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Home My WebLink About03-09-06 IlIO'XO' REV 1/05 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. Fee for this certificate, $6.00 No. ~a~g~ p 12226503 FEB 2 8 2006 Date rrEM 4# 7 SHOULD- READ ASFGLLOWS~ t:lf"^~.~....~.~......~.....~...l.. .~ . 7)_..~m.. . . -.. UA'th?1 /7J .~~~ -. - Cry (.p', ; Rev. 01100 >RINT IN IANENT CKINK 1 Name 01 Decedent (First, middle, Iasl) 1-/ e Ie- Vl 5 Age (Last b,nhday) COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH STAiE FILE NUMBER :. Dale of Birth Monlh, da , ear B. Birth lace ancl stale Of br Other o ERIOuI lient 0 DOA Nursin Home 0 Residence 0 Other- 9. rSN~~~enV~~ (1~~:s~~~f~6uban, Mexican, Puerto Rican, elc.) 507 16 3904 3. Social Security Nurrber 85 Yrs 12,1920 Macon,Missouri Bd. Facility Name (II not instrtulion, give street and nurroer) Cumberland Camp Hill Care Health Center 11. Decedent's Usual Occ ahon Kind 01 wor\l: done durin roost 01 workin life; do not slale retired scho~;io1T~acher East p~~~;~~~ry T\ 16 Decedent's Mailing Address (Slreet, city"own, slate, zip code) 1905 Dickinson Avenue Camp Hill, Pa 17011 12. Was Decedenl ever in the US Armed Forces? DYes l) No Decedenfs Actual Residence 17a. Slale 13. Decedent's Education S eci ElemenlarylSecondary (0-12) on hi hesl rade co Ieled 5+ College (1-4 or 5+) Did Decedent Live ina Township? '4 Maf~al Status: Married, Never married, Wpowed, DMlrced (Specif'/) Dlvorced 15. Surviving Spouse (II wife. give maiden name) 17b. Counly Pa Cumberland 17C. 0 Yes DecedentUved in 17d. d< No, Decedent LiveO within Actual Limijsof T." Camp Hill CityiBoro 18. Father's Name (First. middle. last) 19 Mother's Name (First, nlddle, maiden 5Ufl'lame) Edgar Burkhart 2Oa. Informanrs Name (Type/prinl) Eva Wilson 2Ob. Informant's Mailing Address (Street. cityt1own. state. zip code) Elizabeth Stelzer 10 Cromwell Court Mechanicsburg,Pa 17050 o Donation 21c. Place of Disposnion (Name of cemetery, cremaloty or other place) 21d. location (C~"own, slale, zip code) 231. To the best of my knowledge, death occurred at (he lime, dale and place stated. (Signalure and I~\e) Hollinger Crematory Mt Holly Springs,Pa 22c, Name end Address 01 Facilily 1903 Marke t S tree t Myers~Harner Funeral Home Inc Cam Hill Pa 17011 23b. License Number 23c. Date Signed (Month, day, year) 24 Time of Dealh 25. Date Pronounced Dead (Monlh, day, year) 26. Was Case Referred 10 a Medical ExaminerlCoroner? ~D No so' /~A M. CAUSE OF DEATH (See Instructions.nd ex.mpIes) lIem 27. Part I: Enler the ~ ~ diseases. injuries, or corrplications - that directly caused the death. DO NOT enler terminal events such as cardiac arrest, respiralory alTes\, or ventri:ular fibrillalion wrthoul showilg lhe etio1ogy. DO NOT abbreviate. Enter only one cause on a line IMMEOIATE CAU5.E (F;naldlsoaseor ^C-, ,\ - ""t'" cc y- \ ~"'\ ',-~ "c"v-c,\-i 011 corxt~lOn resulting In dealh) -7 a ~y.]J;,'; ~ ~ "<:' . -l- r ' r- Oue t90 (or as a consequence 0: ,A ~ _ '" Sequen1mIy1is1condilions,;lany, b, ( 'Cr(,,\,I')GlI'4 !.1("'II:V'i u, ~eC, S~ _ :~~h~o ~~eD~~~:~~c~u~~e a Due to (or as a consequenci on. . (disease or injury thaI inrtsaled the events resulting in death) LAST. ~proximale inlerval onsello death Part It: Enler other sianific:anl cond~ions conlribulinlllo death bul not resulting in the underlying cause given in Part I 28, Did Tobacco Use Conlrbute 10 Death? DYes LI Probably o No 0 Unknown Oe 1?'1 r n h c, He ~l"r1d Azo'~cl?\;c... 29 It Female o Not pregnanl within pasl year o Pregnant al time 01 death o Not pregnant, but pregnanl within 42 days 01 death LI Not pregnant, but pregnant 43 days 10 1 year beloredea!h o Unknown if pregnant within the past year 32c, Place 01 Injury: Home, Farm, Slreel, Factory, Office Building, etc. (Specif'/) Due to (or as a consequence oij' . o Yes "-NO d 30b Were Autopsy Findings Available Priol to Col'll'lelion of Cause of Death? DYes 0 No 31. Manner 01 Dealh XNaturar 0 Horricide o Accident 0 Pending Investigation D Suicide Cl Could Nol Be Determined 323. Date of Injury (Month, day, year) 32b. Descrbe how Injury Occurred: 3Oa_ Was an Autopsy Performed'/ 329. Injury at Work? 32f If Transportation Injury (SpeciM DYes 0 No 0 Driver~erator 0 Passenger M 0 Pedestrian 0 Other - Speedy: 33a, Certifier (check only one) 33b_(1S','lll1aIUre end Tille o~r 111, ( Certifying physician (Physician certifying cause of dealhWhen another physician has pronounced dealh and cofTllleted Item 23) _ r " To the besl of my knowledge. death occurred due to the cause(s) and manner as staled ..... ... ..,......"................... ... .... ...m... ........,,"'0 Pronouncing and certifyIng physician (Physician both pronouncing death and certifying \0 cause 01 death) 33C. license NurTtJer 33d. Date Signed (Month. day. year) :~:a~:::/~:::ge.deathocCUrredallhetime.date.andPlace.andduetothC! cause(s) and manl\C!tas stated... ..................0 OS ODttO <('1-L- d - '1- 01..0 On the! basis of examination and/or Investigation, in my opinion, death occurred at the time, date, and place, and due to Ihe cause(s) and manner as stated. ....,,0 34_ Name and Mdress 01 Person Who CofTllleted Cause of Dealh (nem 27) TypelPrinl 35. Rego"ar'sS;gnalureandD;s,,<tNurrller 36. Dale F;led (Mon1h,day, year) {h;c hc..€ i SC\ rY'I5j ~. q~, -< ,/ ~ /' '/ 3'0,'-14 tJ p(O~Vl"H F}V(. I I l""fl 1......1 Of /y /,,~ It.r".;:::.:bi..W' /\ nllo (See instructions and examples on reverse) 32d. Time 01 Injury 32g:. Location (Slreet cityl1own, slate) STONE LAFAVER & SHEKLETSKI ATTORNEYS AT LAW DAVID H. STONE GERALD J. SHEKLETSKI ELIZABETH B. STONE 414 BRIDGE STREET POST OFFICE BOX E NEW CUMBERLAND. PA 17070 www.stonelaw.net OF COUNSEL CHARLES H. STONE JON F. LAFAVER March 8, 2006 TELEPHONE (717) 774-7435 FACSIMILE (717) 774-3869 Cumberland County Register of Wills Cumberland County Courthouse 1 Courthouse Square Carlisle, P A 17013 RE: Estate of Helen Haratine a/k/a Helen E. Haratine File No. 2006-00180 PA No. 21-06-0180 Greetings: On February 27,2006, our office filed a Petition for Probate and Grant of Letter, an Estate Information Sheet, and a Death Certificate for the above-referenced estate matter. Please be advised that the decedent's date of birth was incorrect on the Death Certificate and thus on our Estate Information Sheet as well. The correct date of birth is Apri12, 1920. We are therefore enclosing a corrected Death Certificate for your records and kindly request that your office make all necessary changes to the estate file. Should you have any questions or concerns please feel free to contact our office. Very truly yours, STONE LAF AVER & SHEKLETSKI ~-') /'\L C__. ..... DavidH. Stone DHS/kk Enclosure cc: Timothy J. Haratine, Co-Executor Elizabeth L. Stelzer, Co-Executor c; S : i i