HomeMy WebLinkAbout09-05-07
PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF GUH1berlt4{()
.f)ebott<.ft -Avtl1e GrCifte
COUNTY, PENNSYLVANIA
, Deceased
File Number ,-2 I -07- 09/'-/
Social Security Number I q I -- 5" &, - i c:, '30
Estate of
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
:")
- :riamed in the
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Cry
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(State relevant circumstances, e.g., renunciation, death of executor, etc.) U',
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution ofthe-~~strument{S)7offered
for probate, was not the victim of a killing and was never adjudicated an incapacitated person:
(XI B. Grant of Letters of Administration
.-
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(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.)
MA'I t [ 2007 at 11& ~.;;(Aft::'12.
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
(If not domiciled in PA) Personal property in County
Value ofreal estate in Pennsylvania
$Cf1~
$
$
$
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
the undersigned:
ZOCjoz-
Form RW-02 rev. 10.13.06
Page 1 of2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF Cueubd-f UU ~
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
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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.
c....._..............~
--1-"':'~
'-- _ ~e
Swom to or affirmed and subscribed
before me the C ") of / I day of
",ij ptr ITLAJCL' , (ltt 7
('lhU11IJI( C \'IJ1IIWt'rD
Fo'the Register
Signature of Personal Representative
)
-,
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Signature of Personal Representative
L
File Number:
Estate 0~X::DrT''''--./~
;),1-07- ()~-/4
(l-rv___J- dJ~L~1A-L-
, Deceased
(.;::)
Social Security Number: /q 1- E){ 0 llodn
AND NOW, OC-tc)~ I
Date of Death: 0 - L/ - 01
, in consideration of the foregoing Petition, satisfactory proof
rn, I r
in the above estate
and that the instrument(s) dated
described in the Petition be admitted to probate and filed of r.eLyd as the last ~i~(and Codicil(s)) rf pecedjent. 1
FEES t./XLi Lnd 0. _ 'r5f{l~ fLvt ( vJ,fu[\ J(1 ~}rt
$ '/0 Ci -, Register of Wills ,
Letters ............... ~ ~
Short Certificate(s) . . . . . . .. $ ..:.32. .CJ;:J
R~nciation(s) .......... $ t) . Ill')
bond ... $ lb.()D
~C.P $ /0.00
a ^.A :+-, r Y-YV-J :h GY\. . . . $...r=:;' nO
$
$
$
$
$
$
TOTAL . . . . . . . . . . . . . . $ <t '1 CO (J;Q()
Attomey Signature:
.1>'<: ~aL<,J
j~'t. eta
Attomey Name:
Supreme Court I.D. No.:
Address:
Telephone:
Form RW-02 rev. 10.13.06
Page 2 of2
[" I~. I) cntd, that the intol"matiun hne given I~ correctly copied frum an origmal certificalt' of death duly fill'll v\ :th Hie' ,I"
)l Ii I: .~gistrar 'rhe original \'crtihcate will he forwarded to the State Vital Records Office for permanent filing
WARNING: It is illegal to duplicate this copy by photostat or photograph.
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I,ol'al Rl'gi,trar (J
!'lX for lhl' certificate, ~h()()
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JUL 1 8 2007
Dale
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~~41~IRINT IN" I
PERMANENT
BLACK INK
1131-007
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CORONER'S CERTIFICATE OF DEATH
(See Instructions and examples on reverse)
0::.'
STATE FilE NUMBER
I .
5 AgelLastBlrtooay)
1 Name ol Ot;ceden\ lFlrsl. middle. last, suffix)
Deborah
A
Greene
6. Dale 01 Birth (Month, da , year)
.; Dale of Death lMonth, day, year)
May 4, 2007
45
y"
June 27, 1961
8e County 01 Dealr.
Cumberland
813 Bridge Street
Accountin
. 16. Decedent's. Mailing Address lS1reel, city / IoWn, slate, zip code)
813 Bridge St., Apt. 3
New Cumberland, PA 17070
12. Was Decedent ever in the
U,S. Armed Forces?
Dyes IXINo
13, Decedent's Etiucalion (Specity only highest grade completed)
Elementary I Secondary (0-12) College (1-4 01 5+)
4
14, Marital Stalus: Married, Never Mamed,
Widowed, DivOlced (Specify)
Never Married
~~~nce 17a,State Pennsylvania
Did Decedent
liveina
Township?
17cDVes,DecedefllLivedirt
17d. Qg No, Decedenl Lived within
Actual Limllsof
Twp
17bCoon~ Cumherl,md
New Cumberland
Cl1yiBoro
lB, Falher's Name (First, middle. last, sulli~)
19. MOIher's Name (First, middle, maiden surname)
Ral h J. Greene
Doroth L. Ostrom
2Ob, Inlormant's Ma~iog Address (St/eet, city !town, slate, zip code)
20a tnlormant's Name (Type I Print)
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Doroth L. Greene
140 3rd St.,A t. 12, Renovo, PA 17764
21C. Place ol Disposition (Name of cemetery, crematory or other place)
21d Location lCity flown, slale, zip code)
Hollinger Crematory
22c.NameandAddfessoIFacility Dean K. Wetzler,
320 Main St. Mill Hall, PA
Mt. Holly Springs, PA
Jr. Funeral Home
17751
23b License Number
23c. Dale Signed (Month, day, year)
l1ems 24-26 mus1 tle completed by person
who pronounces death
24 Trme of Death
Unknown
25. Dale Pronounced Dead (Monttl, day, year)
A. M, May 7, 2007
Cid Yes 0 No
30b Were Autopsy Findings
Available Prior to Complellon
01 Cause 01 Death?
I&1 Yes 0 No
31 Mannerol Dealh
o Natural 0 Homicide
o Accidenl 0 Pending Investigalloo 32d Trme 01 InJury
o Suicicle '5Zl Could Not be Delermirl6d
26 Was Case Referred 10 Medical EKaminer! Coroner lor a Reason Other than Cremation or Donation?
~Ye$ DNa
Approximate inlerval: Part 11: Enler other sianrticanl conditions contributina to dealh, 28 Did Tobacco Use ConlnWe to Dealh?
Onset to Death but not resulting in the undetiVing cause given In Parll 0 Yes 0 Probably
o No 0 Unknown
29 UFemale
D Nol pl'egnant within past Vear
o Prec}'lantatllmeotdeath
o Nolpl'egnant, bulpregnant wlttrin 42 days
of dealh
o Notpregnanl, but pregnanl 43 days to 1 year
Defore dealh
o Unknown it pregnanl withrn the past year
32G Place oj InjUry Home. Farm. Slreel. Factory
Office Building, etG (Specify)
CAUSE OF DEATH (See instructions and examples)
Item 21. Part I Enter lhe ~ - diseases. injunes, (l( compIicalions that directly caused the dealh. 00 NOT enter lerminal events such as cardiac arrast.
fespiralory arres!, or ventricular libnllabon without showing Ihe e1ioIogy, Lisl only one cause on each line
~~~;~~n~~~ ~~~ cfise~
Undetermined
Due 10 lor as a consequence 01)'
SequentIally Iisl conditions, II any
~~t~~o8HDERlVi~:;~~~~ a
(disease Of Injury !hat inlliated the
evenlS fesunlflg lfl dealh) LAST.
Due to (or as a consequence 01)
Due 10 (or as a consequence 01)
30a Was an Aulopsy
Pertormed?
32g.LocationollrIjUry(Streel,clty/loWfl,slaltJ)
M
33a Gartiher (meek ooly one)
Certitylng physician {PhYSician certitying cause of death when another physiclan has pronounced death and completed l1em 23}
To the best 01 my knowledge, death occurred due 10 lhe cause(sl and ITIIInnef as stated.- _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0
Pronouncing and certifying physician (PhySICian both pronouncing dealh and cenityirlg to cause 01 death)
To the best 01 my knowledge, €tealh occurred al the time, date, and place. and due to 1he c:Buae(s) and manner as staled_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0
~:~:~sm~~~~~:t~: aAd I Of inveiligation, in my opinion, death occurred at the time, dale, and place, and due to tne cause(s) and manner as slatecL tKJ
Coroner
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'i Date F (Month, day. year)
/I~I 11_101 /'ildoo'7
Oospo,it/oo P,.mt No D I '3 7 b '7 ~
33d DaleSrgned (Month, day,year)
July 16, 2007
34 'M!~i!'l~'I;'~~'!f;""e~f'Cl~'t Ty",/PM'
6375 Basehore Road, Suite #1
Mechanicsburg, PA 17050
~
RENUNCIATION
REGISTER OF WILLS
C.\.:'M6EKI.J1-.t0h COUNTY, PENNSYLVANIA
I~ J - () -7 - () PI L/
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Estate of
nERoRA~ ANNE GREENE
,-
, D~ased
I,
hO(ZOlH'I LoUiSE GREENE
(Prillt Name)
, in my capacity/relationship as
MOTlfEK
of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
BERNARh RA-LPI-t bRfEWE
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'l
/?- 07
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, 19l1atare)
14-0 Tlf/i<-D STrzFfT APT -Ii I).
,
{Street Addre'^J
P',ENoVo
(City, State, Zip)
Pef\; ~.,
i77f,;,'-/-
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this day
of
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 /J'iA-' day
of ~ ' ofOu?
')
KJ> r' , ) /7 .q/u//J /
L7&~V u. V'~Z
Nofury Public
My Commission Expires:
Deputy for Register of Wills
(Signature and Seal of Notary or other ot1icial qualified to
administer oaths. Show date of expiration of Notary's Commission.)
Form R W-06 rev. 10.13.06
COMMONWEALTH OF PENNSYlVANIA
NOTARIAL SEAL
PATRICIA A. RAUCH, NOTARY PUBlIC
RENOVO BORO, CLINTON COUNTY
MVCOMMISS10N EXPIRES MARCH 28, 2009