HomeMy WebLinkAbout03-01-07
Estate of
also known as
PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF Ca.~erl~ COUNTY, PENNSYLVANIA
JOLU7n e. '1Y7. //~ FileNumber 2/- 0 ( - 0 I q I
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. Deceased
Social Security Number ,~Old - /'1 -d 19~~
Petitio~ "islare 18 years of age or older, apply(ies) for:
(COMPLm ~, or 'B' BELOW:)
D A. Probate and Grant of LeUers Testamentary and aver that Petitioner(s) is / are the
last Will of the Decedent dated and codicil(s) dated
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Except as follows, Decedent did not many, was not divorced, and did not have a child bom or adopted after execution o~_'~en~ offered
for probate, was not the victim of a killing and was never adjudicated an incapacitated person: '. :.J~ .
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Q-"B. Grant of Letters of Administration
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(If applicable, enter: c.t.a.; db.n.c.t.a.; pendente lite; durante absentia; durante minoritate)
Petitioner(s) after a proper search has / have ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs: (If
A.dministration, c.t.a. or d.h.n.c.t.a., enter date of Will in Section A. above and complete list of heirs.)
In nC. \ {'q
(COMPLETE IN ALL CASES:; A.ttach 1Idditi0llal shlN!t6lf lie
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lie> D
ss, town/city, towruhip, county, state, zip code)
Decedent, then "q years of age, died on ~~. I ~~ ~ f) (J 7 at
hb4( $pJ,..,'i ~""f.J
Decedent at death owned property with estimated values as follows:
(If domiciled in P A) All personal property
(Ifnot domiciled in PA) Personal property in Pennsylvania
(If not domiciled in PA) Personal property in County
Value ofreal estate in Pennsylvania
61~o<
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$
$
$
$
situated as follows:
Wherefore, Petitioner(s) respectfully request(s) the probate of1be last Will and Codicil(s) presented with this Petition and the grant of Letters in the appropriate form to
the undersigned:
.R.
Form RW-02 rev. 10.13.06
Page 1 of2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF
C /,VrlJ e,...j~
SS
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 of Petitioner( s) and that, as personal representative( s) of the Decedent, Petitioner( s) will well and truly
administer the estate according to law.
Sworn to or affirmed and subscribed
JST
before me the day of
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Signature of Personal epresentative
Signature of Personal Representative
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For the Regi_ f1t>~ __ <1fP.,.".,[_
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File Number:---d-I-lJi- Iqj
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Social Security Number:
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:J.t"JJ1 . in consideration of the foregoing Petition, satisfactory proof
'le."5\~ \'Y\ E.~ T A i.. "\
Date of Death:
N~
, Deceased
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1$ .:JDtS 7
Estate of
in the above estate
and that the instrument(s) dated
d"oribed in the Petition be w1mitted In probate and filed of j"fn as th~ ~ast Witt (and Codicil( s)) of Decedent
FEES ~~~IJctpo1Yl..l~~
$ 4t::...<:::J::> gister of Wills
Letters ............... -..J
Short Certificate(s) . . . . . . .. $ L\ .00 Attorney Signature:
Renunciation(s) .......... $ z.o. <:::C:>
~QP ... $ 10.00
... $
... $
... $
... $
... $
... $
... $
... $
TOTAL.............. $~4 .t)O Rl
Attorney Name:
Supreme Court l.D. No.:
Address:
Telephone:
Form RW-02 rev. 10.13.06
Page 2 of2
:105.805 REV 1/05
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.
~/Jp~
Local Registrar
Fee for this certificate, $6.00
FEB 1 9 2007
Date
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REV 11/2006
. PRINT IN
AANENT
CK INK
COMMONWEALTH OF PENNSYLVANIA. OEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
(See Instructions and examples on reverse)
STATE FILE NUMBER
14. Marital Status: Married, Never Married, 15. Surviving Spouse (n wifa, give maiden name)
WIdowed, Divorced (~
Widowed
. 16. Decedenfs MailIng Add.- (Slreet. city / town, state, zip CXldo)
1105 Dry Powder Circle
18. Fathor's Homo (F1fSl, mlddo, last, suffix)
Menle.~Uffelman
Decedent's
Actual RasidInca 17a. State
17b. County
Pa
Ctnnberland
17c. ~ Ves, Decedent Uved in
17d.D No, Decedent Uved within
Actusl Umils 01
Twp.
City / BO/tl
2Oa. In/onnant's Name (Typo / Print)
Kathleen Goodrich
21a. Method 01 Disposltioo OIl CrematiOn D Donation
D ~ ~ D RemovaIlrom Slate :-~ ex.:. ~uthclrI28d ~ Vas D No
: SeMce . acting as SUCh) 2211. Ucense NlInber
011654-L
19. Mothat's Name (First, mkkIa, maiden sumame)
Martha N/A
2Ob. Inforrnanrs Mailing Address (Slreal city /town, slate, zip CXldo)
s Pa
Funeral Home Inc
23a-c only when certIyIng
phyIician Is not lMliIIlblo III limo 01 daalh to
c:erlify cause ol d8a1h.
. Iloms 24-261llU!1l be completed by pooon 24. TlI11ll of Death 2 ' 15 '
who pnlIlOUI1CllO doalh. I A M. D {\).Q.('
CAUse OF DEATH (See 11IlIlructl0l1ll end elllllllple8)
IIem 27. Part I: EnIaI!he ~ - diseases, ~, or c:ornpIIcatIorw -Ihal clradly caused !he daalh. DO NOT antar termi1aI awnts such as can&ac B/!18t,
/8SlliIOIOrY arrest. 01 venbtcuIar Matlon witI10ul showing the elIoIogy. List only one ClIUS8 on each line.
3Oa. Was an AlAoptIr
Partormod'?
d.
:JOb. w... AlAoptIr Findngo
AvaIIlIble Pr10r III ComplaIIon
01 Cauea 01 Death?
DVes ONo
31. MInner 01 DeaIh
D NaIuI8l D Homicide
D Acctlant D Pencing II1Y88tig8tIon
D SUiCtdO D CoUll Not be Determinad
I Appromate 1n\8rIBl:
I Onsal to Death
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Part II: Enter 0lh8I smiIIaInt cordIIons mnbtlUIInn 10 dIlllIh 28. Did TdJecco Use ContriIlute 10 Death?
but not resulling In !he unclol1ylng CBUSO gillen In Part I. D Ves 0 ProllabIy
DNo~
29. n Female'
~wilhlnpat!lyaar
D Pregnant It lime 01 doaIh
D Not pregnant, but pregnant within 42 days
of dBlth
o Not pregnanl but pregnant 43 days 10 1 yoor
baIora doaIh
D Unknown II pregnant within !he pat!l yeB/
32c. P1aca 0I1~ry: Homo, Fenn, S1reet, FaclOI'(,
0lIice 1luidIng, ate. (Specify)
='~=~
· ...~~~ :;1:
~to(OIas~~
SoquanaaIIy IsI concItIons, II ony,
IMdna 1Il1he causellBBBCl on line a.
EIIIr Iho UNIlERLYNl CAII8E
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Duo to (or as a conooquonco 01):
DYes ri No
32d. limo of Injul'(
32V. LocaIIon ollnjury (5Inlet, city / town, s1lIta)
M.
330. c.rtIfIor (dloc:k only one)
. CertIIytng p\lyaIcIIn (Phytician COftiIyIng cause 01 dBalh when anoIher physician hu plOI1O<Jncad death and compIeIed 118m 23)
To........ 0\ mylcnowtedge, dMIh occurrod due 10'" COUM(I) and _al otmcl.. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0
. =:=:'':'=:;:~ond~~~t~=~~m_..Nled..__u_____________ 0
. ::: ~= and / or InveslIgotIon, In my opinion, dMlh occurred at !he time, d8te, 100 place, and due 10 !he caull(s) Ind manner u IlatIcl. 0
35. Regislrar's
.
I~I/I~II 1'1
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330. Ucanaa Number
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34. sr:~~-7~;n,Death(hom2~ Typo/Pnnl
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RENUNCIA TION
REGISTER OF WILLS
rAl1Y\ber\t1J\~ COUNTY, PENNSYLVANIA
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Estate of JEANNE PlRA
..c;Deceased
I DEBORAH HORNUNG
,
(Print Name)
, in my capacity/relationship as
of the above Decedent, hereby renounce the right to
DAUGHTER
administer the Estate of the Decedent and respectfully request that Letters be issued to
~-th4 6-oadr \~h
,
FEBRUARY 21, 2007
(Date)
JOo
(Signature) . .
2425 BLUE MOUNTAIN PARKWAY
(Street Address)
HARRISBURG, PA. 17112
(City, State, Zip)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this day
of
Executed out of Register's Office
Before the undersigned personally appeared the
party executing this renunciation and certified
that he or she executed the renunciation for the
purposes stated within on this OJ 7 day
o~ aOe(
Notary PUbliC- - -
My Commission Expires: 1-[,( - 0'6
Deputy for Register of Wills
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's Commission.)
Form RW-06 rev. 10.13.06
COMMONWEALTH OF PENNSYLVAI".
Notarial Seal
Usa A. WOOey, Notary Public
Susquehanna Twp., Dauphin County
My Commission Expires Jan. 4, 2008
Member, Pennsylvani::lAo;sociation Of Notari","
RENUNCIA TION
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(] ~GISTER OF WILLS
JJ./1J'/Pr!tr(), COUNTY, PENNSYL VANIA
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Estate of
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, Deceased
, in my capacity/relationship as
(Print Name)
.,S;()n
of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
)(a'fhg ~ad1
r ~br'"u.o.rv; '21-/j..oo'l
(Date)
-1:J ? l-oU1~T Av.p,j ,
(Street Address)
O~kdoJe, N~r 117&2
(City. State, Zip) I
Deputy for Register of Wills
Executed out of Register's Office
Before the undersigned personally appeared the
party executing this renunciation and certified
that he or she executed the renunciation for the
purposes stated within on this ;;? ~ day
of ;z::~ 6 , ;;) (;, " 7
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Notary Public
My Commission Expires: ~v'1 c :J~ ~ 6/ ~
-
Executed in Register's Office
Sworn to or affirmed a~subscribed
before me this :2 ~ day
of f( l!(ltit4( , ~L t) 7
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's Commission.)
Form RW-06 rev. 10./3.06
STEPHEN BUCt(l
~r)La,;' PUOrlC State Of New y~~....
I\Jc 4730628
QU;:Jilf,€U II" .::>uffolk Coun...
C0mrn!SSlon J.t'>tDlres June 30 ~Qi '-I
RENUNCIATION
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R:{ISTER OF WILLS
~htr(1).1l COUNTY, PENNSYLVANIA
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Estate of 3Q. -A N rJ It
, Deceased
. in my capacity/relationship as
of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
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(Date)
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(Signature)
/3Q' &tJaclwa.Y
(Street Address) "
t!/t;eih i)9!JV'LON AI I //70~
(City, State, Zip) /
Executed in Register's OffICe
Sworn to or affirmed and subscribed
before me this -i::---1 day
of ~ .--t:rN7
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Deputy for Register of Wills
Executed out of Register's Office
Before the undersigned personally appeared the
party executing this renunciation and certified
that he or she executed the renunciation for the
purpose~sUJ.ted within on this 2, \ day
of ~~'f ~()cJ 7
M"CHELl MillER
lIC, STATE OF NEW~
NO. OlMI4127210, SUFFOLK COUNTY
COMMISSION EXPIRES MAY 31, ?~~"t F"\
(Signature and Seal of Notary or other official qualified to
administer oaths, Show date of expiration of Notary's Commission,)
Form RW-06 rev, 10.13.06
RENUNCIATION
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Estate of -1 e..o ,10 Nt.
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. Deceased
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M''1J IObSI
, in my capacity/relationship as
of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
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(Date)
oj
Executed in Register's Office
Sworn to or affirmed and s~~cribed
before me this 2-r1 day
of #~rt.AJAL' . "'""Lr.)U7 .
Executed out of Register's Offree
Before the undersigned personally appeared the
party executing this renunciation and certified
that he or she executed the renunciation for the
purposes stated within on this 2 I .1r day
of ~~ '-oo'J
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N . Pu c -, Public- State of____
.. .. 01.101881880
Y CommIssIon ExpIres: CluIIIIIod In - c:c.n,
.........on &pirea O8I3'~o ~
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's Commission.)
Deputy for Register of Wills
Form RW-06 rev. 10.13.06