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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
. y'nM 1M) Ai!:;" '
Plaintiff
FILENO. Ol",-!I)/A! l!iillL20~ I~
IN DIVORCE
VS.
Defendant
NOTICE TO RESUME PRIOR SURNAME
Notice is hereby given that the Plaintiff/Defendant in the above matter, having
been granted a Final Decree in Divorce on the day of
hereby elects to resume the prior surname of -fi'~~-rL, ,
and gives this written notice pursuant to the provisions of 54 P .S. 704.
DATE: """/.;;'-1/0"
, .d
~h)-'l,.~).d'T"
gnatur of name ng resumed
COMMONWEALTH OF PENNSYLVANIA
SS.
day of r; brut1.[f
Notary Public, personally appeared the above affiant known to me to be the person whose name
COUNTY OF CUMBERLAND
"'Wi.!
On the {J. e[
, 20~, before me, a
is subscribed to the within document and acknowledged that he/she executed the foregoing for the
purpose therein contained.
~:;m'" Wh"w; ,~" ~="'o ~ mL;';;iJ !#d
fRlI1MOl.urMlY, NOTARY PU8UC Notary lic
CAIIUSI.E CUII8Mil COUN1Y COURTHOllSE
MY~iXP1RESJANIWlY 4,2010
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WEST VIRGINIA DEPARTMENT OF HEALTH & HUMAN RESOURCES
BUREAU FOR PUBLIC HEALTH. VITAL REGISTRATION
PHYSICIANS I MEDICAL EXAMINER'S CERTIFICATE OF DEATH
ROOM 165, 350 CAPITOL STREET, CHARLESTON, WV 25301
TYPE/PRINT
.
PEFltMNEIiT
8UCKINI(
STATE FilE NUMBER
1 DECEDENTS NAME {FItst, Micir*. Lastl
1 sex
~
':"
HOSPITAL
DlnpahtnT
o ERIQvtp.ollllnl
M
2, OATEOF DE....Tl-l/Martf>. Oar, 1'_1
$"-,)$"';1003
JUNIOR FIKE
4 $()(;W. SECURITY NUMBER
217-40-7027
5a M:3.E-\...aSlBirlMay
I'~I
58
5b UNDER 1 YEAR
"""'~ """
.....
6 DATE OF BlRTl-IIMonlh,
Day,rOOfJ
NOV.1 1944
Cl
01"'" (Spec'trJ
9d COUNTY OF OEAH.
-(!,~r'~()""
12b KIND OF BUSINESSilNDUSTRY
SYLVIA FORSYTHE
DRIVER
ATIONAL FRUIT COMPANY
i
5
~""q
13c CITY, TOWN. OFllOCAllON
13d STREET AND NUMBER
JEFFERSON
KEARNEYSVILLE
RT.1
BOX 362
NO 25430
17 FATHER5N"'ME IFlISl, MIdOIe. Last!
WESLEY A, FIKE
14 WAS DECEDENT OF HISPANIC OFIlGIN'
~$pe(:ity Iio ()I' '1"s-ll yes, s.oec~y Cul>an,
Me..c",n,Pu<>floR>clOn,eICl}(-lNo aves
"""'"
IS AACE "menCS" 1...:1.."
8Iack,Whote...lc
(Spocdy)
\9;" lNFOOI.MIi1'S N....ME (T-,pe/PrinlJ
SYLVIA FIKE
WH ITE
16 OECEDt;NTSEOUCATlQN
($poc"yC>'1lyhlgf>esrgrndeClPlPlelefJ!
Eleme"I~'y,'Sec'.>r<I<<<~ \0 \2\ r..<.>ll<'9l' 1'-4 Of 5
1"'11 168
1% MAILING ADDRESS /511_ ~ N~ or l'ltIal Roole N1ftlbe'_ Dry or To..n Sfal", Zip Code!
RT _ 1
BOX 362
KEARNEYSVILLE
WV
25430
C}t au,,,,1 0 C'ematlOn ~emoval horn Sl~te
Dc.ooatooo o OlherfSpeclfyJ
21 StGNATt!RE OF FUNERAl SERVtCE LICENSEE OR
PERSON ACTtNG AS. SlJCl-I
C;) aJuJ 7n. J3 /l /W.HI...
20b PLACE Of OtSPOSITION (/WJml! at eemeff!rY. e,_or,!, 01'
Olt>er~e!
20c lOCATlON-G,t, 0' T"""" ~tat".
SHENANDOAH MEMORIAL PARK WINCHESTER, VIRGINIA
n NAME AND ADDRESS OF FACILITY
BROWN FUNERAL HOME,327 W,KING ST.
PO BOX 82 MAR IN B
23<1 To l.....oost ')1 my knowll!'dge rleallloee""edat I~ 1__. Ullc,<lndpace stilted
tJ(!I 36
M
Stgnafr.nJ1t>dlil!e....
25 DATE PRONOUNCED DEAD (Morn/l. Day, Year J
~i?5'"- P2PCl3
~ASE REFERRED TOMEDfCAl E~AMIN(R'C(ll'lONHP
~nol
.,4 TIME OF DEATH
27 PART t Ente' tile doseases, 1/1)1.1'"", or c~lCat""'5 that ca~<l 1M <leall> Do not ~",te' IIle mode 01 dy,"9_ SUCh as ca'd"", 0' ,esp,ato,y
a.~s\.sl>ocl<.Of~arttadureLJSlootyonecauseoneacht"lf-'
IMMEDIATE CAUSE tFinal
!t$e"'leOf cOfldillon
result,ooon QeatM
-
/lyfe,,)ov 5<...(..ror!,'c..
DUE TO lOR AS A CONSEOUENCE OF\
COvd/o t/tllC-ul""
.P/Ht;)e
!l.pDt<:wm.,te1nt,,'val
/Bet.....,..nOrl....liI""
,0,,<1-11>
I
I
I
I
I
I
I
I
I
I
SeQ"""ti;lltytistcondi/a:los.
~~,leadingto,n"nedlate
cause Ent<!<\JNQEflCtlNG
CAUSE,(Disease or i.....,y
Ihalirilhalede....",ls
resu/ting '" dealh) lAST
,
DUE TO (OR AS" CONSEOUfN(;€ OFt
DUE TO (OR AS A CONSEOUe.NCf.OF\
,
PARTttQ!!!t!:~~Conl,lbut'''9toOealhbulnol.-esutl'''9intheundertVKY,jca<lsegi'''ll'",Pa'11
28a WAS AN AUTOPSY
P€RFQRMEtP
(Yes or no!
28b MRE AUTOPSY FINDINGS
AVAtlAalE PRIOR TO
COMPLUtON Ol' C.,.U5E
OfOEATI1?(Yes 01 no!
NO
29 MANNER OF DEATH
~tur"t
o AcCoknt
Ds.ncode
o Homocode
31a CERTtFtER
/C/'lecl<onI)I
~I
Xla DATE OF tNJURY
IMcnth.Day.YewJ
3Jb TtlolEQf
tNJURY
Xle ltuJRY /01 WORK?
(Yes or No!
Xk:J DESCRIBE HOW tt..uURY OCCURRED
0"'-
tn~SllQat"'"
M
3Je PLACE OF INJURY - AthOrne,la"" ~'''''\,IaC.\ofy_otloc..
build'''9.etclSpt1cJlyl
3OIlOCATIQN ISlre"t ,,'Xl Numt><>r Of P ,,~; Route f'.\.Jmt>er (::.tv or Town. Sl..tel
Oc.::.UklflOtbe
Determined
o t,EffitFYtNG PHYSICIAN IPhys=an cerflll""fJ cawe 01 death..net! anolhet fJhySJclWl has prono..-lCeC de"lh at'Jd ~'ed Ilem 231
TOlhebestol~"-<'OHIe<:lge.de"lh<>cc""edd<Jelothec:aL<S~'I"rxlmannerasstat"d
o PRONOUNCING AND CERTtFYtNG PHYSICIAN (~iat> both p1Of1O<IIC""J 0e3lh and cerl"v"'9 10 cause ~ ()eatll)
TQthe~$la!""'~"""""<lge.clI!alhOCC\J"edat the t,,,,,-,.datl!. ancrplace, anddu'-'to the C''',scts) arxl rilan..,., dS stalea
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[j?"'~eXAMtNeRICORONER
On the basIS ot eAarrnnalOOO andlor Inoestogat>on. ,n rill' Oll"'IOI1. Oe,lth OCC\J"ed at the 1,111". <late. a",i place a"<l nu.. 10 the causel~1 a"<l manne, d' ,Taled
]lc DATE StGNED/MontI>. Day, Year!
fl/,'
S;,}.J'-o3
w, fA. .2sv. ()
J4 DATE FllEDlMonII>, Oar. y....!
./ 003
Form V$-OO2 (Rev. 6/92)
ST ATE COpy
I hereby certify that the above is a true photographic
copy of a record filed with the Vital Registration Office,
Bureau for Public Health, Charleston, West Virginia.
Witness my hand and seal this second day of
J~"2003'~
Gary L. Thompson, State Registrar