HomeMy WebLinkAbout05-2691
IN RE RUTH MARY HARTUNG
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
NO. OJ -c2~ 9 I
NOTICE OF INTENTION TO RESUME PRIOR NAME
Notice is hereby given that the above-named Petitioner, Ruth Mary Hartung, being a
surviving spouse as of January 12,2002, hereby intends to resume and hereafter use the previous
name of Ruth Mary Ralston and gives this written notice avowing her intention in accordance
with the provisions of 54 Pa.C.S. 9 704.1. A Certificate of Death for the decedent is attached
hereto.
off ~(;/ 0 ~-
Date
eo~;ti::~
TO BE KNOWN AS:
~rf/~
Signature - Intended
COMMONWEAL TH OF PENNSYLVANIA
COUNTY OF ('f 'UBERLM<lI~...J~-
.. Jj1 M
On the ~ day of ~ ,2005, before me, a notary public, personally
appeared Ruth Mary Hartung, kno to me to be the person whose name IS subscnbed to the
within document and acknowledged that she executed the foregoing for the purpose therein
contained.
IN WITNESS WHEREOF, I have hereunto set my hand and seal.
Notary Public .;;;). ~
Notarial sea~ public
Dawn Gi3d1e"ef, ~ eouolY
s. DiIIsbUr<;lo~~~i>I;~s MaY 11, 2005
My Comm,s", a\l<Jl1otNot3f\es
pennsy\vanla~
Me~~pectfully submitted,
WILEY, LENOX, COLGAN & MARZZACCO
My commission expires
By:
d~
,..-
Date: j - ( 7-c~
. Col , Esquire
130 West urch Street
Dillsburg, PA 17019
(717) 432-9666
J.D. # 77944
P g-4:> ~
en. p..- \J\ .
.~ ts ~-
l' --D O.
~~ ~-c
-t:. ~
~ G
o
~
p
~
-
:"",)
c..-~'l
..-, !
H105.905 REV.(09/00)
This is to certify that this is a true. of the record which is .on .file in the Penn_nia Division of Vital
with Act 66, P.L. 304, approved by ,eneral Assembly, June 29, 1953. .
Records In accordance
WARNING: It is illegal to duplicate this copy by photostat or photograph.
C\~5.~/~
Robert S.~erman, Jr., MPH
Secretary of Health
1869071
No.
~)/~
Charles Hardester
S tate Registrar
APR 1 6 ZOOz
Date
H105.144Rev.lt91
COR..l\ECTIID ITEMS: 7
PER. FD DATE. 2- ZO-02b COMMONWEALTH OF PENNSYL.VANIA . DEPARTMENT OF HEALTH. VITAL RECORDS
. . as CERTIFICATE OF DEATH
(Coroner)
012492
TYPE/PRINT
,.
PERMANENT
BLACK INK
"
o
@
~
~
o
w
,
<
Z
o
o
)lI.
p
UNDER 1 DAY
HOUr!! Minute.
;/1
CITY.60A
Silver
~.
DECEPENT'$USUALOCCUPATION
(Go.e ~i<v3<>1__~ <l=i! W<"'~ """'\
Of""'k,ngl'fe:c!oOOlussra'"ood.!
11, Sec.uJl.itu Gualtd l1b. Se.C.uJr..i..tlf
DECEDEHT'$MAILlNGADDRESSiStr@"',Ci,y,Town,S'.'e,Z'pCooel DECEDENT'S
P.O. Box 513 ~~~:f,AELNCE
Mcu.,.haYl,(('..6bWrg, PA 17055 1~.~,~::r~~~fn.
"
~,:. HaAtWl
"
J< ACTIJ<G AS SUCH
22b.
TOlhe bestofmy~no"'edg<'. ."..lh occu".d.tlhtlti...., d.le .ndplae. 51ated
{5ignalu,e.rnJT,t1el
'b.
TIMEDFDEIITH
JR.
STATE F'lE NUMBER
SOCIAL SE.CURlTY N.UMe,"-'"
IlI<TEOfOEIITH IMonil',Day, YEar)
4. January 12. 2002
,02-32-9258
BIAfHPLACE.(C"yaM
S'aleorFCNe,onr"JOlrvl
ittsbur.p,h PA
~~~iIYID
H.. Stale
MARlTN-ST","US-M&,,~
Ne...M.rri.."W;""....~,
D"",eod(SpecIIYI
14. MaJtlt,(e..d
17c.OVes.deeodonIIMldin f,,-t
Rl<Cf-l<merloenlndi.n.aI~e",WM.,.'O
{Speoly)
10.l.vh.ite
SUR\>l\IlNGSPOU$E
I"w,le.g,vi!ffi."ennamel
Ruth MeA!I
TCWH..6'l-tyJ
Raf.M:GY~
Did
.".c.d.nt
li..ina
,,,,,,".h;p? 17d.D ~~;,e:'~~"':.':\il::.: of
MOTHEA'SNAMEiF;'~,Mlddl.,Ma'd""Surnamel
,.,
17l:>.COunt
Cumbe.lt,ca.nd
cil'/Ibor<l
o
19. 7 be..f.f 1 .eo
INFORJ,IANTSMAILlNGADDAESS(Str@<Ot,Cit/ITown,S,ale,ZipCocel
201l. P.O. Box. 513 Mc.chal'l.ic,t,bww PA 17055-05 3
PLACEOFDISP05'TION.NameOfCemelery,Cr.m&'ory L ATION,C;'ylfown,S,ole.lipCode
01 Ott\e,PIo.ce CJ{e.mat~ori Srcl.-e.:t(1 0,
21c.
-'~ f1' 21d.
NAME AND ADDAESS OF FA ILlTY CJiiZ.matifiYJ <::'oc.i..ef~ rf PA
22.. 4 00 Jonc.-6.towl1 KQ. aJ(1[-<-.6oM PA 1710
LICENSE NUMBER DATESI NED
{Mon'h,Day,YearJ
DAnPRONDUNCEDDIOADIMonll> Day,Yeaq
24. 5:20 P M 25. January 12. 2002
n,l'Jdt1:I'. E"""'I\e~_"",inj~'\"""'<:mf1Ill;eOllon.w'nicn.ausod'hedM,h_Do"'leOl.rtl\emodeoldying..u.ha.cardi.correspirotoryarr6.t.shockorll.artl.iluI.
UOlon'YO"eCe_O<1MOhline
DIMr';gnificMloondilionsoont'itlU'I"Il'odog'h.bu'
,.,r 'e'"~'nglnthe"n,,"''Ying causeg'ven in PART I
Gunshot to Head
DUETO(DRASACONSEOUENCEOFj
DUE TO \OR o>,S ~ CDNSECI)'ONCE or)
DUE lO lOR AS 0>, CONSEOuENCE OFj
,
WEAEAUTOPSVFINDINGS
AWlILAElLEPAIOAlO
CQMPLETION OF CAUSE
OFDEIIJH?
MANNEROI'DEATH
N.o.\u,,'l
~D
Ace"lent
" 0
Suicide
..
2&0<. 281>.
CERTIFIER ICheok orOyonol
'CERTIFYltlGPHYSICIAtl(PI1ysiciancer,""ongcau""olde.th~"n.nCRharphySICI.nha'p'onouncadooa'h.ndcompleledl'om23)
TOlhe _OlntyblOwledge. d..lh occu.reddue tolhe oau.~(.landmannefe.ot.ted
:ApPlo,imat.
,'nt.,,'.lb.tw....n
ions",aMdoa'h
PAATII:
DATE OF IN,JURY
(Monlh,Da\',Ye"'1
TIME OF INJURY
INJURYIITWDAK?
DESCAIBii:HOWINJIJRYOCCUARED
Aprx.
Self-inflicted gunshot
Yo, 0 NO)Cl
Hmnici60
o Jan. 12,2002
030.. 30b.5:20PM
o PLACEOFIJ<JURY.A'Mme,lorm..tr..t.loClOI'/,o~iCe
~,<l\~_\5pec"1) Home
SIGNATURE AND
,~.
LOCATION(Stree',CilylTown.Sla,@) PA
Rd.,Mechanicsburg.
P.ndingln.e$l;~';on
,~
Could no' oed.Wmio.ed
o 31b Coroner
lICENSENU DATE$IGfD(Monlh.Day.Yeaq
o 31c. ld. January 14. 2002
NP-ME I<!W l<ooRE51'. OF PERSON WI-lO COMPLETeD CAUSE OF DEATH
(Item27)Ty!>"orPlinl Michael L. Norris. Coroner
6375 Basehore Road, Suite #1
Mechanicsburg. Pa. 17050
'PAONOUJ<CINGANDCERTIFYIJ<GPHY$IClAN(Phy""iMbo'hpronoucclngdeathondcanilyingtocaus@oldealhl
TOlhabellofmVk,.,w!edge,deathoce"""dltlh.ti""'.d.1e,andple.e,and<l....lOlheCllu..c.lar><lm.nner.a.tolod..
AEGISTRAA'SSIGNATUREANONUMBii:A
"ME01CALEXAMINER/COAOtlER
Onlha ballaoJ u.mlnaUon andJo. 1,"a.llgaU"n, in my "plnlon, dealh ouurred allhe Uma, dele,.t><! place, at><! d~'lo the .auae(l)ar>d
mann...n.18let1........,.............. .............,.....................................................,......
31a.
'/;? 0';;/_
I... ". -..-v<.-4.c-??-
It'! A/,!I
M.
/ ,/')/tl 2-
)>i
"
DATEFllED(Morlt Day,Ysrl