HomeMy WebLinkAbout08-27-07
PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF Cumberland
COUNTY, PENNSYL VANIA
Estate of Donald A. Little
also known as
') \~ "70 Or'
File Number /J - (J 1- 0 10
. Deceased
Social Security Number 1955.61-0473
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Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE ~' or 'B' BELOW:)
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D 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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(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 instrument(s) offered
for probate, was not the victim of a killing and was never adjudicated an incapacitated person:
IZJ B. Grant of Letters of Administration
(If applicable, 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 d.b.n.c.t.a., enter date a/Will in Section A above and complete list a/heirs.)
r Name Relationship Residence I
Emma Kerchner Mother 314 East Main St. Mechanicsburg, P A 17055
(COMPLETE IN ALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in Cumberland County County, Pennsylvania with his / her last principal residence at
314 East Main Street. Mechanicsburg. Cumberland County. Pennsvlvania. 17055
(List street address, town/city, township, county, state, zip code)
Decedent, then 27
Maryland. 21221
years of age, died on July 10, 2007
at 1375 Sugarwood Circle, Essex, Baltimore County,
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
(lfnot domiciled in PA) Personal property in County
Value of real estate in Pennsylvania
$
$
$
$
7,700.00
0.00
situated as follows: N/A
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:
I
Signature
Tvoed or printed name and residence
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Emma Kerchner - 314 East Main St., Mechanicsburg, P A 17055
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Form RW-02 rev. 10.13.06
Page 1 of2
Oath of Personal Representative
COMMONWEALTH 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 Decedent, Petitioner(s) will well and truly
administer the estate according to law.
Sworn to or affirmed and subscribed
before me the 9 ../5 f day of
al~ 0 7
j hrf{,fh~. KC rltPrv
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Signature of Personal Representative .-',
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Signature of Personal Representative
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Signature of Personal Representative
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File Number: r;< 1- 0 -1- 0-/ q i
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Estate of Donald A. Little
, Deceased
Social Security Number: 195-62-0473 Date of Death: July 10,2007
AND NOW, OJ ~ vi l~ I ;;(('01 . in 'o",id'mtio~~lh' fO,regoing P"ition. '''',f,cto". pmof
having been presented b re me, IT IS DECREED that Letters e b TA rYl -/':)\ H' L
are hereby granted to
in the above estate
and that the instrument(s) dated
d""ib,d io th, P"itioo b, "'mitt,d 10 pmb", ond fit'" oh';O~f~ I:' tl W~' ('nd C~"i1~')) "fD~d,n':
FEES '___ ,/ ~(LL 11y/ ~/,C)
o Wills
Attorney Signature:
$ I Ie J",C)
Letters 0.. 0 . . . . . . . . . . . '\ -..) '-'
Short Certificate(s) . 0 0 . 0 . . . $~ 'OD
Renunciation(s) .......... $
~W f . o. $ \0. (-::)l~
C'~Jt\~r-..Y'~T\D')" .. . $ C:;. LD
0" $
. .. $
.. . $
. .. $
0" $
. .. $
.. . $
TOT AL .............. $
Attorney Name:
Supreme Court 1.1). No.: 92207
Address:
4660 Trindle Road, Suite 201
Camp Hill, PA 17011
Telephone:
717-761-7573
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Please mail Certificate of Grant of Letters or Short Certificate,
if any, to Shane B. Kope, Esq., 4660 Trindle Road, Camp Hill,
FormRW-02 rev. 10.13.06 PA 17011 Page 2 of2
Donald A. Little
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State
RegIstrar
DHMH 17 Rev 1/2001
OCME 2006
VAUDONLY
wrm
IMPJU',SSED
SEAL
I HEREBY CERTlFYnJAT1'HEATrAc.m:D IS A TRUE COpy OF A
BEeOBD ON 'fILE JNTHE DIVJSIDN OFvrtAL RECORDS.
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/ STATE BEGISTllAK OF ~KECORDS
State of Maryland I Department of Healtn anolVlerrr-cIrnyg":" ,,:,
Certificate of Death
J uDf?Fr~~tl07
1- For State
R i rar
1. Decedent's Name (First, Middle,Last)
3. Time of Death
1013 hrs
Donald
A.
"Little
4a. Facility Name (if r:ot institution, give street and number)
1375 Sugarwood Circle
5. Social Sec..u:ity Number
27
1 CC. City, Town or Location
Mechanicsb1irg
1 Cd. Inside City Umits
1~YeS 2 ONO
314
1Of. Zip Code
17055
USA
10g. Citizen of What Country?
East Main Street
~ 11, Marital Status
~ ~ Never Married
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12. Was Decedent Ever in U.S.
2 DMarried Armed Forces?
. 10 Yes . 2U No
4 D Divorced If Yes, Gi,ve Year . "
13. Was Decedent of Hispanic Origin? (Speciiy Yes or No-
tf Yes, specify Cuban,. Mexican. pLierio Rican, etc.)
1 0 Yes 2:[] No spe~ffy:
14. Race - American Indian, Black,'
_White. etc.
3 D Widowed
Spe~ffy: Wh i t e
15. Decedent's Education (Specify only highest grade completed)
College (1-4 or 5+)
16a. Decedent's Usual Occupation (Give kind of work done
during mast o~ wor~j":lg .life. D9 NOT use retired)
16b. Kind of Business/Industry
Elementary/Secondary (0-12)
12
Heavy Machine
Operator
Construction
17. Fathe~s Name (First, Middle, Last)
Don Little
1 8.Mothe~s Name (First, Middle, Maiden Surname)
'Emma'Zisa
19a. informant's Name/Relationship (Type., Print) .' .
Emma Kerchner . (Moth~i)
19b. Mailing Address (Street and Number or Rural Route Number. City or Town, State, Zip Code)
E. M~iri Street~ Mechanicsburg, PA
20a. Method of Disposition
1 0 Burial 2~Cremation ~'Removal from State
Immediate Cause (Final disease
or condition resulting in death)
-.......
Sequentially list conditions,
if any, leading to immediate
cause. Enter Underlying Cause
(Disease or injury that initiated
events resulting in death) Last
b.
-'-)
Due to (or as a consequence of):
c.
Due to (or as a consequence of):
C)
o UNPENDED
d.
o AMENDED
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IF FEMALE:
23b. Was decedent pregnanfin the
past 12 months?
23c. If yes, outcome of pregnancy
1 0 Uve birth 2 0 Fetai death
4 0 Pregnant at time of death 5 0 Other (Specify)
10 Yes 20 No 9 0 Unknown 90 Unknown
Part II. Other significant conditions contributing to death but not resulting in the underlying cause given in Part I.
3 0 Ectopic pregnancy
23d. Date of delivery
Month Day Year
23e. Did tobacco use contribute to the cause of death?
1 0 Yes 2 ~ No 3 0 Probably 4 0 Unknown
24a. Was an
autopsy
perform~?
1.~Yes 2UNo
25. Was case referred to medical 26.Place of Death (Check oniy one)
examiner? H 't J 0 h
1 I'll Yes 2 n No osp' a : 1 D Inpatient 2 0 ERlOutpatient 3D DOA I er40 Nursing Home 50 Residence 6 ~ Other: Scene
27. Manner of Death 28a. Date of Injury 28b. Time of Injury 28d. Describe how injury occurred
10 Natural 50 Pending FO!f1I\ffJ,oay.Yearj FOUND: Subject hanged self
20 Accident Investigation Ju110,2007 1000 hrs
3 ~ Suicide 6 0 Could ~ot be 28e. Place of Injury - At home, farm, street. factory, office building, etc. 28f. ~~~~, ~~~)t and Number or Rural Route Number, City
4 0 Homicide determined (Specify) residence 1375 Sugarwood Circle, Essex, MD
~~~~~~er 1 0 Certifying Physician: To the best of my knowledge, death occurred at the time, date and place, and due to the cause(s) and manner as stated.
Dne) 2 ~ Medical Examiner:~nnd %~~~~irS s~~t~~minatjOn and/or investigation, In my opinion, death occurred at the time. date and place, and due to the cause(s}
ignature and title of certifier 29c. Ucense number 29d. Date signed (Month, Day, Year)
24b. Were autopsy findings available
prior to completion of cause of
death?
1 ~ Yes
20 No
a.C.M.E. July 11, 2007
Assistant Medical Examiner 111 Penn Street, Baltimore, MD 21201
31.Datefiled(MOnjutyr7200i
OCME
ORIGINAL
1-1 1 ()<;.q<1~ PT\". i(, '(\(1 ,
This is to certifY that this is a true copy of the record which is on file in the Pennsylvania Division of Vital Records In accordance
with Act 66, P.L. 304, approved by the General Assembly, June 29, 1953.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
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Frank Yeropoli
State Registrar
Calvin B. Johnson, M.D., M.P.H.
Secretary of Health
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AUG 2 2 2007
No.
.Date
(J")
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H105.144 Rev. 1/91
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
(Coroner)
c.t)
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TYPElPRtNT
IN
PERMANENT
BLACK INK
SEX
ST,llTE FILE NUMBER
SOCiAl SECURITY NUMBER
UNDER 1 OM
Hours Minutes
181-40-8003
BIRTHPlACE {City and
State (l( F(l(eign Country)
~ID
MARITAl STATUS. Married
Never MlltMd, Widowed,
-(Specifyl
". Divorced
RACE. Americaf'llndan, BIactt. White, etc.
(Spec""1
I.. White
SURVIVING SPOUSE
(If wife, give maiden name)
....
17b.Cou
Philadelphia 17..1KJ ~"="'=of
MOTHER'S NAME (FIf'1l:, Middle. Maiden Surname)
11. Marie Wesner
INFORMANTS MAlUNG ADDRESS (Street. CityfTown. Slate, Zip Code)
P.O. Box 74, Cedars, PA 19423
PlACE OF DISPOSITION - Name 01 c.metery. Crematory lOCATION - CityJ1"own. State, Zip Code
"'''''''''-
Lansdale
oily""""
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ORE Of DISPOSITION
_.Doy,-
D 2'" Dec. 24, 2002
OR PERSON ACTING AS SUCH lICENSE NUMBER
22b. 010382-L
the beei: of my knowtedge, dMth OCctwredat the'ltrM, date ana PIacti'Stated.
(Signature and TItie)
21c.
21.. Franconia, PA
18924
Funeral
ack, PA
UCEN NUMBER
23a.
TIME OF DEATH
DATE PRONOUNCED DEAD ~Month, Day, Year)
~UPTURED ARTERIO-VENOUS MALFORMATION
DUE TO (OR AS A CONSEQUENCE OF):
2..
.Approximate
I interval between
! onset and death
NoD
2.. 1: 35 m t,I, 2.. 21 Dee 2002
27. PART I: Em. the diseases, injurie$ or cornplicalions which caused the death. 00 not enter the mode of dying, such as cardiac or resplratoty arrest, shock or heart faih.tre.
list only one cause on each line.
PART II: Other slgnificanl: concItiont contributing to death. but
not ~ng in m. undetl'jing <*JH given in PART I.
CIRRHOSIS
b.
DUE TO (OR AS A CONSEQUENCE OF):
BLUNT FORCE INJURY
DUE TO (OR AS A CONSEQUENCE OF):
.
WERE A.UTOPSY FINDINGS
-"'llABlE PRIOR TO
COMPLETlON OF CAUSE
OF DEJJH1
MANNER OF DEJOli
DATE OF INJURY
(Month. Day, 'l'8ar)
TIME OF INJURY
INJURY I{f WORK?
NaI'ural
D
DC
D
Homicide
D
D 3~OWN 3iJ.NKNOWN t,I.
o ~~~~~~~MAI home, farm. street, factory, office
3...
Vos Xl
NoD
Accident
Pending Investigation
Could not be determined
21.. 28b.
CERTIAER (Chock only one)
-CERTIFYING PHYSICIAN (Physician certifying cause of death when another physician has pronounced death and completed Item 23)
TohbeMofmyknowe.dge, deethoecurredduetothecau.e(S)andmMnWasbted.....................................
Suicide
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-PRONOUNCING AND CERTIFYJNG PHYSW:IAN (Physician both pronouncing death and certifying 10 cause of death)
Toh ~o'my knowtedge, deethoccurred at the u.n.. date, and place, and due to the caUM(s) and manner.. stated.... .. .....
D,IJ"E ~NED (Month, Day, Year)
D 31,. 31.. 12 Mar 2003
NAME AND A.DDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH
Illem2'(;f1"e"P""MeDonald DO
DO ASS1ST.i;\NT MEDiCAL EXAMINER
~. 321 Unlverslty Avenue
D,&;rEAlED(Mooll1, Day, Year)
-MEDICAL EXAMINER/CORONER
On the besis of examination and/or investigation, In my opinion, death occurred at the time, date, and place, and due to the cauae(s) and
mannerustateel................................................................................................. .
31L
REGISTRAR'S SIGNATURE AND NUMBER
5T ATE OFFICE-3 7- 0
34.
AR 2 4 2003
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