HomeMy WebLinkAbout08-17-05
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This is to certify that the information here given is correctly copied fran: an original cer~ificate of death dU~t filed with me as
Local Registrar. The original certificate will be forwarded to the State VItal Records OffICe for permanent fIlmg.
. .
WARNING: It is illegal to duplicate this copy by photostat or photograph.
1 1 '-. .... ., ',r,
~u~~-;'r)~j>)~
No.
tkn-I"~~
Local Registrar
Fee for this certificate, $6.00
P
I
JUN 20 Z005
Date
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STATE FILE NUMBER
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)143 Rev. 2187
~\--05--013\
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
',)
..r:-
NAME OF DECEDENT (Fir.t, Middle, La.t)
I.
AGE (Last Bmhday)
y,.,
SEX
2. Female
BIRTHPLACE (City and P T t
Slate or Foreign Country) N'OSPfTAl:
Mars, PA ,,,,,,,.., 0
~ h.
FACILITY NAME (If not Institution, give street and number)
h k nl
in
8b, Cumber land
DECEDENT'S USUAL OCCUPATION
(~\I~~~~~ ~~.u~~~r:.)t
8..Lemoyne Bora
KIND OF BUSiNESS {INDUSTRY
Essex House
AS DECEDENT EVER IN
U.S. ARMED FORCES?
Va.O NaG}
SOCIAL SECURITY NUMBER
3. 210 - 20 - 6879
DATE OF DEATH (Month, Day. Vear)
4, June 17 2005
5. 88
COUNTY OF DEATH
ERIOulp8tienl 0
DCA 0
R.........El :=." 0
RACE. American Indian. Bla<;.k, WhIte. et
(Specify)
10. Hhi te
SURVIVING SPOUSE
(If Wife. gl'll'. maiden nama)
u.. Homemaker 11 .
DECEDENT'S MAILING ADDRESS (Street, CilylTown, State, Zip Code)
20 N. 12th Street
II. Lema ne PA 17043
FATHER'S NAME (First. Middle, Last)
18.
INFORMANT'S NAME (Type/Prinl)
20.,
METHOD OF DISPOSITION
Donation 0 Burial 0 Cremalion ~emoval from State 0
. 21.. Other (Specify)
. SIGNATURE OF FUNE SERVICE L1C
MARITAL STATUS. Married,
Never Married, WkiowlKl,
DivorCed (Specify)
14,
IS,
DECEDENT'S
ACTUAL
RESIDENCE
(See instructions
on other side)
17b. Countv Cumber land
Did
decedent
live in a
township?
17e. 0 Yes, decedent lived in
twp.
17d.8 ~':h::t~7~~i~Of
cily/bol'o.
Leo F. Luciano
DATE OF DISPOSITION
(Month, Day, Vear)
6-19-05
2~~ENsDlu~'~5_L
e.
Cf\VI:\~c. ~CSl./V
DUE (OR AS A CONSEQUENCE OF):
28.
: Approximate
I int8fVsl between
: 005et and death
PART II:
Other significant conditions contributing to death. but
not resulting in the underlying cause given in PART l.
27. PART I: Entaor Ih. dla......lnJur'-. or complication. which cau..d lhe d.ad'l. Do nolanler the mode 0 ylng. ....Ch .. ~rdl.c or reapiratory arr.at, .hock or h.art tallura.
LJal on/rOIN c.u.. on 'Kh 1m..
Sequentially Ust conditions ! b.
it any. leading to immediate
cause. Enter UNDERLYING
CAUSE (Dise..e or Injury c.
that initiated events
resulting on death) LAST d.
WAS AN AUTOPSV WERE AUTOPSV FINDINGS
PERFORMED? AVAtLABLE PRIOR TO
COMPLETION OF CAUSE
OF DEATH?
DUE 0 (OR AS A CONSEQUENCE OF):
DUE 0 (OR AS A CONSEQUENCE OF).
MANNER OF DEATH
Suicide
I.W'
o
o
DATE OF INJURY
(Month. Day, Year)
TIME OF INJURY
INJURV AT WORK? DESCRIBE HOW INJURY OCCURRED.
Natural
Accident
Homicide
o
o
o
30.. 3Ob. M.
PLACE OF INJURY. At home, farm. street. factory, offK:8
truiJdiflg, .Ie, (Specify)
308.
H/~I/I/I
Ves 0 No 0
30., 30d.
LOCATION (Street, CilylTown, Slale)
301.
Ves 0 No rg
VesO
NoD
Pending Investigation
Could not be determined
2". 28b.
CERTIFIER (Checl< only 0fl0)
.~~~~F~~fJ::'~1:;:'~~J:S~~:~h c:~'tl;:'~a~~: te:: r~:~.~~:~(:r~~3';-g~X~iza~. h:~r~~~.~~~~~ .~~~~. ~~~ .~~~~~~.~.I~~.~ .~~.)..................
29.
.P-rO~~~~.~I:'Gm~~~;':=.~':.':t:~~~~:: ~~~~:i~~n.~d~r:d;I~~~.d:~~h d~~ t~~Z~:ut~e~'~)~~~ ~:~~.r a. .tated. ... ........... ....... 0
'MEDICAL EXAMINER/CORONER
On the b..I. of examination and/or Inve.tlgatlon, In my opinion. death occurred at the time. date, and place, and due to the caun.C') and
manner a. .tated..............................,.....................,...........................................,............................... ............................ 0
31..
34.
COMMONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INOIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
LUCIANO LEO F JR
PO BOX 9
SHERMANSDALE, PA 17090
_u__h_ fold
ESTATE INFORMATION: SSN: 210-20-6879
FILE NUMBER: 2105-0731
DECEDENT NAME: LUCIANO IV A M
DATE OF PAYMENT: 08/17/2005
POSTMARK DATE: 08/16/2005
COUNTY: CUMBERLAND
DATE OF DEATH: 06/17/2005
NO. CD 005696
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $10,527.47
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TOTAL AMOUNT PAID:
REMARKS:
CHECK# 6526
SEAL
INITIALS: JA
RECEIVED BY:
REGISTER OF WILLS
$10,527.47
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS