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PE1TrIO:\ FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF k/ti.<hrAAf't'c/ COUNTY, PENNSYLVANIA
,,,,,,,,r f.v?./2j j) 211ft' #4
also known as
Ftle Number
-2 J- 0'1- C)g~ 2-
, Deceased
Social Security Number dO / - ;:) &~- /7{)O
I'dilIUIICr(S), who is/arc I S 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 \Vtll of the Decedent dated and codicil(s) dated
named in the
C--)
(Sldtl! rdl!Vwlt circumstances. e.g.. renunciation, death o/executor, elc.)
f' -j
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 [Jrubatc, was nul the victll1l of a killing and was never adjudicated an incapacitated person:
~rant of Letters of Administration
( J ~
(If applicable, ellter: c.t.a.; d.b.ll.c.t.a.; pelldellte lite; durallte absentia; durallte milloritaTr!
Pctltioner(s) after a proper search has! havc ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs: (If
Administratioll. c.I.a. or d.hII Cl.a., emer dLite of Will in Section A above and complete list a/heirs.)
~ Name
d;j -/ ~#~/fy
~ -, .
Relationship
1U4#'
Residence t
r[CA1t:-:t0~ /f-2/h
on
(List stieet address. towII/cily, to"vIz lip, COl/llt)', slate, zip code)
Decedent, th,~n ~ 9' years of age, died on ~, J,3
.Joot .A
at ~
Decedent at death owned property with estimated values as follows:
(I I' domiciled in P A) All personal property
(If not domiciled in PA) Personal property in Pennsylvania
(If not domiciled in PAl Personal property in County
Val1.le of real estate in Pennsylvania
,$/
$ /O()() , {j()
$
$
$
situated as follows:
Wherefore, Peutiol1cr(s) respectfully request(s) the probate oflhe last Will and Codlcil(s) presented with this Petition and the grant of Letters il1 the appropriate form to
the undersigned:
Fo,.", RW-O.! rev {O.13.06
Page I of2
Oath of Personal Representative
COMMONWEALTH OF PENNSYL VANIA
CO~TYOFC:~~~{~
SS
The Petitioner(s) above-named swear(s) or affirn1(s) that the statements in the foregoing Petition are true and con-ect 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,
Signature of Personal Representative
~.~
,.-.)
Signature of Personal Represenlative
File Number: ;) I - 01- O~d
Estate of
, Deceased
<~"')
\~ ';2~- D-OOlo
in the above estate
and that the instrument(s) dated
d,,,,,bed m "" p"n~:~:: ,dnnltcd (0 pmb"e Md filed or:;;];:;;; !i/;:':d:~)~OfDC"d"'t. ~'
$ CIJ /1 00 RegIster 0 WIlls ~\ ~
Letters .. , .,'.... .. _'?!.. v ,- .
ShOl t CertIficate(s) .. ,.... $$ [2) cD Attorney Signature: j
Renunciation(s) ,.....,...
~)(1 P $
C''''\'''-^'+:'rnn--r-;:~ $
$
$
$
$
$
5)
$
TOTAL ..... . . . . . . . . . 5) q ~ . 00
/0 00
5.L1D
Attorney Name:
Supreme Court LD. No.:
Address:
Telephone:
,.... n '" "....
,r'Jl"l!I .'\.."l'-'J': P-~'l' (!I!~).~}I)
Page 2 of2
il lc'lli!\ liLI! IhL' illlf'rIlldliOIl hl'll' gi\l~n i~ correct I) copied Imill ,III origll1dl ,._'nilic;ll, id,k;llh dul\ likd 11'111 Illi' d"
I: 'i.'lsILlrlh' ilrlC'llui cc'rlillc,lk ,\il! hc f(llwarded to the Stall' VILt! Rl'Curds OiliL'l' JUI pl'tlll,IILIJl lillll;.'
WARNING: It is illegal to duplicate this copy by photostat or photograph.
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1\1,.,,1 k"~'I'I!,lr (J
P 12842875
"Ir\' 2 0 2006
J..L",~~___. .. ______ .
) I)" Il'
("- ~I
Co,)
3 REV 02/2006
:fPRINT IN
~MANENT
,l,CKINK
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
Cumberland
7. Birth ace Ci
3 Social Security Number
STATE FILE NUMBER
4. Dale of Dealh (Month day. year)
1, Name 01 Decedent (First. middle, last. suffix)
5 Age (Last Bir1hday}
Terry D. McCafferty
Under 1 da 6 Dale of Birth Month, da
'201
- 26
1700
December 23 2006
1t Decedenl's Usual Occupi1lion Kind of work done durin masl of world life Do nol slate retired
Kind 01 Work Kind of Business I Industry
Road Construction Construction
. 16 Decedent's Mailing Address (Street, city I town, stale, zip code)
1125 Harrisburg Pike Apt. 4
Cartisle, PA 17013
1125 Harrisbur
12 Was Decedent ever in the
U.S, Armed Forces?
fXlyes DNo
Other
o Inpatient 0 ER / Outpatient 0 DOA 0 Nursing Home
9 Was Oeced~nl of Hispanic Origin? f] No 0 Yes
(I/yes, Specify Cuban
Mexican, Puerto Rican, ete)
14 Marilal Slatus Mamed. Never Married
Widowed, Divorced (Specify)
-&J ReSidence 0 Other. Specify
to Race American Indian, Black, White, ele
(Specify)
69 Y~
8b County of Death
6-29-1937 McKeesport, PA
8d, Facility Name (If not institution, give street <Wld numberl
17bCounty
Pennsylvania
Cumberland
19 Mothers Name (First, middle, maidefl surname)
Married
Did Decedent
liveina
Township?
White
Decedent's
Actual Residence 17a Slate
17e&] Yes.Dec.edentli'ledin
17d,D No, Deced_enl Lived within
ActualLlmllsof
Middlesex
Twp
City/Boro
18 fathers Name (First. middle,lasl. suffix)
George McCafferty
Ethel Beattie
20b Inlonnanl's Ma~ing Address (S.lree!. city Ilown, state, zip code)
1125 Harrisbur
PA 17013
2Oa, Infonnanl's Name (Type I Print)
21 a Melhod of Oisposition
o Burial 0 Removal from Slale
21b Date 01 Disposilion (Month, day, yeil"l
PA 17109
Inc.
Complete Items 23a-<: only when certifying
physiClanis not available at time of death to
certify cause 01 death
Items 24-26 must be comple!ed by pen;on
who pronounces death
23, To lhe ~ my ,,,.ledge, de,,, OCC"rred, I
24 Time of Death
)..'.00
23c Date Signed (Monttl. day year)
I.?- ~
1.R-:~3-00
Dyes
CAUSE OF DEATH (See instructions and examples)
Item 27 PART \ Enter the 1tIa!nJlLe.'!'M.ts. - diseases, Inl'.mes, or complications. thai dllectly caused the death DO NOT enter terminal events such as cardiac arrest.
respiratory arrest, or venllicular fibrillation without showing the etiology, List only one cause 0f1 each line
: Approximaleinterval
: OnselloOeath
Pari II: Enter other sianificant conditions conlributina to deatl1
but nol resulting mthe undertying cause given in Part I
28D'dTob~:;..contnbutetoDealh?
o Yes...a-Probably
o No 0 Unkr1Qwn
29 If Female
o Not pregnant wllhlO past year
o Pregnantatlimeotdealh
o Nolpregnanl,butpregnantwithlO42days
ofdealh
o No! pregnanl, but pregnant 43 days to 1 year
ofdealh
o Unknown it pregnanl within the past year
32c Place of Injury: Home, Farm, Street. Factory,
Office Building, etc. (Specify)
=~~~~~t~~~ f~~; dise~
,. ...do:
~ "'V('""," . S'H
Due 0 (or as a consequence of)
L~7{/J
Due to (Of as a co equence of)
i~- -,
lo! .'i
Y"',V?
Sequentially Its! condillOfls. if any.
~~~~ ~OE~~~G gAUsE'
(disease Of injury ttlat initiated the
. events resulling in death llAST
Due to (or as a consequence of)
DYes l't No
DYe, D No
31, Manner of Oeath
~atural 0 Homicide
- 0 Accident 0 Pending Investlgalion
o Suicide 0 Could Not be Determined
32d, Timeo/lnlury
Location of Injury (Street. city I town, state)
3Oa. Was an Autopsy
Pertormed?
JOb, Were Autopsy Findings
Awilable Prior to Completion
of Cause of Death?
33a. Certifier (ched. only one)
Certifying physician (Physician certifying cause of dealh when another physidan has pronounced dealh aoo completed Item 23)
To the best of my knowledge, delth occurred due to the causels) and manner as statSSl_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _...D
Pronouncing and certifying physician (Physician both pronouncing death and certifying to cause of death) .
To the besl of my knowledge, death occurred at the time, dale, and place, and due to the cause(s) and manner I. stltld_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ '
~~~:~~~sm~f~~:;'f~~~:~ and I or investigalkln, in my opinion, dealh occurred at the time, dale, and place, and due to the cause(sl and manner as 1tatfd_ _..0
~
1011
/1.,,(1/ (
de
(See instructions and examples on reverse)