HomeMy WebLinkAbout05-4115
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYL VANIA
INRE: RuH. Fv<:,.ly" SI):I~~
File No. 1lS"" - .LJ lIS
(J'u ~ L~'C.L""l
NOTICE TO RESUME PRIOR SURNAME
(PLEASE PRINT OR TYPE)
hereby
EV-U'-f4V ,S K~ljS
d
(;C: /:jicl.uu~ !Jtlt'L Api, ,) 05
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surviving spouse as of (/UJ1e
Notice
lw.i!n
is
that the
Petitioner,
, residing at,
Pt1 /705{) ,being a
, j ? 'if '7, hereby intends
gIVen
above
named
/V!cd!afi,i;w;utcl
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to resume and hereafter use the prevIOus name of
/U.rlic fwl:;~ /;It1&'i1c1 " ' and gives this
written notice avowing his I ~er intention pursuant to the provisions of 54 Pa,C.S. S
704.1, A Certified copy of the Certificate of Death for the decedent is attached.
Date: OWl{ R JOrJ5 6~L-tl 'C ~
Signature of Petitioner
K~L
Signature of name being resumed
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
On th~st1tlay of .slI eJj , 2005, 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 :~ q.,_ . ~
%O/lUYr<.4! ~ ffJH'--I4'(
Notary Public
COMMONWEALTH OF PENNSYLVANIA
NcIarIaI Seal
",.~G. Manion. Notary Public
"""" 8p!1ng Twp.. Cumberland County
My CommIssion Expires Mar, 8, 2008
Member, Pennsy(vsOIs Association Of Notaries
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'\'<;rhis is to certify tha[ the infonnmiotl here ,~2;ivcn is Ul1"'fCtly ',:opled from an original certificate of death duly filed with me as
)~~ Registrar. The origin;ll ccnific,J((.' \vilJ be forwarded tu the SLae YILt! Records Office for permanent filing.
WARNING: "is illegal to duplicate this copy by photostat or photograph.
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Local RegIstrar ---- f tJ.
Fce for this ctnifiGHC, $2.00
527632
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4(;./1/7
,
Date
No.
Hl05,143"-"2IlI7
COMMONWI:ALTH OF PENNSYLVANIA. OEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
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