Name of Decea !

Icy Number
L
DA IT ND REPRESENT ION R AR NO EX
STAT! OF Jj -:1,e(2 (PREFERENCE BENEFICIARY AFFIDAVIT)
COUNTY o, ~gL ( N~w } aa.
Before me, the unde~r1lgn authority PfflO_.!lW applared ](}b)
'l)
~*'oL ,q ' who, being by me duly swom, deposed as follows:
1 M name la J-,, O O
r A
• Y
2• 1am
1 • (An'1¥ ' kl)
. an ame)
The followlng lnformatlo on my own personal knowledge.
making this swom statement regarding the next of kin of the Insured ~-).'.J. .,/..LL~
-lb,LL~ -1:..1-1 :d~::'-- -:-- ("Deceased")
' nd understand that The Hartford wlll rely on this etatement aa true and ~ccura e In order
3 1 nd1 nd nd to pay life lnaurance benefit prooeeds.
• " "'tl a agrM that If the Information I provide 11 not true and Th• Hartford
pays 11ft ln1uranct btntflt proceeds based on the
:nforrnatlon that I provide, that I WIii reimburse Th• Hartford for all lift lnsuranc
t benefit procHds that Tht Hartford paid due to the
naocurat, Information I provided, wh1th1r lnttntlonal or unlnt1nt1ona1, lncludlng
4• I also understa btntflt payments made to those I Identified below.
nd that If the Information I provide Is not true, I may bt subject to criminal prosecut
penalty ot talst 1tat1men~ or lnsuranot fraud. ion, peh•111• or fines for perjury,
, .,
5. I have read and understand the IMPORTANT NOTICE regarding fraud on page 2.
6. The Oeceesed's aurvMng next of kin are Identified as follows:
WIDOW or WIDOWER The surviving spouse of the Deceased Is:
NAME ADDRESS
DATE OF BIRTH SOCIAL SECURITY NUMBIR TELEPHONE NUMBER
( )
SON(S) and/or DAUGHTER(S) (Natural or Legally Adopted)
The Deceased left no surviving spouse. The only surviving chlld(ren) (natural or legally adopted) of the Deceased are (LIST ALL CHILDREN
EVEN IF OVER THE AGE OF MAJORITY):

/J L="Vv
r, .,_~AO OR:59 <De_ OA-1}. OF BIRTH (l;CIAL r,UR'TY ~,,,.R
I

, C W1 (') - 27- / 7-at/- 29:f-TEL~;

0 ,E-.2to-
NUMBER
2D3..'":,
.J
( )
( )
(
)
- -
FATHER and/or MOTHER
The Deceased left no surviving spouse or chlld(ren ). The surviving parent(s) of
the Deceased ls/are:
NAME ADDRESS DATE OF BIRTH SOCIAL SECURITY NUMBER TELEPHONE NUMBER
( )

IF ONE PARENT IS DECEASED, PLEASE INDICATE NAME:

DATE OFDEA TH:
BROTHER(S) and/SISTER(S) "SIBLINGS" (Natural or Adoptive)
The Deceased left no surviving spouse, chlld(ren ), parent(s). The only surviving sibllng(s)
of the Decease d ls/are:
NAME ADDRESS DATE OF BIRTH SOCIAL SECURITY NUMBER TELEPHONE NUMBER
( )
( )
------
( )
--.------
EXECUTOR or ADMINISTRATOR (Please provide Probated Estate Papers, If available
The Deceased left no surviving spouse, chlld(ren ), parent(s ), or slbllng(s). The Executor )
or Administrator of the estate of the Deceased Is:
NAME _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ESTATET
AXIDNUMBER _ _ _ _ __.__ _ __
ADCRESS TELEPHONE NUMBER(
NOTARIZATION
I declare under penalty of perjury that the foregoing Is true and cor
N # : J • :'
0,
co Afflant's Signature (Person swearing to this Statement) ---+-~ ,.__L. .3o,-,
co ._..£.. ...\~-b -.u--~ -=-.::. .....::~ ------ •.) ~.-
0
,...
0, '-· \'
.... SWORN TO AND SUBSCRIBED before me this Tt:q"t:,A- ~~,;. ..-:~- --.--- --
Notary Public fud> t' C:.
,
•• -~
-•
,-
Cl
u
Sta e of -ILS M commission ex I es
The Hartford Financial ServlcH Group, Inc,, (NYSE: HIG) operatee through lta eubeldlarle
_,__r _.. .......- r
1 /
"'
,
• - \ .

Company and Hartford Fire Insurance Company, under the brand name, The Hartford®, e, Including ~llilinu i,MllbW tfla«ga trPfd Acoldent1nau~anoe.
and Is headqijlM'Nclit efl\:l rlltfolb"Pl:Ua~ llft!ffmrtl, CT 06155, J=or a~dltlonal
details, pleaae read The Hartford's legal notlce at www.thehartford.com. The Hartford
Insurance Company and Talcott Resolution Life Insurance company (formerly Is the administrator for c!m1 1•sln ess written by Aell'3
known as Hartford ur11.ns,11L~~
and clalm aervlcaa for employer leave of absence programs and aelf-funded dlaablllty pr~alM,PrwJM¥dmlni9rrawe
benefltfl¥,CUMMI~ U ct,. U", ,u,,
LC-7088,188S 24
Page 1 of 2 Oil 20
 ,-...,. rHI~ .,.;;,;.;..WW.:ZA - = ' =• m -
The Dece•••dleftno•ur vlvlng •pouae orchUd(ren). The surviving parent(s) of the Deceased ls/are: 1
•I h11.,:
r NAME ADDRESS DATE OF BIRTH SOCIAL SECURITY NUMBER TELEPHONE NUMBER ':t•
..~,.,•••1
( )
:r\'~:,
( ) :'~1
~- 91 ~1
~-,·" ,1
•'-'••l
DATI! OFDeATH:
IF ONE PARENT IS DECEASED, PLEASE INDICATE NAME:.
BROTHER(S) and/SISTER(S) "SIBLINGS" (Natural or Adoptive)
The Deceased left no surviving spouse, chlld(ren ), parent(s), Toe only surviving slbllng(s) of the Deceased ls/are: TELEPHONE NUMBER
NAME ADDRESS DATE OF BIRTH SOCIAL SECURITY NUMBER
( )
( )
( )
( )

EXECUTOR or ADMINISTRATOR (Please provide Probated Estate Papers, If avallable)

The Deceased left no surviving spouse, chlld(ren), parent(s), or slbllng(s). The Executor or Administrator of the estate of the Deceased Is:
NAME _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ESTATETAXIDNUMBER _ _ _ _ _ __:...._ _ _ __
ADDRESS TELEPHONE NUMBER (- - )- - - - -

NOTARIZATION ,,. A /:21 ?) • 3 :;JJ-:g~

I

I dee/are under penalty of perjury that the foregoing Is true and cor _,___.,__ .,. 'J: 1 . ·\':~,
... A ~. .
Afflant's Signature (Person swearing to this Statement) _ _ _~~b-':....J~-1- :..._-L-\t----:: J.~~.L£~:....:: :.~~------:c.~-
SWORN TO AND SUBSCRIBED before me this ~"'C) day of-----ii~: :==---.---- 202~ :_~r;__ 1:-
' .e., -.>
- -- ...
,
1 otary Printed Name i c-;_ i ..J,J, -- •
Notary PubllccO tC Nk..s =~ 0
M commission ex Ires ~~""'!IE." ......... ·J ~1' --r:. .. C ~l
State of &l'LS----- ") j .,

The Hartford Financial Services Group, lno,, (NYSE: HIG) operates through Its subsidiaries, Including ~ittrlnttnMID Wtf\a~Q~Pf d A"'cek\~nfT't!fur~nQe: ,-
Company and Hartford Fire Insurance Company, under the brand name, The Hartford®, and Is headqijlr\W<fit et\~ t-l~~P"h~ Ci oe1·ss. For ad<:!lllonal
details, please read The. Hartford's legal notice at www.thehartford.com. The Hartford is the administrator for c;Ri~r,.s lness written by A&lhat~ r
Insurance Company and Talcott Resolutfon Life Insurance Company (formerly known as Hartford Llfi f.nSlJt~~ ~~,~IDP ri:~~alKrPrW~d mmis1taflve
and claim services for employer leave of absence programs and self-funded dlsablllty beneflM¥,CuM MI~ UN tct,. U\l, l.Ul.l
LC-7088·1BBS Page 1 of 2 0112024
 Import1nt NoUce • Please read the statement that applies to your state of residence and sign the bottom of the page.
for residents of 1JI states EXCEPT Arizona. Alabama, California, Colorado, Florida, Kentucky. Maine, Maryland, New
Jersey, New Yo~, Ohio, Oklahoma, Oregon, Pennsylvania, Puerto Rico, Tennessee, Virginia and Washington: ,Any .
person who knOwtngly presents a f~lse or fra~dulent claim for payment of 8 loss or benefit or knowingly pres~nts false 1nformat1on
in an application for insurance Is guilty of a cnme and may be subject to fines and confinement in prison.
For Residents of Arizona: For your protection Arizona law requires the following statement to
appear on this ~orm. Any ~erson who knowingly presents a false or fraudulent claim for payment
of 8 loss is subJect to cnmmal and civil penalties.
For Rt1ldtnts of Alabama: ~y pers_on who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
who knoWingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines
or confinement in prison, or any combination thereof.
For Residents of California: For your protection Callfornla law requires the followlng to appear on this form: Any person who
knowingly presents false or fraudulent Information to obtain or amend Insurance coverage or to make a claim for the payment of a
loss Is guflty of a crlfn!l.t)El,{Tiay be subject to fines and confinement In state prison.
For residents of Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an
Insurance_ com~any for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment,
tines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides
false, Incomplete, or mllSleadlng facts or Information to a policyholder or clalmant for the purpose of defrauding or attempting to
defraud the policyholder or claimant with regard to a settlement award payable from Insurance proceeds shall be reported to the
Colorado Division of lnturance Within the Department of Regulatory Agencies.
Fo~ residents of Flortda: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of
claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
For residents of Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a
statement of claim or an application for insurance containing any materially false information or conceals, for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
For residents of Maine, Tennessee, and Washington: It is a crime to knowingly provide false, incomplete or misleading
information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines and
denial of insurance benefits.
For Residents of Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or
benefit and who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement In prison.
For residents of New Jersey: Any person who knowingly files a statement of claim containing any false or misleading
information is subject \o criminal and civil penalties. Any person who includes any false or misleading information on an
application for insurance policy is subject to criminal and civil penalties.
For residents of Ohio: Any person who, with intent to defraud or knowing he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
For residents of Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer,
makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a
felony.
For residents of Oregon: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto that the insurer relied upon is subject to a denial and/or reduction in
insurance benefits and may be subject to any civil penalties available.
For residents of Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person
files an application for insurance or statement of claim containing any materially false information or conceals for the purpose
of misleading, information concerning any fact material hereto commits a fraudulent insurance act, which is a crime and
subjects such person to criminal and civil penalties.
For residents of Puerto Rico: Any person who knowingly and wtth the intention of defrauding presents false information in an
insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any
other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be
sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars
($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present,
the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be
reth!·Cjd to a minimum of two (2) years .
. - '.Il- .f,1lr~sldents
. ',I'

of Virginia: Any person who, with the intent to def~aud or knowing that he is_facilitating a fraud against an insurer,
submits an application or files a claim containing a false or deceptive statement may have violated the state law.
)

1-0/t,sldents of New York: Any person who knowingly and with Intent to defraud any Insurance company or other person files
)
l
.- --~
' - an __appllcatlQ!I for Insurance or statement of claim containing any m~terlally false information, or conceals for the purpose of
·,
r-tfl.sle~~g, _lAformation concerni!Jg aJJY ~ct mate ial thereto, commits a fraudulent insurance act, which is a crime, and shall also
·bt-S~t,ject. td a-c)vil penalty o,t 19 e eed fi ho nd dollars and the stated value of the claim for each such violation.
1

/,, :-.This_ ,-: ,;._ thi • te to the best of my knowledge and belief.

Lf19--).i Date
Page 2 of 2 01/2024
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C.Ufylng l'hyalclan lalMl1tan Hoaplce I Ewa Drift lulll 100, NJ OIOl3~101
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ll!.!-----fl~~.-. 81.DlonlNo. ,11,0111~- IOUOl)N...lllr
~/Mi&f,,/i C-- VOMI 1 01/19/2010, 112°"4

Issued In Mount Holly Township

Burlington County
Katl,/een D. Hoffman, Registrar
January 29, 2010 •

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This is to certify that the above is correctly copied
from a record on file in my office.
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Certified copy not valid unless the raised
Great Seal of the State of New Jersey
or the seal of the Issuing municipality Jose h A Komosinski, State Registrar
or county, is affixed hereon. Bureau of Vital Statistics
,
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,c_,..J, ____~THIS DOCUMENT IJAS MULTIPLE SECURITY FEATURES TO DETER /?RAlJD,: VOID.ffALTEREDrJ • :·---
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80003:99301 Q,
NEW .1i;AAl'V ni::l>aDTu.,.... n~ up . . . . . . ··- - - ···- - - - - · ___ _ • '· BOOO3? 9 3 Q1 {), , ~
NEW JERSEY DEPARTMENT OF HEALTH AND SENIOR SERVICES ITATI PILli NUMBEft
CERTIFICATE' OF DEATH 20100002&18
••• L...,N...... _ _ _ ,..__ I
Julia CoffN LIMB
.1b, Aleo Known M (AKA). Ir Arr, Mddll, Leet. SidllJIJ
r ONLY

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4a.Age 5. 01111 of Blr1h (Mo,()lymj i l ,f-- ;{Y, 9' \
Female I 203-14-8281 1 84 Years , 01/01/1928 r;:·· / (t;·
6. Blrthplac. (C'I>' & SIMIFawlg,t~Cou~
l\j; Phlladelphla, PA
t,Ul; \I
7a. R ~ ,Tb. Col.lily • , \7c. Munlctpally·/C·ly., . ,
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NJ Burlington Delran Tovmahlp \I_\~'./{,
7d. street Ind Number • I'
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\ 7e. Apt No. \ 7f. Zlp. C6de 17g. lnskte City Umltl?
59 Stoneham Drive ,, 08075 • , 'Yn , l'. •.1\\l
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a.;.;:r In US Armed Forcet? \Sb. If Yff, Name of war. •. v1:::-.J.'•'.·,,\• I,._.
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11. Fathe(a Name lFtlC. Mlddle, u,o
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l ',1,\,,1,\,i ,,3c;'\Ma!lfng Addreaa (S""' and Numb«, Cly, SIie., Zip Code)
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14. Method or Dlapotltlon 15. Place otOtspoalllon c,,a,ne otcemetay, cnlffllby, 18. Location- City & State/Foreign Comtry /)11

, Burial Forest HIiis Cemetery 1

Huntlndon Valley, PA US ,._t' /, ·,;.
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Not Spanish / Hl1panlc I
. i%,High school gra~uate or GED completed White
Latino
,' / 23. 0_9.cupation of D.c:ede
__- !'It (fype o f ~ ~ - fflOllt ollfe, even I reltecf T24. Kind of Bulln11lllndustry
,,,, Custod11I Aide ;;? • I Publlc Education
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; 2!5. N•me:and ~dd;,ii.-o f ~ Emptoy,r
.· 1 City ,9f Phhdelphll School Dlstrtct. Phlldtlphll, PA
~ -· - - - -

;;.,28. Op'F'ronou~ Dead (MQOl}'Mj 28. Name ct Ptl90n Prono111clng OHlh

\ ,..0,111412010 autria 'fulian
, •27,-T!Jne Pronou~ed Dead (24.,,, 29. Llclnte Number 30. 0119 89\ed (Mo.Ol)IM)
: _1836 • • 28NO11317200 I 01/1412010
31. Date or Oelth (MoK»y!Yr) 32. Time ot Death (24•"' 33. W11 Medical Examiner Contacad? ,34. Place ol Death
'
01,11~010 .., ' ' 1 '1535 I No Hospice Faclllty
361. Facllly Nam,,, (ff pot ln•Mutlon. Qlw mNf and mnnlJe,j
,, ' Samaritan Ho• Ice , . '
e.,unlclpa,lly , ' , ' ' •1 1 :' 36c. Courty
Mount Ho'lly Townthlp__ - - - ~ - - ' - - - - • Burlington
-,,- • · 1•a. PART I - IMM-EOIATE CAUSE -~flnal dllu• or condllon r11u~ In dNth. 8~r'ttt lat concltlora, "any, lead~ lo 1
ic.AUSE OF DEATH: 1hl c.ute Iliad on Line 1. Enllr the UNDERlYINO CAUSE (dll•• or lri~ that lrihtld tha evtl"D rttullng In deal\) lAST.
"T.
 NEW JERSEY DEPARTMENT OF HEALTH AND IENIOR IIIMCU ifAff pg Alii@K
CERTIFICAle OF DEAllf 20100002111
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0111912010 1120H4

Issued In Mou11t Holly Township

Burlington County
Kathleen D. Hoffman, Reglst,:qr
Ja11uary 29, 2010

This is to certify that the above is correctly copied

from a record on file in my office.
Certified 'copy not valld unless the raised
Great Seal of the State of New Jersey
or the seal of the Issuing municipality
or county, is affixed hereon.