HomeMy WebLinkAbout05-18-06
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
AHRENS THOMAS J ESQUIRE
5521 CARLISLE PIKE
MECHANICSBURG, PA 17050
___nn_ fold
ESTATE INFORMATION: SSN: 191-26-6752
FILE NUMBER: 2106-0429
DECEDENT NAME: HERSHEY JOHN 0
DATE OF PAYMENT: 05/18/2006
POSTMARK DATE: 05/17/2006
COUNTY: CUMBERLAND
DATE OF DEATH: 02/20/2006
NO. CD 006716
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $1,000.00
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TOTAL AMOUNT PAID:
$1,000.00
REMARKS:
CHECK# 01-1032
SEAL
INITIALS: JA
RECEIVED BY:
REGISTER OF WILLS-
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
HI 0' .SO'i REV I/O'
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.
No.
Aor Qfl/Lweu,
Local Registrar
Fee for this certificate, $6.00
p
12478203
a 0./3-' OttJ
Date
YIS
7 Oat. 01 Bvth Month, da , ea'
HIOS IOR....OI.\l6
TYPEMlINT IN
PEAIlANfNT
BLACK INK
I Name ot ll<<edonI (F.sI, _Ie, Iasl)
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIACATE OF DEATH STATE FILE NlAoIBER
0-'
JOHN O. HERSHEY
s IvJe ILasl borlhday)
90
20
lib County 01 O..m
Dauphin
Harrisburg
whitp
" 11 Decedenl's Usual Occ lion KIOO of wo,t. dOne dUf mosl of WOfk kte: do noI slate retired
KM 01 Work Kind 01 BuswlessAnduslry
ExecutivE" Milton Hprshp:y Sch.
~ 16 Decedenl's Mailing Addfess (Street cdyJlown, slale. lip code)
13 ll<<edenI's Educa","
EIemenIaty&condary (I} 12)
12
ado""
CoIeQe (I'" I> ~.)
5+
104 Maliwl SlaIU$ Marned. Never marned.
W_. llMlrced (SpeaIy)
marrJpd
15 Survrvllg Spouse (If wie. gIVe maWkn name)
77 5 Oak Oval
Mechanic~burg. PA 17055
17, Slate
}>~T\na .
~:. ~-.. 17e ~
I""""",.
Yes. OecedefllLNed in .
Mona E. Miller
UppE"r AJlpTI
'"I'
lib. Counly
Cumberl<"l~d
lld 0 No. 0eced00I L"ed WIIOO
AcIual L..... 01
C.yiSorO
18 Fallle,'s Name (F.... _Ie, last)
19. Macher's Nan~ (flrSl. niddIe. maIIen SUfname)
Davi.d H. Hl"rnhp.y
lOa lIllo/manrs N.Jma (Type'pt"J
Mona E. Hernhey
May Foutz
:>II> tn_'s IoIa*'v -"'ISO..t e..,_ sla1e, 14> code)
775 Oak Oval. Mech8nicfiburg. PA 17055
234. To Ih. best 01 n~ knowledve. d.alh oceIM,ed .llhe Ilme, dale and pIac. Slaled IS91alIM. and lOll
21e. 1\Ic. '" O&pusilon (Name 0I~, Clomalofy I> _ place)
o
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U)
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U)
<:
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21a Method ot OisposllOll
o Bur'" XiX C,ema"," 0 Remml.IOO Slale 0 Dona","
o 0IIler - SpoaIy..
22a Signalur8 of Funeral Service licensee tOf person acting as such~
?It) .
HOOVPT F H & Cremator'. Inr..
221:. Namo'nd_...oIfacllly
PA 17112
( .
FD010092-L
oover F H & Cremator . Inc.
23b_ l.J:ense N.....roec
POHox 475. Hershev. PA 17033
23<. Dale Sogned (Month, day. year)
. Items 2..26 roost be COflllIeled by persoo
_ ptonounces dealh
24
/:
26 Was Case Ae....ed 10 . Medo:aJ u.n....lCo<onet"
,S' K f/. Yes 0 No
CAUSE Of IlEA TH (see Insltucllons and examples'
Item 27. Pari I: Enter Ihe ~ - dfieases, Wt;uf1e5. Of COfIl*:alons - IhaI diracit)' caused the dealh_ 00 HOT enter 'efJrm ev nls sl,.Ch as cardiac arfest.
fesprillory Itresl, Of ventriclHilf fibflllallOll WlIhout showIlg the etiology 00 HOT abblevlale. Enlet' only one cause on a IN
IIIIEOIA TE CAUSE (F...I d....se I> ^-^ C-- d . \ L f' ,.,.-, 1.. _
condllJon,....IllJ.lIle.IhJ -7 a.u'_-_"'''-_O_~q..".____~ (io.., __ r--j-__.. ~ ,-Ll"...-.,-
Due, (Of as i-~uence 01)
SequeoIlal'flos1condillOlls,dany. _ _~~ r.QuJ r-t~ S~ ;-C"UUI 13 l ~ n__
iNdllQ to the cause lI5Ied on line a Due ao (Of as a conuqueoce oQ f
. Enllflhe UNOEAL YING CAUSE. rf!.
. (disoaseOlinjurylhalWlilraled the --H-I- n .. rA. ",,,*1..1 u_____
tvenf$ 'esW19 WI <team) LAST 0... 10 (I> as a cJnsequence 01)
: Approx.............. PaI111 U.W _ ........nlcundWns_1odeath.
: onsellD dealh td: nor resulng" the ~ cause gwen In Pall I
3Oa. Was an Autopsy
PetIoIrNd?
3al Descrl>e"""'" Occunell
28 Old TQba(x:o Use ComriJule 10 Dealh?
o Yes 0 Probably
)l. No 0 Umr-.
29 . Female
o Hal Pf8QN~ wih" pa$! year
o Pregnanlll"'" 01 <lealh
o No! ptegna... b\( ptegnanl W1IIm 42 days
oIdealh
o No! ptegnanl, b\( ptegna.. 43 days 10 I Y'"
belore dealh
o U_. ptognanl......1he past Y'"
32c. PiaceollnJllY Home. Farm. Street. factofy-. Clfk:e
~_ etc (SpeaIy)
o Yes Jlf No
d
JOtJ. W..e Autopsy FlIldings
Available Pro 10 ~lebon
01 Cause ~ Oeam?
o Y.s 0 No
31 Manne, of Oealh
~ Natural 0 Honicde
o Acc_ 0 Pending Investigaloln
o Suicid. 0 Could NoI [Ie Oellf_
32a Oal. 0I1n!ur; (MonI1. day, ,...,
32l U,__hpy(SpeaIy)
o on-.QlOf_ 0 Passengeo
o _ 0 0UleI - SpeaIy.
32lI. Loca"," (SO.... cJyilown_ Slale)
32<1. Tmeollnplry
II
t-
Z
w
o
w
U
w
o
LL
o
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33a. Certlfiet (chec1l onI\' one)
Certlfylog physlclan(Physiclall ce<1llylllJ ca.... 01 deaIh when anolhet physicIln has ptDOOUnCed death end """"""ell lem 23)
To IhI ttesl of my knowledge, death occwred due 10 the cause(lt and manner IS lUted..
-log and cetlilylog JIIIlslclan (Plly5ielall boItl ptDOOUnCIllJ dealhand cenifylllJ 10 cause 01 <tealh)
To the _ o' l1li' knowleclue. de.1h occurred II the lime. clote. and place,.... due 10 tile COtISeI"and.......... a, '..,..1...,._____,_______
_aleu_lcllfGt1ef
On the buis of euA1lirYUon oIndJor invesl6galioR. in my opinion, dulh occurred al the limit, d.a&e, and place, and d...1o ltat> eauMCs).and manMf D sbIIed mm___O
3~ RegislJor's 36 Dale Fled (UonIh. day. yeor)
d: c? ~ -0(0
mm__'__m_______________._._..__.O
33D. sv-'r--~ ~
/Z.-I: .
33c License N_
3Jd Dale Sogned (__ day, ,NI)
'1'"1-/ S'2- \ 2- ~ 2- <l - 0 ~
34 N.Jm"nd_essolPefsonWlloCon4>leledCauseolOeaIh(.em}?,~ .1.. i/ {~
1 /7d..f,.f/SVtt-Y- /7t),,,/ .
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