HomeMy WebLinkAbout14-5454 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLAV�ANIA
C--
IN RE: � S o V1 �.�1�` �•`"1
NAME CHANGE OF File No. I ' S fe* MAO— C) I
SURVIVING SPOUSE . �
(D C:11
1
r.a
NOTICE TO RESUME PRIOR SURNAME -7
(PLEASE PRINT OR TYPE)
Notice is hereby' given that the above named Petitioner,
residing at,
12 r2Xe r -I�C�.� I'� ng
G11v CUMI�e� a, ',being a
surviving spouse as of aee [l VCc , ��hereby intends
lf<ZbeXc�kJ�
to resume and hereafter use the previous name of
nA V- rC e d/V and gives this
written notice avowing his her intention pursuant to the provisions of 54 Pa.C.S. §
704.1. A Certified copy of the Certificate of Death for the decedent is attached.
Date:Q 6 " 14 l
Si ature of Petitioner
MAA, J-1,, I A k�,,/V"
ature V name being resumed
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
001�-
On the 15t� day of Zgepj 12er ,2063;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 hand and official seal.
Notary Public
(Note: This notice must be accompanied by an original certificate of death for the
decedent)
Prothonotary,Cumbedand County,Pdisle,PA
//S 7.S"j,G( My Cammissfon Expirese Fnst I�anday of.laity 201
M-o--' a as 7 o2G 57094
„t
COMMONWEALTH OF VIRGINIA
CERTIFIED COPY OF DEATH RECORD
COMMONWEALTH OF VIRGINIA CERTIFICATE OF DEATH
COPY Ii DEPARTMENT OF HEALTH-DIVISION OF VITAL RECORDS-RICHMOND
REGISTRATION. CERTIFICATE
FOR DIVISION OF AREA NUMBER NUMBER MEDICAL EXAMINER'S STAT NUMBER VITAL RECORDS 228 2161 CERTIFICATE
DECEDENT FULL NAME (first) (middle) (last)
OF DECEDENT 2.SEX male female
. 1CIC ❑
3.DATE OF (mo.) (day) (year) 4.AGE _ IF_U_NDER 1 YEAR__ IF UNDER 1 DAY 5.DATE OF (mo.) (day) (year) 6.WA DECEDENT
DEATH _ __ __ _
�// GC months T days hours -I minutes BIRTH EVER IN U.S. yes no
!1 ,5 I I I I 1 O 1956 ARMED FORCES?❑
years 7JV
PLACE OF 7.NAME OF HOSPITAL OR INSTITUTION OF DEATH(it none,so stale) Out Pat. 8.COUNTY OF DEATH (ii independent city,leave blank)
DEATH /�rrs,✓�� i DOA Emer Rm Inpatient
9.CITY OR TOWN OF DEATH inside city or town limits? 10.STREET ADDRESS OR RT.NO.OF PLACE OF DEATH
yes no
If 71S
USUAL. 11.STATE(OR FOREIGN COUNTRY)OF DECEDENT'S RESIDENCE 12.COUNTY OF DECEDENT'S RESIDENCE (il independent city,leave blank)
RESIDENCE
OF DECEDENT Paiwlyania
13.CITY OR TOWN OF RESIDENCE inside city or town limits? 14.STREET ADDRESS OR RT.NO.OF RESIDENCE I ZIP CODE
yes no 1
c �o
m ❑ 1
PERSONAL 15.NAME OF DECEDENT'S FATHER 16.MAIDEN NAME OF DECEDENT'S MOTHER 1
g DATA OF �v�,,,,.�
n S DECEDENT B. Qttegm Jagimlyn M. Wame .
c b 17.RACE OF DECEDENT 18.OF HISPANIC ORIGIN? If yes,specify Cuban,Mexican, 19.EDUCATION(Specify only highest grade completed)
cn Puerto Rican,etc. I�1 2
c m 0 no [1yes
o c y1LyL� Elementary/Secondary(0.12) College(1d or 5+)
v 20.CITIZEN OF WHAT COUNTRY 21.BIRTHPLACE(state or country) 22.NEVER MARRIED❑ DIVORCED ❑ 23.IF MARRIED OR WIDOWED,NAME OF SPOUSE
c (if divorced leave blank)
E
LEA Cal MARRIED WIDOWED ❑ r7en
i.fer M. Otter i
_=n V
t 24.SOCIAL SECURITY NUMBER 25.USUAL OR LAST OCCUPATION 26.KING OF BUSINESS OR INDUSTRY 27.INFORMANT-OR SOURCE OF INFORMATION-RELATIONSHIP
OMPLIter
_' E
a>o
°2 �� �7[T Er M. OttO9C17 -
LL
,� 28.PART I.Enter the diseases,injuries,or comp'ahons that caused the death.Do not enter the mode of dying,such as cardiac or respiratory arrest,shock,or bean failure. INTERVAL BETWEEN
>n$ CAUSE OF DEATH List only one cause on each line.
I ONSET AND DEATH
m IMMEDIATE CAUSE(Final disease or ./,,` /+ !j/� �i•V11� O
a m E To -� (A) 1✓J yLA /�/A
condition resulting in death) DUE TO(OR AS A CONSEOU CE OF):
Z � MEDICAL
a a EXAMINER:
c o Sequentially list conditions,if an leading (B
$5 + to immediate cause.Enter UNDERLYING )DUE TO(OR AS A CONSEQUENCE OF):
CAUSE(Disease or Injury that Initiated
2 Complete and sign events resulting in death)UST
$ medical certification Z (C)
a e (darn 28)end give a8 LD PART 11.Other significant conditions contributing to death but not resulting in the underlying cause given In Part I. 28a.AUTOPSY? yes no
e 3 copies to funeral C
(J{
€ director as soon as AUTHORIZED BY:
I L�r ❑
LL
I°1 sitar Inquiry.
i m W 28b.IF FEMALE,WAS THERE A PREGNANCY 28c.IF EXT AL CAUSE,IT WAS 28d.DESCRIBE HOW INJURY RELATING TO DEATH OCCURRED
e W IN PAST 3 MONTHS?
V PRIMARY or CONTRIBUTING r--
O J TO CAUS DEATH {#7 rel e 4, b"1/,
n < Yes❑ no❑ unknown❑ ./ ! C L./' ! ,t/ /y+
c NOTE:If 0 28e.TIME OF INJURY (mo.) (day) (year) 28f.INJURY OCCURRED 28g.PLACE OF INJURY(home,farm, 28h.(city or town) (county) (state)
"Pending"muregis-st be LU A M factory,street,office bldg.,etc.) 1
her oted,noeiy decision
v/�/�C... .�z /L 71J�" while not while _
her of final derision ! f� at work ❑ at work � �Q�e 4-
as
� l�1 //✓!�j /f I/
as soon as possible. 28ii.l CERTIFY that I took charge of the remains described above.viewed the body,made inquiry and in my opinion death resulted at or about (AM)(PM)from:
NATURAL CAUSES❑ ACCIDENT_❑ SUICIDE_ HOMICIDE❑ UNDETERMINED❑ PENDING❑
__ CS
ACTUAL1 7E SIGNED:
SIGNATURE'I-
NAME OF ME IC a _r ___=_ �__.jq,e____________________I- -- --------
�OAMINER
FUNERAL 29. BURIAL REMOVAL CREMATIO 30.PLACE (name of cemetery or crematory)
DIRECTOR OF BURIAL. (city or county) (state)
❑ E] REMOVAL,ETC. r1JJ.. ) 1M..71folk, T m
31. (Signa re of fu I director egally filing this certificate) 11� NAME ONp FUNERAL H. D. �`ELM..711 1S2: VC1sa T
► Jf O ESS: 111501 , J1 L .
Funeral Service me No /ff Await ,
REGISTRAR 32. (si ature of registrar)
DATE RECORD
' FILED:
r
12 14/11
< RESERVED FOR
REGISTRAR'S USE
THIS IS TO CERTIFY THAT THIS IS A TRUE AND CORRECT REPRODUCTION OF THE O IGINAL RECO FILED WITH THE VIRGINIA BEACH
DEPARTMENT OF PUBLIC HEALTH,VIRGINIA BEACH,VIRGINIA
DATE ISSUED:
EC 14 2011
SEAL: EPUTY REGIS R
ANY REPRODUCTION OF THIS DOCUMENT IS PROHIBITED BY STATUTE.
DO NOT ACCEPT UNLESS IT BEARS THE IMPRESSED SEAL OF THE VIRGINIA BEACH HEALTH DISTRICT CLEARLY AFFIXED.
Section 32.1-272,Code of Virginia,as Amended