-!OUU) READ AS FOLLOWS:
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COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
'11051<l3Rev.2J87
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AGE (Last6irthday)
Monlh.
1Th. CouIIt~
MARITAL STATUS - M.niBd.
l'leverMlrriecI.Wdowed,
Divoread(Specify}
1.aeVer marrie
Vet.lIf(;edentUV$din l.Qlr'Wr
1Td.o ~~N:;~~of
R'-'oo IS) :~~) 0
R ce _ Am9!ican In .n, Black, Wllle. et
,_,
10. whi te
SURVlVlNG SPOUSE
~f""..;v....idonn.m.)
.. 47
COUNTY OF DEATH
VB.
...cumberland
DECEDEm-S USUAL OCCUPATION
(or"=':~~....r."~
. CflW.stomer care re 11t.elephone
o CEDE S MAlll G ADDRESS (Street. Ci\'rfTOWI1. State, Zip Cod.\ OECf:.OENT'S
ACTUAL
RESIDENCE
(SlNltnllructlOlls
ooolheralde)
st Pennsbora
KINO OF BUSINess IINDUSTRV
~elect Specialty Hospital
If.S DECEOfNT EVER IN DECEDENT'S EOOCATlON
U.S.Al'tMEDF~' ~ .
CQI.OO
VnO No (1-4015+)
1~ 2
1128 Columbus Ave.Apt.l
1'. Lema ne PA 17043
FATHER'S NAME (1'11'$1. Middle. L.st)
...
INFORMp.,HT'S NAM {T
,,..
METH 0
J\llwR
<wp
C~~Ib('l((>
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LOCATION _ CityfTOWTl. Slale. ZIp Code
17088
aefferstown,PA
LICENSE NUMBER
N.
DATE PRONOUNCED DeAD (Month. Day. Yeas)
3,02.3.
...
...
: ApproiOmale
.lI1tefYalbe\we
: onaet and d..th
231).
WAS CASE REFERRED TO
Yh
27. PART I: Ellt4Irtll.41._.In/U.......ce>mpliooU<>."whldocal....1tI.4......DOnoI...1M1tI.ma4.oI41'1nu..ucll........IK......plrMary.....~.hac:k"'h..nr.llu...
LIoI...."'__"on_ljn.o.
PART II:
r sillnlllcant condibon~ contributing 10 death, but
r<:llretUltingln\tlll~lng<:a\lBegi'<<ll'>lnPp.,RT\
0(
TO( ACON UENC
S8quenti.ll)'lIllcondiliona
ileny,leadingtoimmedillle
CliI....Enl<lrUNOERlVING
C"USE\Di_eor~
tI1lt initialed evenls
rt'SUIling 011 dealh) LAST
WfoS AN. MlTOPS'( 'MORE AU"I'Q?SV FINDINGS
PERFORMED? AVAILABLE PRIOR TO
COMPLETION OF CAUSE
OF DEATH?
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V.sO NOJiJ veaD
,al.. Db.
CERTIFIER (Check only on.)
.~~':h~"j;"I..NfJ~~=~=\1e:c~~5'jlla:tO:&-:~hl.~=(:r~~a~h~~r.r.~~,~.~~~.~.~.~.~.~~.~.I~~.~~.)...
MANNER OF DEATH
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DATE Of INJURV
("'''''Ill. O'Y. v...}
TIME OF INJURV
INJURV AT 'NORK? DESCRIBE HOWINJURV OCCURRED
Naturll
Homicide
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3041. 3Gb. M
PLACEOFINJURV-Athome.larm,slrael,lactory,olIica
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vesD NoD
30c.
Accklent
Pendlngln~ntllllllon
SIGNATUREANDTll E
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LOCATION (Streel. CJtyfTown. Slatel
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FCERTIFIER
NOD
s.....
Could nol be delermiflld
n.
"MEDICAL EXAMtNERlCDRONER
On ttIa bill. of .umlnal/on .nd/or InWl.tlg.lIon.ln my opinion, d..th occurred.1 Ilia time. dall, nd pt.c., .nd d",a to Ih. cus.e(.' .nd
R'IInn.,.......d..............................."..........................................................................<-"'..'"..m................................
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REGISTRAR" SIGNATURE AND NUMBER
.......0 31b.
L1CENS~'OER l..1.11V OATESiGNED(Moolh,oay,Vear)
......0 31c. ~ '"\ 31d.
NAME AND ADDRESS OF PERSON v.+IO COMPLETED CAUSE OF DEATH
(It am 27) Type or Prlnl
.0 ()IL 1j\\WArVI\H\I>,V
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DATEFiLED(Month.o.y,Vear)
"PRONOUNCING AND CeRTIFYING PHYSICIAN (Phy.lclen boltl pronouncing death end certifying to ClIUH oId11lh)
To the bat of my knowlacllle, d..1h occurred It IlIellme. dlte, .nd pl.ce. end due 10 tn. ceu.u(.) .nd manner II .llltId......
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