HomeMy WebLinkAbout07-24-07
PETITION FOR PROBATE AND GRANT OF LETTERS
,
COUNTY, PENNSYLVANIA
REGISTER OF WILLS OF
Estate of
j1;hJfl-RLJ tJ,
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File Number
2-} -- O~7 - 0'"703
, Deceased
Social Security Number / i"tJ -;:, ~ - t, "I' r
also known as
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
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Except as follows, Decedent did not malTY, was not divorced, and did not have a child born or adopted after executionC1Jti the instrumefui$) offered
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for probate, was not the victim of a killing and was never adjudicated an incapacitated person: ' ~. ~ -
--n C
~rant of Letters of Administration~-: i=J :;
. (If applicable, enter: c.t.a.; d.b.n.c.t.a.; pendente lite; durante absentia; durante 11iinor'uate)
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Petitioner(s) after a proper search has / have ascertained that Decedent left no Will and was survived by the following spouSe: (if any) antt heirs: (If'
Admlllistratioll, c.t.a. or d.b.n.c.t.a., enter date of Will In Section A above and complete list of heirs.) , ~j~ W
(State relevant circumstances, e.g" renunciation, death of executor, etc.)
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Name
Relationship
Residence
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(COMPLETE IN ALL CASES:) Attach additional sheets ifnecessary.
ylvania with his / he ast principal residence at
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Decedent, then t.- 9
years of age, died on 45- / / - 0 7 at
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Decedent at death owned property with estimated values as follows:
(If domiciled in P A) All personal property
(If not domiciled in P A) Personal property in Pennsylvania
(I f not domiciled in P A) Personal property in County
Value of real estate in Pennsylvania
$
$
$
$
situated as follows:
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
tile undersigned:
~G.;1~ dHMb~ /-!,""LL
f!HI(,l('.sJ,uN.& h-
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Form R W-02 rev. /0 /3,06
Page 1 of.2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
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 know ledge and belief of Petitioner( s) and that, as personal representative( s) of the Decedent, Petitioner( s) will well and truly
atlminister the estate according to law.
SS
COUNTY OF
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Signature of Personal Representative
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Sworn to or affirmed and subscribed
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Signature of Personal Representative
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Signature of Personal Representative
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Estate of
, Deceased
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AND NOW,
having been presented before me, IT I
are hereby granted to
in the above estate
and that the instrument(s) dated
described in the Petition be admitted to probate and filed ofreC!
FEES
Attomey Signature:
as the last Will (and Codicil(s)) ofD
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TOTAL . . . . . .
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$ 10. LY)
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$
$
$
$
$
$
$
$ (pl.Ot;
Attomey Name:
Letters
Short Certificate(s) . . . . . . . .
it :f';/
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. . - -.. -I
Supreme Court I.D. No.:
Address:
Telephone:
Form R W-O] rev. / O. /3. 06
Page2of2
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Thi _, is 10 certify that the information here given is correctly copied from an original certificate of death drly fikd w th me as
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent fit ng
WARNING: It is illegal to duplicate this copy by photostat or photograph.
No,
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Fee for this certificate, $6.00
Local Registrar
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13354886
MA Y 1 5 2:007
Date
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REV 11/2006
I PRINT IN
'o4ANENT
,CK INK
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
(See instructions and examples on reverse)
Dauphin
. S. Hershey Medical Center
STATE FILE NUMBER
4. Dale of Death {Month, day, yea!l
_6088 5-11-2007
1. Name 01 Decedent (First, mit:klle, Ias\, SUffiK)
Richard W. Smith
5. Age (Last Birthday)
_ 69
6. Date of Birth (Month, day, year)
6-25-1937
Steelton, PA
0tl1e,
o Nursing Home 0 Residence DOHler. Specify:
9. Was Decedenl of Hispanic Ongin? XJ No 0 Yes 10. Race: Amencan Indian. Black, While, etc,
(I! yes, specify Cuban, (Specify)
Mexican, Puerto Rican, etc.) Whi te
v".
8b. County of Death
8d. Facility Name (If not institution, give slreet and number)
319 7th Street
17b County Cumber land
17c.O Ves, Decedenl Lived in
17d.aij No, Decodenl Li....wrthln New Cumberland
Actual Limits 01
TwO
ruck Driver
. 16. Decedenfs Mailing Address (Street, city I town, stale, zip code)
12. Was Decedent ever In the
U.S. Armed Forces?
Dves aijNo
Decedent's
Actual Residence 17a. Stale
13. Decedent's Education (Specify only highest grade completed)
Elementary' Secondary (0-12) College (1-4 or 5+)
12
Pennsylvania
14. Marital Status: Married, Never Married,
Widowed. Divorced (SpecifY!
Widower
City/Bore
18. Father's Name IFirst, middle,lasl, sl1ffi~)
John Smith, Sr.
208. Inlormanfs Name (Type I Print)
Ms. Paula E. Keener
19. Mother's Name (First, middle, maiden surname)
Daisy Griffey
2Ob. lnformanfs Mailing Address (Street, city I town, state, zip code)
319 7th Street. New Cumberland, Pennsylvania 17070
21a. Method of Disposition i [X Cremation 0 Donation 21b. Date of Disposition (Month, day, year) 21c. Place 01 Disposition (Name of cemetery, crematory or other place)
o Bunal 0 RamovaJfromS!ate ! W..Cram.llonorDonalionAuth~ Cremation Society of PA
o Other - Specify: : by Medical Examiner I Coroner? 4:..J Yes D No
22a.Sig ofF IS~~e(o~n~.cting~s~~)" 22b.LicenseNumber 22c.NameandAddressofFacility Auer Memorial Home and
. ~ (.. /wu... ~ 4100 Jonestown Road Harrisbur
Comptet ems 238< only when certitying 233. To the best 01 my knowledge, death OCCUlTed allhe time, date and plat! slated. (Signalure and tdle) 23b. License Number
physician is no! available at lime of dealh to
certify cause 01 death,
21 d. Location (City I town, stale, zip code)
Harrisburg, PA
17109
tlems 24.26 must be completed by person
. who pronounces death
24, Time of Death 1 '. \ 5
CAUSE OF DEATH ( Instructions and examples)
Item 27. Part I: Enter the ~ - diseases, inluries, or complications - thai directly caused the death. DO NOT enler tenninal events such as cardiac arrest,
respiratory arrest, or ventricular fibrillation without showing Ihe etiology. List only one cause on each line.
Inc.
23c. Date Signed (Month, day, year)
D1
26. Was Case Referred to Medical Examiner I Coroner lor a Reason Other than Cremation or Donation?
OVa, ONO
/
Dves 0'''''
3Ob, Were Autopsy Findings
Available Prior to Completion
01 Cause of Death?
DVes ~
31. Manl'l8r 01 Death
~:ral 0 Homicide
o Accident 0 Pending Investigation
o Suicide 0 Cauk:! Not be Determined
Part II: Enter ether sioniflcanl conditions contribulina 10 dealh, 28. Did Tobacco Use Contribute to Death?
bul not resulting in the underlying cause given in Parll. D( Ves 0 Probably
o No 0 Unknown
29. If Female:
o Notpregnantwilhinpaslyear
D Pregnantaltimeoldeath
o Not pregnant, but pregnanl within 42 days
01 death
o Not pregnant. but pregnant 43 days to 1 year
before death
o Unknown il pregnant within Ihe past year
32c. Place of Injury: Home, Farm, Street, Factory,
Office Building, etc. (Specify}
Sequentlaly list comtl~ions, n any,
IllalloQ to the cause listed on line a.
Enter !he UNDERLYtNG CAUSE
(dsease or injury that Initialed the
events resulting In death) LAST.
a D~~{r:~l~h. oY\~("f eM bbli"M
b. ~,{)t;jfla fo-lU lootll>lt I'Ch
Due to (cJ as a consequence on:
D~~;~~nll"~~ \\l.4I\ t~" c,tI
~i:r:~~~'~\dise~
308. Was an Autopsy
Performed?
32d.Ttmeollnjury
329, Location 01 Injury (Street, city f town, slale)
338. Certifler (check only one)
Certifying physk:lan (PhysiCian certilying cause of death when another physician has prooaunced death and completed item 23)
To the best of my knowledge, death occurred due to the cauI.(a) and manner as stated.- _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0
~~o=:~~~,a~~ =~~:~~~(::::~ :hli=:~n~n~:c:~~~rt~':~ot~:~:;~~~a:~ manner as staled- _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0
~:~::8m~;,:~~;~~~: and I or investigation, In my opinion. death occurred alltle lime, date, and place, and due 10 the cause{sl and manner as slated_ 0
35. Registrar's Signa
~ (
ndo;st"ctN~ ~
lo<.l/l~I/I/1
~ ~h !-to
33c_ License Number
MT \ '7)11, 31
34. Name and Address 01 Person Who Completed Cause of Death (llem 27) Type I Print
Ii A-l.>':>A- N Stt ~ 1 ~ u M.S. Hershey Medical Ctr.
'1 l~n Hershey, PA 17033
Disposition Permil No
0117033
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RENUNCIATION
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. REGISTER OF WILLS
C () (v1{l, fi/Lt..~1MJ COUNTY, PENNSYL VANIA
~ 1-07-103
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Estate of
fL 1 C Hrt-!L(.)t.-L S- i'---ctfH
, Deceased
I,
C/~ftf~ 1/1 Sju/:/?t
, in my capacity/relationship as
of the above Decedent, hereby renounce the right to
c- I (Print Name)
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administer the Estate of the Decedent and respectfully request that Letters be issued to
\
i.N~ '-L.r~ S'~j)'1 ~'L,^ o-!'~ S ~i'v'tke/'
'N
6/;;i!o7
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(Signature)
b 3/f /ld:- 5Y
w~ &~-' Ilt /liJ70
(City, Slale, Zip)
(Date)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this day
of
~
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Dr\..Q.;'
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( 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
purp~stated within on this c2C; day
of ~A ~ ~ , c:1oo1
j~~{ID~~
No~
My Commission Expires:
Deputy for Register of Wills
(Signature and Seal of Notary or other official qualified to
administer oaths" Show date of expiratIOn ofNOlary's Commission")
NOTARIAl SEAl
MARGARET A DARHOWER NOTARY PUBLIC
CARLISLE BORO, CUMBERLAND COUNTY PA I
MY COMMISSION EXPIRES OCTOBER 27 2008
Form RW.u6 rev" )0" 13"06
RENUNCIATION
L
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REGISTER OF WILLS
C vI Mf,~LtJ-;v..,o COUNTY, PENNSYLVANIA
~{-07-()70.3
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Estate of
{L'i'L H M-IJ
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c; iv--t--n1
, Deceased
I,
M 1~-P-- i e....o 5 \Z
S'i-Ve6-61L
, in my capacity/relationship as
ofthe above Decedent, hereby renounce the right to
(Print Name)
O/tl^(;t{'iWL.
administer the Estate of the Decedent and respectfully request that Letters be issued to
\tvT L.L.l::.4M S...,s.[i,
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m.Jr(~1) .s
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't lfm Rtf-ff{ ,;2(X)7
(Date)
l")8 J1lMV.5
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(Street Address)
'j2.. 4 "t:tt~/-4 v,'I1e... P n
/
\?OZ.3
(City, Stale, Zip)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this day
of
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{:;. .\' \.Q.. .3)
f1d
o
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
~ted within on this ~)~ day
~~~~
Notary Public 'I
My Commission Expires: CU~3,D....... ~8'
Deputy for Register of \Vills
Slgnature and Seal oiNotary or other OniClal cuallDed to
J.drr'.lr.lsrer oaths. Show date of expIration or'No:ary's Commlsslon.)
;'":"orm :") ff'Ji6"Qv ).
COMMQNWEAU'H Of. p VlVA
NOTARIAL. SEAL .
LAURA A. TARASEWICH, Notary Pubtic
SusQueha~a Twp..' Dauphin County
My Commisslon.~xPlre~,,~Ug: 30. 2008