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Home My WebLink About04-18-07 PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF WILLS OF Cumberland COUNTY, PENNSYL VANIA Estate of Blake A. Myers also known as Blake Myers File Number :2/-fJ7 -D.?yrj J . Deceased Social Security Number 208-42-6380 Petitioner(s), who is/are 18 years of age or older, apply(ies) for: (COMPLETE ~' 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 of the instrument(s) offered for probate, was not the victim of a killing and was never adjudicated an incapacitated person: IZI B. Grant of Letters of Administration (/fapplicable, enter: c.t.a.; d.b.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 Administration, c.t.a. or db.n.c.t.a., enter date ofWiI/ in Section A above and complete /ist of heirs.) I Name Relationship Residence I Christina M. Myers Spouse 3 Orchard A venue. West Nanticoke. P A 18634 (COMPLETE IN ALL CASES:) Attach additional sheets ifnecessary. Decedent was domiciled at death in Cumerland County, Pennsylvania with his / her last principal residence at 9 Rvan Drive. South Middleton Townshio. Cumberland County. PA 17007 (List street address, tOlfln/city, tOlflnship, county, state, zip code) Decedent, then c;n years of age, died on 1/15/2007 at Rockvi Up-, Mnnt..grrrP-ry CDnnty. PA s s s "" ~~ ~ ~ ~..: :..,;)<'"L...) f __ I': situated as follows:"] ~?2 :? ._'.,j Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant OfLc~~ ~ apIUPnate f~~ tbJ the undersigned: \., .' /, r-'" r-. 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 (If not domiciled in PA) Personal property in County Value of real estate in Pennsylvania 50,000.00 T d or rinted name and residence ~) ~d II ~ -t.. 3 Orchard Avenue, West Nanticoke, P A 18634 Form RW-02 rev. /0.13.06 Page 10f2 Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA SS COUN1Y OF ~ff e ~ . 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 before me the /1Ir;1 day of ~~ tII:tJd .~ .. Fo< the Reg;_ (IU{Jia'11A~ '7n~ Signature of Personal Representative Signature of Personal Representative Signature of Personal Representative o S~ --;~~ . . ,:.'~-~ ;;:;1 -- .....'.. ......-, __1 e) _.,-~ (-)' ;~ ..' "--- " 1---, (.""'-:-::J; <= -..J ::0>.. v ::::0 ; ;':~ t ) ',-..) + - - ~ ! co File Number:---lj - () I ... aC>R , v '-,'::1 -)......,-,-- ::rJ ---I -~ _.r.", Estate of Blake A. Myers , Deceased N C.J1 Social Security Number: 208-42-6380 Date of Death: 0111 5/2007 AND NOW, having been presented before me, IS are hereby granted to Christina M. Mvers , cOCiJ 7 , in consideration of the foregoing Petition, satisf8ct<lry.proof CREED that Letters of Administration 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 ( FEES 4 Letters............... $ O.LD Short Certificate(s) . . .J.... .. $ , Renunciation(s) .......... $ ~ ...1 rmahrlYL ... $ . .. $ . .. $ .. . $ . .. $ ... $ . .. $ .. . $ TOTAL. . . . . . . . . . . . .. $ lo,m lCJ, (If) Attorney Name: Supreme Court I.D. No.: Address: 340 Market Street Kingston, P A 18704 Telephone: 570-283-5800 II~ Form RW-02 rev. 10.13.06 Page 2 of2 VALID ONLY WITH IMPI{E~SED SEAL tHEREBY CERTIFY ':(HAT'THE ATTACHED IS A TRUE COpy OF A RECORD ON FILE IN THE DIVISION OF VITAL RECORDS DAT~ISSUED: r'EBO 6 2007 ~;J.~ / .. STATEREGIsTRAROFVI ~RECORDS Please Type or Print in Black Indelible Ink. Ensure All Copies Are Legible. State of Maryland I Department of Health and Mental Hygiene 1- For State Certificate of Death Usual Residence of Decedent 108. State 1Ob. County 7. Age (In yrs. last birthday) 01470 1. Decedent's Name (First, Middle,Last) . Blake A. ~ 3. Time of Death 1838 hrs 4a. Facility Name (W not institution, give street and number) 11505 Monongahela Drive 5. Social Security Number 208-42-6380 50 m C11rl:erlarl 1Od. Inside City Limits 1 OVes 2/ifNO 9 Faylen [ti\e 1Of. Zip Code 17007 10g. Citizen of What Country? USA 11. Marital Status 12. Was Decadent Ever in U.S. 1 0 Never Married 2 ~ Married Armed Forces? 1~ Ves 20 No 30WidOWed 4 ODivorced IIYes, GIveY.... 15. Decedent's Education (Specify only highest grede complated) Elementary/Secondary (0-12) College (1-4 or 5+) 12 2 13. Was Decedent of Hispanic Origin? ( Specify Ves or No- li Ves, specify Cuban, Mexican, Puerto Rican, etc.) 14. Race - American Indian, Black, White, etc. 10 Vas 21j1 No specify: 168. Decedenh Usual Occupation (Giva kind of work dona during most of working life. DO NOT use retired) Quartermaster Corp SpecifyWhi te 16b. Kind of Business/Industry US Navy 17. Father's Name (First, Middle, Last) Marlin E. Myers 19a. Informant's Name/Relationship (Type, Print) Christina M. Myers 18.Mother's Name (First, Middle, Meiden Surname) Betty J. Fuhrman 19b. Mailing Address (Street and Number or Rural Route Number, City or Town, State, Zip Code) 3 Orchard Ave. West Naticoke, PA 18634 20b. Place of Disposition (Name of cemetery, crematory or other place) ~ FH & Q.~It:itny Date 2Oc. Locetion - City or Town, State 1/19/'2!1J7 M::.. Iblly ~, m J/Vd_ 22. Name,and Address of Fa~ F\re:al Oa:el& Cr::eratia1 Se!rvia:s Pal:kville ~ IBrfi:I:d Ri. Parkv:ille, M) 21234 Approximate Intarval Between Ons91 and Death 23a. Part I. Enter the disease, or complications that caused the death. Do not enter the mode of dying, such as cardiac or respiratory arrest, shock, or heart failure. List only one cause on each line. . Immediate Cause (Final disease a. Canp1ications of chronicalcchol use or condition resulting in death) Due to (or as a consequence of): ~ , o AMENDEi23a 27 23c. II yes, outcome of pregnancy 1 0 Live birth 2 0 Fetal death 4 0 Pregnant at time of death 5 0 Other (Specify) , 1 0 Ves 2 0 No 9 0 Unknown 9 0 Unknown OCJ UNPENDED IF FEMALE: 23b. Was decedent pregnant in the past 12 months? 3 o Ectopic pregnancy Sequentially list"conditions, if any, leading to immediate cause. Enter UOllerlying Cause (Disease or injury that initiated events resulling in death) Last b. Due to (or as a consequence of): c. Due to (or as a consequence of): d. Par! II. Other significant conditions contributing to death but not resulting in the underlying cause given in Part I. 23e. Did tobacco use contribute to the cause of death? 10ves 20NO 30probably 4~Unknown .. 24a. Was an autopsy performed? 1 ~ves 20NO 26.Place of Death (Check only one) Hospital: 1 0 Inpatient 20 ERfOutpatient 30 DOA Othe'40 Nursing Home 50 Residence 6 ~ Other..Scene 28a. Date of Injury 28b. Time of Injury 28c. Injury at Work? 28d. Desaibe how injurY occurred (Month. Day,Vear) 10Ves 20 No 24b. Were autopsy findings available prior to completion of cause of death? 1 ~ Yes 20 No " -. -. ") 25. Was case referred to medicel examiner? 1 Ves 2 27. Manner of Death :} 1 IX] Natural 5 0 Pending J 2 0 Accident Investigation 3 0 Suicide 6 0 Could not be 28e. Place of Injury - At home, farm, street, factory, office building, ele. 4 0 Homicide determined (Specify) :; :u ~~~~er 1 0 CertIfying Physician: To the best of my knowledge, death occurred at the time, date and place, and dua to the causa(s} and manner as stated. ..J one) 2 ~ Medical Examiner: On the basis of examination and/or investigation, in my opinion, death occurred at the time, date and place, and due to the C8use(s) j) and manner stated. _ 29b. Signalure and title of certifier 29c. License number 29d. Date signed (Month, Day, Year) :) 281. Location (Street and Number or Rural Route Number, City or Town, State)