HomeMy WebLinkAbout01-31-07
REGISTER OF WILLS OF
PETITION FOR PROBATE AND GRANT OF LETTERS
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COUNTY, PENNSYLVANIA
Estate of
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, Deceased
File Number dJ /O{)o'i . QOCJS
Social Security Number 2 t.f if-V 2- 2() 2 :1
also known as
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE 'A' or 'B' BELOW:)
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D 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
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(State relevant circumstances, e.g., renunciation, death of executor. etc)
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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 oft~!l.'.iPstrumen~ offered
for probate, was not the victim of a killing and was never adjudicated an incapacitated person: ..~
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'hZf B. Grant of Letters of Administration
r (If applicable, enter: c.t.a; d.b.n.c.t.a.; pendente lite; durante absentw, durante mmon/ate) it n.""
Petiuoner(s) after a proper search has / have ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs: tJtJ..~: 'f:".
AdmulIstratlOl1. c.t.a. or d.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs) ~~ ~~~
Name Relationshl
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(List street address. towlllcity, township, county, state, zip code)
Decedent, then '7 b years of age, died on ~ at
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Decedent at death owned property with estimated values as follows:
(If domiciled in P A) All personal property
(If not domiciled in PA) Personal property in Pennsylvania
(If not domiciled in P A) Personal property in County
Value of real estate in Pennsylvania
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$
$
$
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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:
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Form RW-02 rev. /0.13.06
Page 1 0[2
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COMMONWEALTH OF PENNSYLVANIA"" 0 --.J ,
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COUNTY OF 0.umberlaoc{ ~~C :' ~:~
The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true and:~~h-ect t;the be~t'o/::..:
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the knowledge and belief ofPetitioner(s) and that, as personal representative(s) of the Decedent, Petitioner(s) Will well anctUuly
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Oath of Personal Representative
administer the estate according to law.
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Sworn to or affirmed and subscribed
before me the 319- day of
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Signature of Personal Representative
Signature of Personal Representative
Estate of
Social Security Number: dI t/f- '10/, ~3
AND NOW, ,k/1 OLflllG 3( , oX:lJ
having been presented before me, ~ Letters
are hereby granted to ~(Llld. ,
, eceased
Date of Death:
e foregoing Petition, satisfactory proof
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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 (a
Short Certificate( s) . . . . . . . .
Renunciation(s) ..........
Attorney Signature:
Attomey Name:
L, SLl I Vl(l(; L (to\{ f} L
Supreme Court I.D. No.:
3QO I MafllL+
(IOJrP (t1~ /~
SfrecJ
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Address:
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Telephone:
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Form RW-02 rev, /0. /3.06
Page 2 of2
H105.805 REV 1105
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. 9S
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WARNING: It is illegal to duplicate this copy by photostat or photograph.
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13105285
No.
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Local Registrar
Fee for this certificate, $6.00
JAN 2 3 2007
Date
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REV 1112006
I PAINT IN
~ANENT
CKINK
Cumberland
11. Decedent'sUsual
KkldofWor1c
Maintenance
. 16. Decedent's MaIllngAddrass (Street, city flown, state, zip codel
37 Meadowbrook Court
New Cumberland, PA 17070
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
(See instructions and examples on reverse)
7. Bi1I-.;ace ( Wlds1al'"
STATE FILE NUMBER
6. Date 01 Birth (Monlh. day, rl
- 2023
4. Date of Death (Month, day, year)
January 21, 2007
76v~.
Sb. County of Deatl1
OIhec
July 26, 1930 Raleigh, NC O'npalienl OERIOulpalient OOOA ~Nu~ingHome ORes--. OOlher.Speci~:
Bd. FecIl1y Name (II no! insl-', gIV9"'" and ~r) 9. Wes Dacadent 01 Hispanic 1l<igIn? IKI No 0 Yes 10. Raea: Amarican Illden. Blacl<, W1rila, ,~.
(II yes, epec;~ Cuban, (Specify)
West Shore Health and Rehab M'xtcan,PuartoRlcan,'~.J White
12. Was Decedent ever in the 13. Decedent's Education (SpecIfy only hiltleSl grade completed) 14. Marital Status: Married, Never Married.
U.S. Armed Forcos? Elementery 1 Sacondary (0-12) Collage (1-4 0< ';.j WIdowed. Div"""'ISpecify)
OVas IXlNo 12 Married Marie Anderson
=e~~ 17a.Stale Pennsvlvania
1Th. CoooIy York
DId Decedent
LiY&~a 17c.QQ Ves,DecadantlNedin Fairview
Township? 17d. 0 No, Decedent Lived within
ActuelLmltaol
Too.
18. Father'. Name (FII'St, middle, last, suffix)
Fred H. Fuller
208. Informanfs Name (Type I Print)
Gerald W. Fuller
21a. Method of DIspositIon
19. Mother's Name (First, mldde, maiden sumame)
Pe ie L. Hamilton
2Ob. Inloonanfs MalIng Addreas (Stroet. city 1 town, slate, z\>-J
37 Meadowbrook Court. New
21~ Place " DIapoeb (Name 01 cametery, """,lory "oIher ptece)
CilyIBoro
:" 22a.
Cumberland, PA 17070
21d. Location (City I town, state, zip code)
PA 17109
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I Approximate Interval:
, Onset to Death
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Part 11: Enter other sialificant COI'Ilttinm: conh1butiM to dAAth,
but not resuhing In the uncIerIyingcause {Pven in Part!.
28.~~ Use Contribute 10 Death?
)oK~es 0 Probably
o No 0 Unknown
29. If Female:
, 0 Not pragnant wlthn past year
o PlOi/'Ull1tattimeot<tea~
o Not pregnant, but pteglanl within 42 days
oIdealh
o Not pregnant, but pregnant 43 days to 1 year
before death
o Unknown If Pf8!1lMI with!n the past year
32c. Place of Injury: Home, Farm, Street, Factoly,
OfflcaBut~ing,'1c. (speci!y)
~aJlyUstcondtions,lany,
leadlna 10 the cause ~sted on One a.
Enter !he UNDERLYING CAUSE
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Due to (or as a COOS8QU8llC6 of):
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OVes
3Ob. Were Autopsy Findngs
Available Prior 10 Completion
of Cause of Death?
OVes ~
31. Manner of Death
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o AccIdent 0 Pending InvasIIgetion
o Su_ 0 Could Not be Deteminad
32<1. TIme of Injury
320. Location of Injury (Street, city !town, stale)
308. Was en AuIopey
Perlormed?
M.
33a. CertI1Ier I"'*' "'Y ona)
CartIfyIng _ (P_ ce<1Ify1ng cause 01 daelh whan anolher phyaIcian has pronoonced daeIh end compIated Item 231
To lhebettof my knowfedge, dIIth occumKI due folhecause(s) and manner allat8l:L _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ 0
~:.::::,:=':':::" ~~: :lhti:~~~~IoU::~= manner al slltecL_ _ _ _ _ __ _ _ _ _ __ _ _ __ 0
= =":'~= and I or investigation, in my opinion, death occumMf at the time, ute, and plact. and due to the C8Uae(I) and manner II silted.. 0
35, Registrar's S'
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THOMAS P. KUNKLE. D.O.
500 BRANDT AVE.
P.O. BOX 423
NEW CUMBERLAND. PA 17070
(717) 774-0300
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January 17. 2006
Lisa Marie Coyne Esq.
Coyne and Coyne
3901 Market Steet
Camp Hill PA 17011
RE: Lidia Marie Fuller
Dear Ms. Coyne:
I have been the attending physician for
Marie Fuller at West Shore Health and Rehab since
Feb. 28. 2005. She is now a resident in the
advanced Alzheimers Unit.
She is confused at a11 times and not
oriented to time or place. She has very poor
memory for the short term and is unable to manage
her affairs.
This is a permanent and irreversible
condition and will only progress over time.
TPK/kkb
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