HomeMy WebLinkAbout11-28-07
PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF CVM '~ri~. #'\ 3
COUNTY, PENNSYLVANIA
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Estate of 0 c- + "-
also known as
MVlr)t.,.
File Number
a\
b\
" bOlD
, Deceased
Social Security Number
I y 1- ) 2- - 3738""
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
named in the
(State relevant circumstances, 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 instlUment~ffered
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for probate, was not the victim of a killing and was never adjudicated an incapacitated person: Q ~
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(lfapplicable, enter: c.t.a.; d.b.n.c.l.a.; pendente lile; durante absentia; durante mitfo!iTJI..rt)
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./ Petitioner(s) after a proper search has! have ascertained that Decedent left no Will and was survived by the following spouSGW~) anctll1irs:
Administration, c.t.a. or d.b.n.c.l.a., enter dale of Will in Section A above and complete list of heirs.) "S?:::' :J!:
c' ::D W
.z~. Grant of Letters of Administration
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Decedent, then
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years of age, died on I' ~ IQ ~ Ld..t 7 at
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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
situated as follows: ;::: ~ I' S t-
Al..h-.I
f3 V7,.., tL.
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$'~(j<J
$
$
$
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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:
T ed or rinted name and residence
f3rt..,....J~ L-.--..}C M~{'s ~
31-/1< s "I(,'~/) sY'/o;:; ~ i-
t- r7. //1 17 c. 'J)
FormRW,02 rev./O./3.06
Page 1 of2
Oath of Personal Representative
COMMON\\E-\L It! OF PENNSYLVANIA
ss
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The Petltruner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true and correct to the best of
tbe 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.
Social Security Number: I ~ I
AND NOW, DD\:)€....'\"(,,,.\~_r , :doD"\ , in consideration oft e foregoing Petition, satisfactory proof
having been presented before me, IT IS DECREED that Letters A -
are hereby granted to B,e.<"\fu Lee \'f\CJ~.J
Sworn to or affirmed and subscribed
~
before me the
day of
Signature of Personal Representative
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Signature of Personal Representative
File Number:
a\ 0,
t....c<.. M "YJrS' ~
32 3.738-
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Estate of ;:j \:'\. Y
, Deceased
Date of Death:
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in the above estate
FEES
Letters .............. . $ ~D
Short Certificate(s) . . . . . . . . $ d~ Attorney Signature:
Renunciation(s) ......... . $
)( Q $ to Attomey Name:
~~ $ 'S Supreme Court LD. No.:
$
$ Address;
$
$
$
$ Telephone:
$
TOTAL. . . . . .. . $ ~~
FOr/II R W-IJ2 rev /0,/3,06
Page2of2
H105.805 REV 101/07)
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00
This is to certify that the information here given is
correctly copied from an original Certificate of Death
duly filed with me as Local Registrar. The original
certificate will be forwarded to the State Vital
Recor~...O!Jice for permanent filing.
~~ /Jl7~. NOV 1/3 20~
Local Registrar Date Issued
P 13989094
Certification Number
CJ
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REV 1112006
I PRINT IN
MANENT
\CK1NK
COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH' VITAL RECORDS
CERTIFICATE OF DEATH
(See Instructions and examples on reverse)
STATE FILE NUMBER
d\ 0
1_ Name of Decedent (Firm, middle, last, suffix)
Jay L. Marsh
5 Age {LasIBilttxlay)
65
Select Specialty Hospital
6. Dale 01 Birth (Month, day, year)
9/23/42
Harrisburg, Pl\
Yrs.
ad. I=acility Name (II not instiMion, give street and number)
Sb. County of Death
Cumberland
11.Decedenl'sUsualOcc lion Kindolwor\(done most 01 Iile. 00 not stale retir
Kind 01 Work Kind of Business Ilndusll'y
Su ervisor Chromalloy
- 16. Decedeors Mailing Address (Stree!, city / town, stale, zip code)
3487 Sullivan st.
Mechanicsburg, PA 17050
12. Was Decedent ever in the
U.S. Armed Forces?
o Yes CJtro
13. Decodenl', Educallon ISpecjIy onJy rnghe.. grade comple'ed)
Elementary I Secondary (0-12) College (1"4 or 5+)
U NK
Decedenf'
Actual Residence 17a. Sale
17b. County
Pennsylvania
Cumberland
3. Social Security Number
181 -32
4. Dale of Deaftl (Month, day. Year)
3338 November 10
Other.
14. Marital Stalus: Married, Never Married,
Widowed, Divorced (Spec'M
Married
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OOlhe,.SpecjIy:
10. Race~ American Indian, Black, White, ate
(Specitn Whi te
Brenda L. Biery
Twp.
Did Decedent
Uvelne
Township?
17e. 0 Yes, Decedent LiveQ in
17d. Kl No, D-.nl Uved wltI1in
AcllJaI lmlls of
Mechanicsburg
Swenson
City I 80m
18. l=alheT'S Name (FIf'St, mWle, Iasl. sutIlx)
Roger L. Marsh
Brenda L. Marsh
19. Mother's Name (Rrsl, middle, maiden surname)
Catherine E.
2Ob. lnlorrnanfs Mailing Address (Street, city llown, state, zip (:Ode)
3487 Sullivan st. Mechanicsbur PA 17050
21b. Date 01 Disposition (Month, day, yearj 21c. Place of DisposItIon {Namt-otcemetery, cnmI8!OIY Of other pIBce) 21d. Location (City Ilown, state, zip code)
Evans Cremation Service Leola, PA
22<:. Nemeand Address 01 Facilily Sulli van Funeral Home
51 N. Enola Dr Enola PA 17025
208. tntonnanfs Name (Type f Print)
228. Sip'" 01
. ~ 4//
24. Ttmeofn"'.s g
CAUSE OF DEATH (See Instructions and examples)
Item 27. Pari!: Enter the ~ - diseases, injuries, or compIlcations - thai cjrectty caused the death. DO NOT enter terminal events such as cardiac arrest,
respiratory arrest, or ventricular ftbrillalioo without showing the etiology. UsI only one cause on each line.
nems 24-26 must be compIeIed by person
:' who pronounces death.
I Approximate interval:
I Onset to Death
,
I
,
.
I
I
I
,
I
I
I
.
I
;:. \ \'^'~ 't:
~=S~j~1'ld~
C:' .
~t. ;"<,, S
Due to (or as a consequence o~: ,
C\~'''...'1,.,'L\,,!,,~ ~ 1'~L'\..c
Due to (or as a consequence oQ:
f' :-I -t \A. IV\. O~.J . ~
Due 10 (or as a consequence of):
'" Cr->'\ 1\ \",",'V(", \;>t ~......." ....',..\"
~c'>f'.M"'"
SeqoentiaUy list oondtions, it any,
=~~~~~U~~a,
(_"'In~rylha'inilieledlha
events resulting 11'I death) LAST.
b.
c.
d.
308. Was an AtIfopsy
Perlormed?
DYes ~
3Ob. Were Autopsy Ftndings
Available Prior 10 Completion
of Cause 01 Death?
31.~rofDealh
[}(N'luraJ 0 Hon>dde
o _I 0 Pendill9lnve'tiga.on
o Su"" 0 Could Nof be Delemined
M.
321. II T~'lion In~ry (Speafy)
o Driver I Operator 0 Passenger DPedestrian
Other . Spea~'
33b. Signature and TIlle of Certifier .:).,.;1
,;>-!,.9 ~VV\ ! i,"--...........
OVes ONo
32d. TlI7leollnjvry
33a. CsrtJIIer {check only one)
Certifying phystclan (Physieian certifying cause 01 death when another physician has pronounced death and completed Item 231
To 1M best 01 myknoWtedge, death occurred duete ttte cauae(s) and manner as stated_ _.. _................ _........................................
~~o;:m~":fa: =~J::~a:c:=~~ ~I~~~=~~~=~oto::~~:~ manner as slated-........ _-_.......... ...... ...... 0
~,:~::m~n:"x~~= and J or investigation, In my opinion, death occurred at the time, date, and place, end due 10 the cause(s) IIld manner as Itate<L 0
231>. Ucense Number
R. ~ ~ cp..:l. 5 't L
23c. Dale Signed (Month, day. year)
11- iO- d,001
26. Was Case Referred to Medical Examiner J Coroner for a Reason Other than Cremation Of Donajion?
DYes ONo
Pen II: Enler olher sionilicant condiIions ronlribulina 10 dAsth,
but not resulting in !he undetIying cause given in Part L
32g. Location of Injury (Street. city !town, state)
33c. License Number 33d. Dale Sigrwf (Month. day, year)
t ~ <.J ';"1 'I _~ 1. . l I \ I III t t
34. Name and Address Of Person Who Completed Cause of Oealh (l1em 27j Type I Print
i.)C I',}; I 11 i ;: Yi/\ I ( ,If 0\ J
qy;
28. Did Tobacco Use Contribute to Death?
o Yes o Probably
ONo DUnk......,
29. " Female:
o Not pregnant within past year
o Pregnant al time 01 death
o Notpregnanl,butpregnanlwithin42days
ofdea'"
o No! pregnant, but pregnant 43 days fa 1 year
betoredeath
o Unknown if pregnant within the past year
32c. Place ollnju'Y: Home, Farm, Street. FacIOlY,
0IIIce BLrildng, etc. (Specjly)
35. Registrar's
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