HomeMy WebLinkAbout03-13-07
PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF C v rnf!, .t n ....~ u D COUNTY, PENNSYLVANIA
Estate of
also known as
mA fl,.'1
H"
]) ilL. ou..!
File Number
~ \ ,0 1- :J\..\~
. Deceased
Social Security Number ;l 0 ~ - () 'J - ~ S s 6
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE 'A' or 'B' BELOW:)
o A. Probate aDd 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
. ......,.J
~=: ~
'---:-- 0 -..J
';~ -'.
(State relevant circumstances, e.g., renunciation, death of executor, etc.) i '"..- 8:;;0 "~:
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after e:<ecution Pt~inStI1.ftMnt(s) offere"cii
'. ..,-"""",
for probate, was not the victim of a killing and was never adjudicated an incapacitated person:-_';..i
,........1 I I
:;;
~. Grant of Letters of Administration
(If applicable, enter: c.t.a.; d.b.n.c.t.a.; pendente lite; durante absentia; durante minoritat
Petitioner(s) after a proper searc@) have ascertained that Decedent left no Will and was survived by the foUowing spn'lM {if' "'''){) ...~ heir': (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.) .
R.
'9. I?q.
(COMPLETE IN ALL CASES:) Attach additional sheets if necessary.
Decedent was domi~iled a~eath in County, Pennsylvania with his /~ast principal residence at
"'..., Ho""~"1 rOIflG€. f2a140 i.S.,....,'tVc SPrTn....(I~ (?A '''')007- I=D'7, 3 ye~lt.s
(List street address, taWil/city, township. county, state, zip code) ,
Decedent, then <2?' S years of age, died on ~ at C A <<1 1. i s ~ c k1: c;. I ow It \... (f).s J>. C..r)J T g-,e
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
situated as follows: CiJlfcc..( ''''''~ i)et.T - CCa~~~("lC" 8~rv~ PA'
G, 0 8'5'. 'I ...
cll~c ~J"
Ae~~
$
$
$
$
Wheretore, Petitioner(s) respectfully request(s) the probate 9ftln I".... ur;1I ,,"..I ('')~:n;l(r) rn ~..L..d VY 1(\. (\,1" f ",L:L: &l'Id the grant of Letters in the appropriate form to
the undersigned:
T ed or rinted name and :residence
'1 Po l'l is ,;
r<'Ct'fY\rtt() 3. D\TLoW ~tt-
Ptt\ . , ') c1D"
Form R W-O 2 rev, 10. 13. 06
Page 1 of2
I
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF C (.I V"t\ 0 \S:n '-~ u Q
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) of the Decedent, Petitioner(s) will well and truly
administer the estate according to law.
before me the \~
f'\&w, , ~1
~~~L
or the Register
day of
Sworn to or affirmed and subscribed
:.:l_']
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. r'~',
Signature of Personal Representative
c.:>>
(J1
(JJ
File Number: ~ 1 ~ () 1- 0 ~4 '-4
Estate of rvlCl ~ ~Dl' +\ 0 LU , Deceased
Social Security Number: ~O~ - D 1 ~ tiSSb Date OfDeath:~ 1 \ 0 -,
AND NOW, rY1rl rr 1\ \3 .:JOOk in consideration of the foregoing,Petition, satisfact~ry proof
having been presented before me, IT IS DECRE~ that Letters
are hereby granted to , -.J L e
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 (and Codicil(s)) ofDec~ent. \ ~
FEES ,bj~\A~~~"L,
45. r:b v Register of Wills 'PAJ\1ve;\/ .tX/'---
I ~ - on Attorney Signature:
Letters ............... $
Short Certificate(s) . . (~ . . $
Renunciation(s) .......... $
...JCr ...$
~'--^- \-0 .. . $
... $
...$
. .. $
... $
... $
... $
.. . $
TOTAL . . . . . . . . . . . . . . $
\b .CD
S; ~OO
Attomey Name:
Supreme Court J.D. No.:
Address:
Telephone:
-7';;1 -00
Form RW-02 rev. /0./3.06
Page 2 of2
15.805 REV 1/05 '2' ' 01 - d\.lL-~
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 certi~cate will be forwarded to the State Vital Records Office for permanent filmg.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
No.
li-.~~~
Local Registrar
Fee for this certificate, $6.00
p
13311329
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1. ...... oIllocedont (Rrst, middIo, 10II, sufIix)
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH · VITAL RECO~DS
CERTIFICATE OF DEATH
(See Instructions and examples on reve....) SlATE FILE NUMBER
4. Date 0I1leaIIl (Month, day, Y8IIl
March 7, 2007
H10l;-143 REV 1112006
lYPE I PRINT IN
PERMNENT
8l.ACl( IN/(
\ .
5. Aqa (lAst Birthday)
85
v,..
lib. County of De8III
Cumberland
11. DecedonfllllUll
Kind of Woot<
Sales Clerk
17C.:g. VII, llocedont UYed In
17d. C1J No, Ilotedont UYed wII1In
AcluII Li* of
South M;rlrllptcm
Twp.
CIty IIloro
o
~
~
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21d. Location (CIIy I town. 1Il8te, zip code)
Laureldale, Pa
Pa 17013
23c. Date SIgned (MonIl1, day. yeer)
_ 24-26 ...... be "'"'4JIeIed by ~ 24. illll8 01 0eetI1 25. DlIIe I'nlnoII1c8d Deed (MonIh. !*!y, yeer)
wflopronculC8tdldl. / (): 01 A- M. 1H4k" 7 z.~o 7
CAUSE OF DEATH (See InetructIona and aumplea)
IIem 27. """ I: en. llelDil..lil.Mnlll- di&aaII, ...... 01 compIIcaIIans - tlal dnc1Iy <:8UIId lie cIeI6'1. 00 NOT enter tsnniteI_1IUCh 88 C81diec_,
~ -.... VlIlIIIMar IIlrIIIIIIon wII10ul sIlowIng lie eIIoIogy. UIl orly one cue III eed111ne.
26. wes C888 Iemld to MedlcaI E_ 1 Coroner for a Reason Oller then Clemelion or Oonelion?
o VII iBNo
AppruxineIe illIMt Part II: Enter other 28. Old Tobaa:o Uae ComlbuIIo to 0IdI?
0nseI1o 0uIIl bul not ~ tl... UIldIrIyIng ceuse gIVIn In Part I. 0 VII ~ PlCbebIy
DNo D~
::I:~=~
=1IIl condIians. illIff,
to ....._""IIne..
e.- UllDEllLYINO CAUSE
="~~~....
s c:..P S IS
Due III (cr .. . conoequence 01):
b. l LO~ "r~1 OJ u. ~ D/ PI at. ~
Due to (or II . conoequence 01):
~d"rn~
()~.5
bA^fS
29. If Female:
IE NcI prepnt- pill yw
o I'rIgnen allIme 01 deeIIl
o Nor prepnt. but pregnant wIlht1 <l2 days
ofdaelll
D Not ~ blt pregnanl43 days to 1 yeer
bekll8 deeIIl
o UnI<nown. pregnanl wIIhIn !he pill yw
32c. ==:""~ ~ Factay,
Due to (or II . ccnaaquonce 01):
d.
D Voo I1J. No
o Vel IDiT No
I5i1 NaItnJ 0.-
D Aa:idanI 0 PIIlCilQ IIMlStIgation
o SuIddo 0 CcluId NoI be Oelenninod
320. TIme of /njlry
32g. LocalIon 0I1njtJy (Snel, CIty 11IlWn, state)
30L Was 11\ Al*'PBY
Pel1onned?
311>. Were ~ FlncIngI
..._PrtorIO~
01 Calle 01 0aaIh?
31._oIDeath
321. ~ TIIIlIpOfleIIon lopy (Specfy)
o IlItver 1 Operator 0 PaI8IngIr oPede$iIn
0Ih8r . SpodIy.
33a. c.tIh (dlodt orly one) 33b.
. ~~~:....:::..~~~.:=':~_~_~_~~-:n~_________________ 8( .
. ...............1IllI CIIIIfylng phyIldIn (~boIIl prIIIlOlIUlg daa1h and cer1IfyInv to ClUIO of _I 33c. NIInber :
. ::.. ~ ~ dIIlII occunad II'" time, dIl8,lIId place, IIId due 10 Iho CllUll(I) IIId - II -.I.. - - - - - - - - - - - - - - - - - 0 /1f lJ <5
on !hi...... of .-1IllI1 or InvHIIgItIon, In my opinion, -. occunad 1\ 1ho d.... d_ and pIIc<l.1IId due 10 Iho ClUll(I' and __ .. I1IIed.. 0
M.
~
*
o
~
z
33d. 0e1e S9lOd (Month. day, year)
C>3 ' tJ '7 .~{)tJ 7
35.
.
I~ I \ J ~ 1\ J 0 I
36. Date FIe<I (MonIh, day. year)
;C; OJ ,
DlsposI1ion Permit No.
() 11~ 4.Z'::;-