HomeMy WebLinkAbout01-18-07
PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF C" .,11-> e,lo,-, r~
COUNTY, PENNSYLVANIA
Estate of
also known as
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File Number
dl-07 - OCJ..rLS
, Deceased
Social Security Number
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Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE 'A' or 'B' BELOW:)
o A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is / are the
last Will of the Decedent dated and codicil(s) dated
named in the
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Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution ofihtFl~meni(!l:) offered~'
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for probate, was not the victim of a killing and was never adjudicated an incapacitated person: ... , :n
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(State relevant circumstances, e.g., renunciation, death of executor, etc.)
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IT B. Grant of Letters of Administration
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(If applicable, enter: c.t.a.; d.b.n.c.t.a.; pendente lite; durante absentia; durante ,liiiJoritate)
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Petitioner(s) after a proper search has / have ascertained that Decedent left no Will and was survived by the following sj5()use (if any) mtaheirs: -(If
Administration, c.t.a. or d.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.) . a
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Residence
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(COMPLETE IN ALL CASES:) Attach additiollal sheets ifllecessary.
C. eU "L e rial, c1 County, Pennsylvania with his / her last principal residence at
i5 I) I C H:..d il(:" r(~ d
(List street address, town/city, township, county, state, zip code)
Decedent, then .5~'
years of age, died on
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at
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Decedent at death owned property with estimated values as follows:
(If domiciled in P A) All personal property
(lfnot domiciled in PA) Personal property in Pennsylvania
(lfnot domiciled in PA) Personal property in County
Value of real estate in Pennsylvania
$
$
$
$
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"9 t[e
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situated as follows:
Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant of Letters in the appropriate form to
the undersigned:
Typed or rinted name and residence
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Form RW-02 rev. 10./3.06
Page 10f2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF
The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true and correct to the best of
the knowledge and belief ofPetitioner(s) and that, as personal representative(s) ofthe Decedent, Petitioner(s) will well and truly
administer the estate according to law.
Sworn to or affirnled and subscribed
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Signaturof Personal Representative
Signature of Personal Representative
Signature of Personal Representative
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File Number:
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Estate of
C:-. .,.......,
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, Deceased~;
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Social
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Date of Death:
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AND NOW,
having been presented
are hereby granted to
in the above estate
and that the instrument(s) dated
described in the Petition be admitted to probate and filed of record as the last Will (
Letters
$ J 35 00
'10 ell
FEES
Sh011 Certificate(s) . . . . . . . . $
Renunciation(s) .......... $
JCP ... $
~1u $
$
$
$
$
$
$
$
TOTAL .............. $
Attomey Signature:
;000
SOd
Attomey Name:
Supreme Court J.D. No.:
Address:
Telephone:
Form RW-02 rev. 10.13.06
Page 2 of2
H105.112 REV. 1/05
(FEE FOR THIS
CERTIFICATE 86.00)
WARNING: IT IS ILLEGAL TO ALTER TUIS COpy OR
TO DUPLICATE BY PHOTOSTAT OR PHOTOGRAPH.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF HEALTH VITAL RECORDS
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
CERT. NO. T 6106401
December 27, 2006
Date of Issue of This Certificatfon
Sex
Name of Decedent
Male
Lynn
S.
Dum
Rrst
Middle
Last
182 - 40 - 9032
Social Security No.
Dec. 21, 2006
Date of Death
Date of Birth Dec. 21,1948
Birthplace
Harrisburg, PA
Place of Death
Mother's Home
Perry
Spring Twp.
Pennsylvania
Facility Name
COLinty
City. Borough or T::wnship
Race
White
O t' Business
ccupalon
. Decedent's
Marr led M 'I' Add
allng ress
Teacher
Armed Forces? (Yes or No)
1521 Main Street Mechanicsburg
No
Marital Status
PA 17055
Number
StreEit
Cit'i or Town
State
JoAnn F. Dum
Informant
Name and Address of
Funeral Establishment
Funeral Director
James F. Nickel
Nickel Funeral Home, P.O. Box 910, Loysville, PA 17047
(b)
Type II DM
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Part I:
Immediate Cause
Cardiopulmonary arrest
Interval Between
Onset and Death
(a)
(c)
Morbid obesity
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Part II:
(d)
Other Significant Conditions
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Describe how injury occUrre(.i\:;:! .
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Manner of Death
Natural ~
Accident 0
Suicide
Homicide
Pending Investigation
Could not be Determined
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Name and Title of Certifier
Albert B. Knouse Jr.
M.D.
(M.D., D,O" Coroner. M.E.)
Address
46 Red Hill Court, Newport, PA 17074
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~ to
d:; /)I!>/;'U a _ ~'---' 50-455
~aJ RegIstrar of Vllal Records Dlstnrt No
December 25, 2006 101 Barnett St., New Bloomfield, PA 17068
DatF~ Rerelvprj hV IJlC;al Reglstreu
Stmet ,A,(!(jress
CltV. Borough. T:Jwnsh~r