HomeMy WebLinkAbout05-31-07PETITIGN ~'GR PROEATE ANI) GRANT ®~' LETTERS
REGISTER OF WILLS OF
COUNTY, PENNSYLVANIA
Estate of -~ 'r KO S S ~Q, ~ r File Number I 'U t -[1 ~,,,o(~/
also known as ~ r
,Deceased Social Security Number t b ~ - b 4' - 3b 3 ~
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE 'A' or 'B' BELOW:)
named in the
^ 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
(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 of the if}sti:timent(s}~ffered
for probate, was not the victim of a killing and was never adjudicated an incapacitated person:
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Ia1 B. Grant of Letters of Administration _~
(Ifappiicabie, enter.• c.t.a.; d.b.n.c.t.a.; pendente life; durante absentia; durante ntriioritate)
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
Adntirtistration, c. t. a. ord.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.)
tvame - - - ---- ~ rL O ~. 1-1 ~ ~ P~4 1 ~ O 1 5
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33g 6 s-~~ ~~1, sly ~P~ l na i 3
Lo r ~ p. ~ (~ ree.v~ 5 ~ S~e.r ,
(COMPLETE IN ALL CASES:) Attach additional sheets if necessary. t 0 to
Decedent %vas domiciled at eath i ~m~ e.r ~ 4 r~ County, Pennsylvania with his /'~1'ast principal residence at
(List street address, townt/ciry, township, coungl, state, zip code) 0.PP ~ ~ '
Decedent, then a 3 years of age, died on 5 ~ O `~ at i a. ~ 010 0: , w~ '
Decedent at death owned property with estimated values as follows: $ 5 0 ~ e
(If domiciled in PA) 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 $
situated as follows:
Wherefot-e, Petitioner(s) respectfully request(s) the probate ot'the last Will and Codicil(s) presented with this Petition and the ;rant of Letters in the appropriate fotTn to
the undersigned:
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Farm RW-U? rev. 10.13.11(
~lli
~r-(e ~ .~ ~ , 8no - E~s~
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RO~4-D ~ C-a~t-~ i SLC' ,
Page i o`2
®ath of Personal Representative
COMiv10NWEALTH 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 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 ~ ~ day of
v?
For the Register
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Signature of Personal Representative
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Signature of P rsonal Representative
Signature of Personal Representative
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File Number: ~ O<< ~ O~ ' ~ ~-~
Estate of ,Deceased
Social Security Number: ~l9('t9~'3t93g Date of Death:7125~0"t
AND NOW, 1 ~7"i . in consideration of the foregoing Petition, satisfactory proof
having been presented befo e, IT IS DECREED that Letters ~ '~ ~ ~ ~ ~~~~~ a_r
are hereby granted to ~ ~ ~ •t ~ ~ 1 ~ ^'~~ ~ a ~ ~ . ~ a~~' ~ 1'`k1Am i 4 S.
m the above estate
and that the instrument(s) dated
described in the Petition be admitted to probate and filed of
FEES
Letters ............... $ ~ ~~
Short Certificate(s) ........ $~~Q ~ ._
Renunciation(s) .......... $
~ ... $10. C`~
tom.... $ ~> .cx~
... $
... $
... $
... $
... $
... $
... $
TOTAL .............. $ . U
Form RW-0' rev. lG.I3.0(
Telephone:
as the last Will (and
Attorney Signature:
Attorney Name:
Supreme Court I.D. No.:
Address:
of Decedent.
of Wills
Page 2 of 2
105.805 REV ((1 U07)
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00
P 13620318
Certitication Number
N105.1M REV 112898
TYPE / PEBNT IN
PERMNIEN(
SIACK MK Nat na/.
3
n
"his is to certify that the information here given is
orrectly copied from an original Certificate of Death
my filed with me as Local Registrar. The original
ertificate will be forwarded to the State Vital
records Office for permanent filing.
~. ~!~- rrlA`/ ~ 9 ~ 2007
focal Registrar Date Issued
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS '
CORONER'S CERTIFICATE OF DEATH
(See Instructions and examples on reverse) STATE FlLE NUh®ER
1. Name d Derdea IFh0. nitldle, ~ rM) 2. 5« 3. Saar SemNy Number /. Dale d Deem (Magh, Ee!', Y~1
3638
68
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May 25, 2007
Jeremy R Keifer Male 1 61 -
5. Ap (Let EIrBMay) Undr t Uaur 1 e. DW d Bklh 7, and emY « r. Plo d Daem Clrai ar)
23 raeN °"' ~' ei` April 6, 1984 Carlisle, PA
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Cumberland Carlisle 1000 Block of US Rt. 11 i~rcen,RrermR~iron,em) ( White
Daadea'n Urr d e«N eons meta Na. Do na eYN
11 12. was DerodrN ev« h the 13. DerotleMe Edrrm (Spedry Day elynr Bede angired) 1e. Mules .ear: Herded, Never Merdetl, ib suwwnp span.IN rdb, pNe rromen romel
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d U.S. antra Faar9 ENImuNary ~ semndsry (P72) GNeps (iJ «5+) waoaed Daaced (Spedp~
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1 survey co, ^r« f7ra 12 never married
18. De«dne'e ~4 MA«e (SbaeL dry / mrar, Barr, zip cede)
Dm Darodem
Darotlsnl'a
raid R ne. err PA ~ nc. ®v«, Daadere lrrd h W _ Ponnahnm Twp,
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18. FearYa Name (FYr, nYdde, art euANe ~
William F. Keifer, Jr. 19. Momefs Nero (FNr; nadde, maiden uanrro)
Stephanie Pattison
20a. mmmrnra Name (nTe / Pud) Z00. Inmrriwxe MaMN) Aadr«n ISaer, oNY (town, rw, mde)
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William F. Keifer, Jr. e, PA 17013
870 Easy Road, Carlis
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