HomeMy WebLinkAbout07-07-05
'110S.H05 REV 1105
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.
p
11560707
No.
tl-n-n. JJ? tJ;;;WA..I/cr-
Local Registrar
Fee for this certificate, $6.00
.IlIN I '1 Z005
Date
ITEMiI 3
SHOULD KEADASFOLt{)WS:--
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COMMONWEALTH OF PENNSYLVANIA. DEPA.RTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
143 Rev. 2J87
..
COUNTY OF [)€A TH
y~.
SEX
2. female
STATE Fll.ENUt.lllER
SOCIAL SECURITY NUMBER
96
BIRTHPlACE lCiIy.rId
State or Foreign CouI1!rYl HOS ITAL
Connellsville, lnpMi.... 0
1. P IL
FACILITY NAME IlfnotlllStilulloo.liI~ street aI1d numb!r)
,.
h
175
01
3737
[)ATEoF,WTHtMonth.~i._Y"")
~ June 2 200s'
,,-'I
NAME OF DECEPENl tFiRt, Mlddkt. LlI8l)
1. lara
AGE (Last&rttl<1e.y\
ER/O<Ilpalw,nlD
SURVIVING SpOUSE
(lwilio.jIM"'*-"_1
"",,0
~o ~)O
RACE . American 1ndlti1. BIe<:k. WhlIII..1 .
(Sf*;ifY)
white
10.
&b. Dauphin
DECEDENl'S USUAL OCCUPA lION
(~~~-=-:=l
Pa roll Clerk ~ederal Gov 'rnment
11.. 1ib.
DECEDfNT'S MAILING ADDRESS (SlrHt, ClyITOWI1. state. ZIp Code)
k.Susquehanna Twp~
KIND OF BUSINESS I Itil .IJSTRY
Bentley Assisted Living
AS DECEDENl EVER IN
U.S. ARMED FORCES?
y'"D Nol&1
12.
DeceDENTS EDUCATION MARITAl STA lUS - U.JriBd.
(Spoocily g..- __I Ne.... UerriBd. Widowed.
~ Collego tllvoroolI(Spedfy)
13, 12(o.\~) (Hor5+) 1-4. widowed
Pennsylvania DId 17c.D Yes. deced8l'ltlived k'l
''''''''''
ijv.lne
Cumberland LownlNp? 17d.~ ~~:'::of New Cumberland
UOTHER'S NAME (Fnt, Middle. MBkIen $WI.me)
11. Sarah Clauser
INFORMANTS MAILING ADDRESS (SIreet. CilyfTOWIl. S18I11. Zip Code)
2Ob. 320 Avenue E, Rendondo Beach, CA 90277
PLACE OF DISPOSlTION- Neme of CIHTMIl.ry, ~ LOCATlON ClyIT_n. Stele. ZIp Code
orOIUrPlBce
21c.Con-O-Llte Crematory 213.chaefferstoWD, PA 17088
NAMEIoNDA.DDRESSQfFAC1LITY art emore , nc.
nc. P.O. Box 431, New Cumberland, PA 17070-0431
LICENSE NUMBER DA SIGNE
".. inZZ1tJ36-L :~.Do,.y_,
WAS CASE REFERRED TO A MEDI~AL EXMtINERICORONER?
21. Y.. . :Y\!;.V No 0
cw...pl.-.IoIy.......I,.hDC~O'''-ortl..I..... :/IpproldmBle PARTH; Qltlerslgnilk:al1ttof1dilion$COtItribtiIWlglOde8Ih,but
.~" no\r~in'ihll~C8UltlliJivenll1PAATI.
:on&lllBfldde.lh
".
332 Sixteenth Street
11. New Cumberland, PA 17070
FATHER'S NAME (FnI, Middl8. la$11
1'. William Vol ht
INFORUANl'S NAME (TypelPrint)
2Oa. Suzanne E. Vanderbilt
METHOD OF DlSPosmON
9urilI1 0 Creff\8llOn ~emoVlIIromS"1e 0
Clllw(Specify)
FU SE
Of to':DENl'S
A{ \JAl..
Rt- IDENCf
(S, in5tructions
or, .herslde)
17LStale
...
17b. County
dtylbofo.
Ilems 24-26 muiM b8 c:anplB1ed by
plQOIl\lo'hO~Gnttt.
24. M. 25.
27. PART I; E_............ln)wllucw_pl__QlCBIf_tM....... Danol.na.'tMm.....olllwl....._h..
uoe.....,on._on.-chl....
..
""
S8quenli.sIyUstoondlllons b_
ileny.kl8dlogloimmedi.te
QlUH. ~ UNDERlYING
CAUSE (Disease or injury [ o.
-1tuoI.,i\i8I8deverlllo
rBSUlling on ON\tIllAST d.
WAS AN AUTOPSY WERe AUTOPSY FINDINGS
PERfORMED? AVAILABLE PRIOR TO
COMPLETION OF CAUSE
OF DEATH?
"'""
E O(ORM" ONSEOIJENCEOF)
y"O
MANNER OF DEATH
Nelural 13 Hornk:ide 0
-"" 0 Penditlglnvesliglllion 0
Suicide 0 Cwldnolbedeleonlt1od 0
DATE OF INJURY
(_, o.y. v..,)
TIME OF INJURY
INJURY AT WORK? OlooSCRIBE HOW INJURY OCCURRED.
'PRONOUNCING AND CERTIFYING PHYSICIAN (Physld8nboUl ?fOOOO<\""'9 deaU\ end ~ \oaur.e <>I."6I1\)
To u.. be.. of my knDwl.d!t8, d..lh ~O::O;:WT8d Bt th8 tlm.. date,....d pl_. and dUfl to th. c.su.llI(sIBnd Il'l8IIn..-.,1 .lated...
o
mmmO
SIGNATURE AND
2a.. 2ab.
CERnFIER (ClIeck only one)
;~~GJ::=~.If:$~c:~i.rdUJ:l:!a=~~~:~~~dOllJ=II~h:t~~~.~.~~~~~~~~.~~~~.~.~.~~)...
".
30.. 3Ob.
PlACE Of lNJURY - Al harne. farm. sl'&el.lacloly. oIfice
t>ullding..lc(Spocll)l)
....
YelD NotKJ
NoD
.MEDICAL EXAMINER/COROHER
On ~b"'" ot .1l.....lnl>\lOfl UlOlor IffQltlptlon. In my opInion, d..ll, OClCllfrL.
_Mr...IiIt".....................................................
".
lJ.REGISTR.Cln~~ ~
Ilh"tlm..datB.....dpl..:...nddu.tolh..ceu...j.).nd 0
~d
"
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent: Clara G. Eisley
Date of Death: June 2, 2005
Will No.:
2005-00535
Administration No.: 21-05-0535
To the Register:
I certifY that notice of estate administration required by Rule 5.6(a) of the Orphans' Court
Rules was served on or mailed to the following beneficiaries of the above-captioned estate on the
27th day of June, 2005:
Name
Address
Suzanne E. Vanderbilt
Duncan S. Vanderbilt
Michelle E. Vanderbilt
Richard E. Desmond
Robert Eisley Desmond
Sarah Ellen Desmond
320 Avenue E, Redondo Beach, CA 90277
4779 Park Drive, #114, Mukilteo, WA 98275
3456 Gamet Street, #340, Torrance, CA 90503
110 E. 40th Avenue, Eugene, OR 97405
401 Botetourt #1, Norfolk, VA 23510
3 Glen Ridge Lane, Pittsburgh, PA 15243
Notice has now been given to all persons entitled thereto under Rule 5.6(a).
Date: 2':1 Jv...~ 'toO'S'
~~?~,
ROBERT P. KLINE, ESQUIRE
Attorney 10# 58798
714 Bridge Street
Post Office Box 461
New Cumberland, PA 17070-0461
(717) 770-2540
Counsel for Personal Representative
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