IN THE COURT OF COMMON PLEAS OF LEHIGH COUNTY, PENNSYLVANIA

CIVIL DIVISION

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Plaintiff	:
vs.	:	File No.
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Defendant	:

NOTICE TO RESUME PRIOR SURNAME

Notice is hereby given that the Petitioner in the above matter is a SURVIVING SPOUSE, as evidenced by the attached certificate of death, and hereby elects to resume the prior surname of , and hereby gives this written notice pursuant to the provisions of 54 P.S. § 704.1.

Date:	Signature

Signature of Resumed Name

COMMONWEALTH OF PENNSYLVANIA)

) SS.

COUNTY OF LEHIGH	)

On the	day of	,	, before me, a Notary Public, personally appeared the above affiant known to me to be the person whose name is subscribed to the within document and acknowledged that he / she executed the foregoing for the purpose therein contained.

In Witness Whereof, I have hereunto set my hand and official seal.

Notary Public

(Rev.0708)

IN THE COURT OF COMMON PLEAS OF _______________ COUNTY, PENNSYLVANIA

DORIS A. GLAESSMANN

2009-03-23

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