HomeMy WebLinkAbout04-11-07
PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF
CUMBERLAND
COUNTY, PENNSYLVANIA
Estate of DIM&~~O'p~PENS
also known as
File Number
.9, \ C~ -1 D3'-,\\
. Deceased
Social Security Number
163-60-2125
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
(State relevant circumstances, e.g., renunciation. death of executor, etc.)
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution ofthe instrument(s) offered
for probate, was not the victim of a killing and was never adjudicated an incapacitated person:
Ii] B. Grant of Letters of Administration
(If applicable, enter: c.t.a.; db.n.c.t.a.; pendente lite; durante absentia; durante minor/tate)
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
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 Name Relationshio Residence I
DANIEL COPPENS SPOUSE 813 NORTH WALNUT STREET
MECHANICSBURG, P A .17055 -" .
'.,' r..... ,r-""'i
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. "..-r; :0::'1
(COMPLETE IN ALL CASES:) Attach additional sheets lfnecessary.
~
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Decedent was domiciled at death in CUMBERLAND County, Pennsylvania with his / her last principal teSiaeDce at-
813 NORTH WALNUT STREET. MECHANICSBURG. PA 17055 -
;-1
(List street address, town/city, township, county, state, zip code)
C)
Decedent, then 43
years of age, died on 3/17/07
at HARRISBURG HOSPITAL--::
c-;.
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 PA) Personal property in County
Value of real estate in Pennsylvania
22,450.00
$
$
$
$
92,060.00
situated as follows: 813 NORTH WALNUT STREET, MECHANICSBURG, PA 17055
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:
DANIEL COPPENS 813 NORTH WALNUT STREET, MECHANICSBURG, PA 17055
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) of the Decedent, Petitioner(s) will well and truly
administer the estate according to law.
before me the
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19nature of Personal Representativ
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Sworn to or affirmed and subscribed
day of
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-
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Signature of Personal Representative
j ( ,
Signature of Personal Representative
C):.J
File Number: d. \ D l \)3 ~f1
Estate of \)\~ N\ Co .W-0-s,
Social Security Number: \ \.o?:> In.O d\'d.S Date of Death:
, Deceased
3 \\\ \~COI
AND NOW. \\ 'V".\ \ \ . ~ I . in ,owid,,,,tion of th, foregoing p,tition, ".,"",tory proof
havmg been presented before me, IT IS DECREED that Le~s \ e LC:;\ '~.~f'ne(\Rr'W
C" '" ~ 1
are hereby granted to ('\ ~,\~~' \ '-J
in the above estate
~
FEES
Letters ............... $
Short Certificate(s) . ; . . . . . . $
Renunciation(s) .......... $
0~S?
Pr\..-'-b ... $ ~, 0 0
-=:L-...\ )Qf'~S . .. $ \ S - 00
...$ I
.. . $
.. . $
;.. $
...$
.. . $
~CY'O
TOTAL .............. $
JlnO .(5)
dO 00
\~ . ()D
Attorney Signature:
Attorney Name: '<'t>r12-.L ,,^, t..€-l)'€.~VA...
SupremeCourtLD. No.: t;qor'"L
Address: Pv ~ q ~
N.e.w C Al__ W-~ Pr+ I =ffJ=?lJ ~) '7
.. . $
Telephone: q"(r c:p)~ 6<!t2---'\
Page 2 of2
Form RW-02 rev. 10.13.06
H105.805 REV 1/05
This is to certify that the information here given is correctly copied from an original certificate of death dul~. filed with me as
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent fihng.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
No.
~I!;-=~
Fee for this certificate, $6.00
p
13378593
11(04.
J./J. ;{tf(f 1
,
Date
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-,
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\..P
Hl05.143Rev 01}()6
TYPElPRINT IN
PERMANENT
BLACK INK
t NoJmecIOeced8lll(FifSl.rnddIe,IaSI)
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
Diane
5 Age (laS1birthd1y)
43 v"
lb. County 01 Oeath
163 - 60
to, RK.:AmericaIltRdiaft,IIIck.WhiI..eIC.
(-
white
IS. SuMvingSpouu(....gIYt..-_)
Daniel Coppens
7, DaleolBilth MonIh,da , ear andslateOl'lor.
Feb. 14, 1964 Pottsville, PA
ad. F.ciIil.y Name (Unot nstlulion. give street and nurrtler)
3. Social Secur~ NWJber
813 North Walnut street
Mechanicsb , PA 17055
18. Father's Name (F'5I, middii, !as!)
11a. SIaIa Pennsylvania
17tl. CoonIy CUmberland
14. UlftalSlaM:MlrriId,Nev.-manied,
~H"") ~~_(_
0iI1locodooI
Uti In. 11c.D Ves,OecedentLN....
T~?
T"P
170.1i1 ~=..liY""'" Mechanicsburg
Cily<1loIo
19. MoUler's NaITll (Fnt. rridcIe, AlIidBnaumama)
Daniel J. Coppens
Catherine Burns
2Ob. INotmanl'. MatIng Addr.. {ShII. clyAoMl, 1liiie, ~ code)
813 North Walnut street
Mechanicsburg, PA 17055
John Kubeika
20a lnlorfnBfll's Name (Typ$IpriN)
a
w
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::>
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~
o AemDVal"om Stale
2tc. fltac. 01 0isp0di0A (Hamil of temetefy, CJtIl'HWy Of olher plica)
o Donalion
Spring Hill Cemetery
22c, Name and 1ddr8$$ of Fdy
210. Locatioo(CIy-.._...._1
Shippensburg, PA
8 Market Plaza Way
Malpezzi Funeral Heme Mechanicsburg, PA 17055
230. l..... H_ 23c:. Data S9>od _. day. ,ou)
,~
24 TrneofOeath as. DatePronooncedOead(MonttI.day"ear)
1/3S- p.. IlIlord-, n I 2c07
CAUSE OF DEATH (See Inslrucllons and eumpln)
lam27 Part I Enterlhe~-diseases......1e$ orCO'!JllicaIIOllS-lhaldwecll'lcausedlhedealh DO NOT enler Iernwtalzven suchascardlacsnesl
,._ao", ..,,_'_""'......s'"1hea~ DO HoT_"",. ~2ic_o'''..a: / I.
=~.::.us:~'::...~. Ll~'{dld~jtL~__~tt2~ '4UL
~lisIcoodDJns ifany r::!2~eo~___ _ __ ~_ _ _ ______~
_ :::~ =~~::c':J: I Due'" (Of as I consequence oQ:
. =::::inlh~~ST~ ~iO(o.-asaconsequenceDO----
26. Was Case Referred kl . WedQI Euri\tdCoroner?
"'Vos 0 No
: Appfoximale intervat ParI II: EflItI oilier sD*ant condIions conlridiM to dull,
: onsetlo dealh buC no! resublg il... ~ cause pen in Plltl
!/-;lW l(t/f;~ScJ~
:3~~ u __.___u____
,-----.-
30lI Was an AYopsy
Perlofmed?
32.. Date otlnjury (Uonlh. day. yeat)
32b. osscrilo how InjuIy Occun..:
28 Did Tobacco Use CoItiUI k>> Death?
o Ves [3 Problblr
ONo D_
. FtmiII:
[] Hot pregnant lNiIbin past year
[] PNQnuf.1lmI of6Mlb
o Hal precJlMl, blA P'egAIflI wiIbin 42 d.tys
ol-
D Not pftgnanl. but plegMnI43 dip 10 1 real'
--
o Unknown iI pregnanl wthin III pasI pal
32c Placo" qury: Homo. Far... _ F-V. <lib
Sutintl."'C_
o Yes 0 No
o
3Ob. W". Autopsy Findings
AvdabltPriorll:t~tb
01 Caus. of OAth?
DYes DNa
31. Manner 01 Oealh
o NalUtal 0 Uomil:ide
o Accidenl 0 Pendlng Invesilgation
o Suicde 0 Could No! Be Deterinfl8d
32d. Time ollnjuty
".. Loao"'(S1lOSl_._1
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W
a
w
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w
a
"-
o
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331. Canlliet (chad< "'" ona)
Ceftilying IJbVskLan (Phy:iician certitrno causa 01 dealb.men anolher physician has proooonced dlalR and ~ad 118m 23)
To Ibt bat of..... knowa.dgt, dUlh occurred due to the cause(sl and manner aI slaled ......_.._.M_.___...._..__._...._...~._..~.
Pronouncing and certifying ph,lklan (Physician bo$h proooorv.:ing dealn and certifying \0 cause of ~Vll
To.... buI of In)' know686gI, death DCcurred al&he time, dall, and piau, and due 10 the cause(l) and 1NMII.IIIWed.............__............_____.._....................__.O
Medkat uamlnerlcoronet
On.... bas. of enrrinaUon and/or InvaUgatlon,In my opmlon, de.Jlh occurred al the lImB, d.1Ie, and pIKe,.nd due 10 the cauae(s) and mannu at stated .........0
35 Registrar's Signature and Oisllic& NuntleI
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