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Home My WebLink About08-10-07 Estate of Susan L. Semuta also known as PETITION FOR GRANT OF LETTERS OF ADMINISTRATION J) 1- ()7 -n75fJJ No. To: Deceased. Register of Wills for the County of Cumberland in the Commonwealth of Pennsylvania Social Security No. 202365849 The petition of the undersigned respectfully represents that: Your petitioner( s), who is/are 18 years of age or older, appl for letters of administration on the estate of (d.b.n.; pendente lite; durante absentia; durante minoritate) the above decedent. Decedent was domiciled at death in Cumberland County, Pennsylvania, with h er last family or principal residence at 208 Senate Ave. Aot. #1015. Camo Hill. PA ~ "'" (list street, number, Twp. or Boro.) Decedent, then 60 years of age, died 6/ 2007 at 208 Senate Ave. Camo Hill. PA Decedent at death owned property with estimated values as follows: (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: Estate opened for litiQation purposes. ~IIJOO.OO $ $ $ $ Petitioner after a proper search ha S the following spouse (if any) and heirs: Name ascertained that decedent left no will and was survived by Relationship Residence 244 Big Springs Road Etteffi PA 25 S. 8th Street, Apt. B Lemo ne PA 414 Hivner Road Harrisbur 17319 Me an Martin Dau hter Mia Semuta Dau hter 17043 Michael Semuta Son PA 17111 C) THEREFORE, petitioner( s) respectfully request( s) the grant of letters of administration in thi: appropriate form to the undersigned. Ul .r:- ~e~ 'V~ 244 Big Springs Road Etters PA 17319 ~ '" or o 1J :E "'~ ~i "'0 '" '" 0 '" ";:: ~.;:: ~~ ......... .a 0 '" 6b iZi OATH OF PERSONAL REPRESENTATIVE COMMONWEAL TH OF PENNSYL VANIA } ss COUNTY OF Cumberland 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 above decedent petitioner(s) will well and truly administer the estate according to law. .~ { ~ ~ C) ;s -o~ -:"~ l~~2 r-...,) ':::::.~) ~ --' ::nn c: G) 0-\_:-; -;--1 a ....-"." ;: No. )}, / -() 7- -75lfl ci VI .." Estate of Susan L. Semuta , Deceased GRANT OF LETTERS OF ADMINISTRATION AND NOW , in consideration of the petition on the reverse side hereof, satis cto proof ving 1?een presented before me, IT IS DECREED that /vU qao M.artJ n is/are entitled to Letters of A~stration, and in accord with such fmding, Letters of Administration are hereby granted to -.iUll~. n in the estate of Susan L. Semuta FEES OD J ,etters of Administration. . . . . . $ ,?f). Short Certificates (5 )...... $ ,gO.DD R " $ L0/){) _10f~tV~fu~~' $ 1~-lJO TOTAL _ $ Filed . . . . . . . . . . . . " A.D. 75. DD IIb/kf" j) /1 s '7/7 111()"; '<.{h I\!\ dl-C 7 -D 75Cr: LOCAL REGISTRAR'S CERTIFICATION OF [If::l, H VVARNING: It is illegal to duplicate this copy by photostat or photoTap'L Fcc I", Ihi, ,-nltlll~li( '.hll'l ;"ii;"S(1['ii?f;:t-~ /", ~'" '4'J'/'-,:, \,,~/ liii.a.. \?"7::.\ '~~~~~/-~' t~.. ~ .~~. i~ c), .. < _~ ,,~ ".. ':bJ '~. 1t'1.&"';-< ~~, ,- ;' .-J/ \'% ,~~",;; ;;"'-~ 1',f > . . 1<.. ""~<~ :'''':-/,MEN1 \)\~,'I'! '-!!':./~(.!I!J/"!;'-""- -__.f__1J.5. 5118..3. 1'c'niitC,JlillIl \iI'l1:" I REV 11/2006 I PAINT IN MANENT \CK INK ThIS t., I,) en I th h: i'!fOrm,llioll here ~Ivell j, ,'orl'l:ctilc'o)1j", ro,;, "J'l~illal I 51ifil'~lle 01 Death ':lIh likd l'lt'l i1h' (leI! RC~'lrar. The origlIlal ,t'Li'i,aic'I\1 h, \'\\;Iri.l'd [(, the SLIll' Vil;li ~)~'~'''''''H''H !'Ii",' " JUN 3 U 1007 -~--L___l_____ i'!c'dl ReglSl!'.1 Datl' 1:'';Ul'd C) (::;0 --::-:0 , '-'-1 ','C) ",: 1'-- -_.~ ~q 1~,.J C.::) t':::) -..l :n- C G~) c /~"'... 1'1 o COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS CERTIFICATE OF DEATH (See Instructions and examples on reverse) Ul r 1_ Name 01 Decedent (Rrst, middle, lasl. suffix) Susan STATE FILE NUMBER 19. Mother's Name (First. middle, maiden sumame) Evelyn Saline 20b. Informant's Maijing Address (Slreet, city llown, slate, zip COde) 25 B South Eighth Street, Lemoyne, PA 17043 L. Semuta 5. Age (Last Birthday) 6. Date of Birth (Month, day, year) 60 Y~ September 23,194 8b. County of Death 8d. Facility Name (If IlOt institution, give street and number) Perry Kinkora Pythian Home . 16 Decedent's Mailing Address (Stree!. city I town, state, zip code) 208 Senate Avenue, Apt. 1015 Camp Hill, PA 17011 18. Father's Name (FlfSt, middle, last, suffix) Lyle Polito 20a. Informant's Name {Type / Print) Mia E. Semuta 12_ Was Decedent ever in the U.S. Armed Forces? DYes ~No Decedenrs Ac1ualResidence 17a. State Pennsylvania Cumberland 13. Decedent's Education (Specify only higheSl grade completed) Elemental)' I Secondary ((}'12) Coflege (1-4 or 5+) 12 2 17b. County 202 - 36 4. Date of Death (Month, day, year) June 26, 2007 5849 Other' fig Nursing Home 0 Residence 0 Other - Specify Q9 No 0 Yes 10_ Race: American Indian, Black, While, etc (Specif}) white 14. Marital Status: Married, Never Married, Widowed, Divorced (Specifyj divorced Did Decedent Livefna TownShip? 17c. ~ Yes, Decedent Uved in 17d. 0 No, DecedentlNed wilhin Actual Limks 01 E. Pennsboro Twp City/Boro . ~ 21 c. Place of Oispositioo (Name of cemetery, crematory or other place) Evans Crematory Schaefferstown, PA 17088 21d, Location (City I town, stete, zip code) 22c. Name and Address of Facility Parthemore FH & CS, Inc., P.O. Box 431, New Cumberland, PA 17070 Approximate interval Part II: Enter other sianificant COOOitions conlributioo to death, 28. Did Tobacco Use Contribute 10 Death? Onse! to Dealh but nol resufting in lhe underlying cause given in Part I. 0 Yes 0 Probatily Jl!. No 0 Unl:nown 29_lfFemale o Not pregnant wilhin past year o Pregnanlatlimeofdealh o Not pregnanl, but pregnant within 42 days of death o Not pregnanl, but pregnant 43 days 10 1 year before death o Unknown if pregnant within the pasl year 32c. Place of Injury: Home, Farm, Street, Factory. Office Building, etc. (Specify) Hems 24-26 must be completed by perr;on who pronounces death. 2..00'1 CAUSE OF DEATH (See instructions and examples) Item 27. Part f: Enter the ~ - diseases, inJUries, or compiicalions -Ihal direclly caused Ihe death. DO NOT enter !erminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. Ust only one cause 011 each Una :~~~AJe~~~~~~ J~1~\ disea..::. Sequentially list conditions, if any, ~~l~~~o tTNeD~~~I~~A~~nEe a (disease or inju'Y that inrtialed the events resulting," dealh) LAST. 3Oa. Was an Autopsy Performed? 3OtJ. Were Autopsy Findings Available Prior 10 Completion of Cause of Death? 31_ Manner of Dealh ~ Natural 0 Homicide o Accident 0 Pending Investigation o Suicide 0 Could Not be Determine<! 32d. Time 01 Iniury o Yos 1ZI No Dyes DNo 23c. Date Signed (Month, day, year) :3"u,e 2.<.0 I lOOl lZl\! 33 26. Was Case Referred to Medical Examiner / Coroner for a Reason Other than Cremation or Donahon? Dyes I&JNo M. 321. If Transportation Injury (Specify) o Driver l Operator 0 Passenger Dpedestrian DOther-Specify_ 33b. Signalure and Titie of Certifier ~~~ 33a. Certirler{dleck only one} Certifying physician (PhYSICian certifying cause of death when anolher physician has pronounced death and compleled Item 23) To the best of my knowledge, death occuned due 10 the cause{s) and manner as slated- _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ~ ;~:u':~~fa~ :::~~:~~:a::c~~:.:~~; I~h.~~~~:~:;n~';~:c~~~:"~~e;o'~~a:::.:.~~:~ mann" as Slaled. _. _ _" . " _ . _ . . . _. 0 Medical Examiner I Coroner On Ihe basis of examination lInd I or investigation, in my opinion, death occurred at the time, date, and place, and due to the C8Use(S) and manner as stated_ 0 32g_locationoflnjury (Street, citY/lown, state) .~ 33c. License Number I\.A.-t? D I:, I -440 -L. 34. Name and Address of Person Who Complete<! Cause of Death (Item 27) Type I Print Madhu Menon, MD, FRCS Pinnacle Hea~h Family CarE 1021 /I~I /1/ I Disposition Permit No. tJ / / 7 c1 s ? Newport, PA 1707A Estate of Susan L. Semuta also known as ,~I . () 7 - OI7So".~ Q c5 '""" 0 -..J . <P,') :n>: ~.::. ::': ,:-) ,7) 'co" (.-- =::-"rn ",':J"] 0 RENUNCIATION No. , Deceased The undersigned,Daughter (Relationship) (Capacity) '-.~. -' ".,./..... )'j '-_.I I :'8 ~i~ o U1 ~ of the above Decedent, hereby renounce(s) the right to administer the estate and respectfully request(s) that Letters Administration be issued to Megan Martin ! Witness ~ hand this Sworn to or affirmed and subscribed day of ,JiJn. Notary llc . ~ My Commission Expires; ~\t:... (, I 2l) \0 (Signature and seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's commission.) RW-3 Mia Semuta, 25 Lemoyne (Address) (Signature) (Address) (Signature) (Address) COMMONWEALTH OF PEf\!N8V!.VA!\!lA Notarial Seal Kelly J. Koppenhaver, Notary Public City Of Harrisburg, Dauphin County My Commission Expires Apr, 6, 2010 Member, Pennsylvania Associa';c:n of Notaries PA 17043 NOTE: Renunciations executed outside the Office of Register of Wills are required in some counties to be notarized. also known as RENUNCIATION C) No.,} 1-0 7 -()7Jff:,~ ':O~(.2 -'\;1 -~-~) r-~ c:::J = --l J':P c:: L;'" Estate of Susan L. Semuta (;) , Deceased 1',._.--. ::I:~ 5 .. ~l .r.- The undersigned, Son (Relationship) (Capacity) of the above Decedent, hereby renounce(s) the right to administer the estate and respectfully request(s) that Letters Administration be issued to MeQan Martin Witness -1#--- hand this iIJ!:J!t!"s.+ ?a> 7 (Signature) Michael Semuta, 414 Hivner Road HarrisburQ PA 17111 (Address) (Signature) (Address) (Signature) (Address) Sworn to or affirmed and subscribed before me thiS~ day of ,~. COMMONWEALTH OF PENr'-JSY'LVANIA Notarial Seal Kelly J. Koppenhaver, Notary Public City Of Harrisburg, Dauphin County My Commission Expires Apr. 6, 2010 Member, Pennsylvania Associ~'nn of ~!ot2ries Notary ic k My Commission Expires: v.~ ~ 120 iQ (Signature and seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's commission.) NOTE: Renunciations executed outside the Office of Register of Wills are required in some counties to be notarized. RW-3