HomeMy WebLinkAbout10-03-07
PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF (.)\...>'cv\ t>~ ( ~ COUNTY, PENNSYLVANIA
Estate of
also known as
tr\.J e.t..u
File Number ;}.. \ b'\ b ~ 0'3
Social Security Number ~ t? \ - } b - 1;<9 (
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE ~' or 'B' BELOW:)
o A. Probate aad Graat .rLetten Testameatary and aver that Petitioner(s) is / are the
last Will of the Decedent dated and codicil(s) dated
('"")
c::;O
. ~~rJI
.........-.
c_"")
C~'~:)
-,
n~ed in the
'..-i_J :,...;..--.
,---, "-',
(State re/ev01ll circumskmces, e.g., renunciation, death of executor, etc.)
.:-')";.
Except as follows, Decedent did not marry, was not divorced. and did not have a child born or adopted after execution of the itist@,nent(s) o~
for probate, was not the victim of a killing and was never adjudicated an incapacitated person: :02~
...di) B. Grant ofI.etten or Admillistratioa
'-'( (If applicable, enter: c.t.a.; db.n.c.t.a.; pendente lite; durante absentia; dur01lle minoritale)
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 of Will in Section A above and complete list of heirs.)
(COMPLETE IN ALL CASES:) Attach additiolUll s1teets if lfeCesBary.
(
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
(Ifnot domiciled in PA) Personal property in County
Value of real estate in Pennsylvania
situated as follows: I ~ /V1 'It f ~
Wherefore, Petitioner{s ~~~s ~:;~ oV~ $iIl and Codicil(s) presented with this Petition and the grant of Letters in the appropriate form to
the undersigned:
(..0
FormRW'()2 rev.10.13.06
Page 1 of2
Oath of Personal Representative
COMMONWEALTH OF PENNSYL VANIA
COUNTYOF Cu'M.~' c.~
The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true and correct to the best of
the knowledge and belief of Petitioner( s) and that, as personal representative( s) of the Decedent, Petitioner( s) will well and truly
administer the estate according to law.
: SS
Sworn to or affirmed and subscribed
Q~fC ~
Signotllre at PtirsonoJ Represtmlative
before me the
day of
Signature at PenonoJ Rkpre$mJative
o
So
:--.~-:]
r~~j
r-
':~~
--J
o
~)
Signature ofPel'$onoJ Rkpreserliative
-~=:: i"rl
I
C)
;-,~
. '~--'. .r'-'~
- )C~)-::-i;:i
"U
~ C<)
File Nmnba-, J. \ ~ '1 b "itS -< U1
Estate of I\I'e- l ( l' ~ ~ ~ ~ l ~ 0..-'" . Deceased (...)
Social Secwity Number: '~b \ - 16 - I (q ( Date of Death: q uS o~ T <{ J .1 ~
AND NOW, --1)<.... \v~( ~ . ~Dtfl-, in consideration of the foregoing Petition, satisfactory proof
having been presented before me, IT IS DECREED that Letters tJ f 4/'.imutI/J Jio,hr A"\..
are hereby granted to
in the above estate
and that the instrument( s) dated
described in the Petition be admitted to probate and filed of recor
FEES
Letters ............... $
Short Certificate(s) . . . . . . .. $
Renunciation(s) .......... $
f!/; ... $
. . maiN:;' . .. $
i-eL '" $
.., $
... $
... $
... $
... $
... $
TOTAL . . . . . . . . . . . . . . $
(p {)i 0 lJ
"f,tIO
/tr&V
/0-.00
~. 00
Jp
Supreme Court 1.D. No.:
~7~
.. fe, 7f, LUiAi~
!tJ/Ji :l.-
IPf] ulfsl!1!lYlMlSJ,
(lM~k PI! /7LJ!~
Attorney Signature:
Attorney Name:
Address:
(7/l) rJ 'I9~c/3s~
/'
Telephone:
~ 7. OD tr.OO
Form RW-Q2 rev.l0.J3.06
Page 2 of2
HIOS.90S REV.(6/06)
This is to certify that this is a true copy of the record which is on file in the Pennsylvania Division of Vital Records III 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.
/} ~ '#
c..:--o ~ ~~ 1f~~
No.
Frank Yeropoli
State Registrar
Calvin B. Johnson, M.D., M.P.H.
Secretary of Health
4197437
SEP 2 1 2001,_
l J
~.= ~te
.' '; ;"Q,
, __L_
. 1
G-::
..
'-'
..........'
C~)
c-; -c:
--II
C)
c..T1
c:...1
TYPE/PAINT
IN
PERMANENT
III.ACK INK
NAME OF DECEDENT IFIl'SI'. Middle. L_I
.. Nellie
so
.. Female
STRE F....E NUMBER
SOCIAl SECURITY NUMBeR
.. 201 _ 16
082903
'() '1 eft D3
~,
COMMONWEALTH OF PENNSYLVANIA. OEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
H1OS.143 AIt't_ 2187
K.
DAlE OF OERH ,McN'I. 0.,. '.."
.. August 9, 2002
AGE (lasl Bir1May)
UNDER 1 VENl
-- "-
BlRTHP\.ACE (C.ty ~
SlaNOIFcrillgflCounrrYl
=",,0
80
V<s.
COUNTY OF DERH
.. CUnt>er land
Ie.
"..
""'
-
Min.
Clllmerland _7 .7..0 :...-=-.:::..
MOTHER'S NAME {First. ~. Maden Su-narne)
Cora Barber
MAAI1AL SWUS -........
NM4r w.m.ca. \McIowIed.
--
Widowed
W. pennsboro
SUOMVlNG SPOUSE
l....~~~
twp.
......
-
2002
II.
N'OAMANrs MAIl.H3 ADORESS lSwMt. City/bMt, s...lip Codet
_1560 Webster Dr. Carlisle, PA 17013
Pl..ACE OF oeSPOSrTlClH. NefN of c.m.tery. ~ LOCAnON. CiIynOwn. Staile. Zip eo.
..""'"'-
.... Mt. Zion Cemetery .."- Allen, PA
-AND~SSOf'FAClUTYHoffman-Rot Funera
_.219 N.Hanover St. Carlisle,
LICENSE NUMBER
..... wtJ-':))::>300L
...
I~.
I inleNIlI bMwreren
: 0..- and'"
I
:
PART I: OINt SigniftcMl concMioN ~ ID dMIh. but
noI ~ in............~... in PNIT I.
ORE OF INJURY
IMclt\ll.Oay. -.arj
TIME OF INJURY
INJl.IAV R WORK? OESCRt8E HOW INJURY OCClJAAlED.
...0
NoD
Suiado
o
o
__ 0
__.... 0
Could nd be dellImllMd 0
.... 0 NoD
--
Id.i \ la \ 101
34.
c<~() A-,
a.. 2eL a.
CEJnWlER ICt.ecJt oniy ~
OCERTJFYING ""SlClAN (Phy5lCoaI\C~ COMISe d dNth when ar>Ott'Ier phvsoc.an ~ pronounced deatto ~ c~ Ilem 23)
To...... 01 1ft)' 1tnoWMd9t,.... ace""".... to" e.-e(s) and mannM" staltlM. . "
~
~
~
:rl
o
(;
w
"
<(
Z
'~WG AND CEFlITIFYlNG PHYSICIAN (Phy5ICliI" boItl ;)I~nc,r>g Clealtl and Cerlltyong IOCause 01 dealt'll
To"'- boNt 01 my knowfltdgfl, .ath Gee....ted.. h.... cUtle, aM place. afld due to Ihe uUM(s) and manner.. "Med.. .
-IIEDtCAL EXAMINlRlCQRONt!R
On the a..eis of euminatlon and/or investig.ation, in my opinion, death oc(:urred allhe lime, dale, and place. and due to the cause(s) and
",anner as stated..
11a.
REGISTRAR"S StGNAJ'URE AND N
~ \ 01 oq~
RENUNCIATION
o
c;o
,.'~ -:0
'J.~d
C
C;
--1
~TER OF WILLS
~~L~ 'COUNTY,PENNSYLVANlA
-G
I
~
3!;
"-;,?
en
(..0
Estate of
Nell Lt'
/ h/lltnCi!/J
o~ L( ut Pfw
, Deceased
I, G J.cqs~lint N~
CD/1J
, in my capacity/relationship as
of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
lJf61CLK RhfJods
I (J 10; ( 01
(Dale)
_$ '1 E{)~
(Signatur~
(Street Address)
(City, State, Zip)
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
purposes stated within on this day
of
Executed in Register.'s Office
Sworn to or affirmed and subscribed
before me this .5 day
of 06-fb~ , -;;lo61
Notary Public
My Commission Expires:
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's Commission.)
Form RW-06 rev. 10.13.06
c:;( \ C) '\ DC\()'?>
RENUNCIATION
c>
=0
~-~.}~
..-t.O
.~~~:. f~~
()) ;>....
a
("';:
I
0:.
RE~TER OF WILLS
(}/~bda/l COUNTY, PENNSYLVANIA
-0
..D
---\
~)
, -",
WJ
U1
W
Estate of AI.f / h 1
/~ ~; JJ YY7U/>
, Deceased
I, ~f\-p..f'r N-S--~ A-V
(Print Name) l
hA~ t:+TetR....
, in my capacity/relationship as
of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
De/)(fL K j(h()(}rl~
~b- 3-07
(Date)
~~~
(Signature) ~
(Street Address)
(City, State, Zip)
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
purposes stated within on this day
of
Executed in Register's Office
Sworn to or affirmed <3d subscribed
before ~. day
of - ,~.
Notary Public
My Commission Expires:
(Signature and Seal of Notary or other official qualified to
administer oaths_ Show date of expiration of Notary's Commission.)
Form RW-06 rev. 10.13.06