HomeMy WebLinkAbout12-20-07
PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF C UM.~ E"R..L-A-N "P
COUNTY, PENNSYLVANIA
Estate of
T"~n B Bl.!j+~'\dt -Tr
File Number
~\
01 He; \
o ,.....,
_ c::,
lit~ 310 ~ n ~
"T) Q
, .-:~ :::;; f"'T1
.',:;: ,'- ("")
.::::-~~€ ~
r~~)
. '1
also known as
, Deceased
Social Security Number
,"j
j
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE 'A' or 'B' BELOW:)
;~:~~ ~~,~
to')
,
.~--:J
~. OJ
nam~ ti{~e
, -}
(Stale relevant circumstances, e.g., renunciation, death of executor, etc)
Except as follows, Decedent did no~arry, 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:
I'Zl B. G rant of Letters of Administration
(If applicable, enter: c.t.a.; db.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 db.n.c.t.a., enter date of Will in Section A above and complete /ist of heirs)
Relationshi
S<l'1-'\
5lJV\
ot~\i ~ t:r-
"
Decedent was domiciled at death in
3}7 west- G--rt-eIl\.S{-l-ftf
(Lis! street address, town/city, township, coun ,state, zip code)
County, Pennsylvania with his / her last principal residence at
~4- [lDS'S- Aec~",-\cslo, ()'r k
Decedent, then "I years of age, died on /'J11\J(Vo-I.vu-13, uY{)=f at ~ ~11 J"Pl('o.t ~P' bt(
CZGUt- Pc"'~(.,{'r<> I""V' C(;'''\btvl~ (~~ I te\o\li\Si1va,l{i'\
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 PAl Personal property in County
Value of real estate in Pennsylvania
2. 6b f /r01:I ( tro
$
$
$
$ /",,0 ~, fK:,
I
situated as follows:
3")7 ~\Jf'S+- G-tee.... 5tre~t fi\.ecktl'tlCs \p~Iy"T tDev..1I\51Iv'll-t 1<1
) t-l-
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
v-'sf-
6,/'....'1/A
~ f- /-'1~ d..~~,U';',-.---,
f'A
/7't:'5s'
Form RW-02 rev. 10.13.06
Page I of2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
G CrY' bu-lcuJ
SS
COUNTY OF
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.
Sworn to or affirmed and subscribed
Q
,~C)
~....~~o
i -c~.~ ~-:;
.~>.~ 52
. :;lC)
)' j ..J....,
before me the
Signatl/re af Personal Representative
File Number:
_J ::-r;
-"~
~:J -1
~~
Estate of
Social Security Number:
"
Date of Death:
AND NOW,
having been presented before
are hereby granted to
and that the instrument(s) dated
described in the Petition be admitted to probate and filed ofrecord as the last Will (and Cod'
=
=
-..I
o
rll
(J
N
o
'-: .1!
c
. )
._~
.,
."'--'1
~-j
J>
-il...
,
r:
;1
S?
.,;~
N
in the above estate
FEES
Letters ............... $
Short Certificate(s) . . . ~. . $
RenunC:iati~n(S) .......... $
cf -\0 ... $
Av.. ...$
... $
... $
... $
... $
... $
... $
'" $
TOT AL . . . . . . . . . . . . .. $
,-~l 00
0)0
Attorney Signature:
(i
5c 0 1(- W , Ii cYWlS (/\r-.
6 3 'ilCf 3
Attorney Name:
10
5
Supreme Court LD. No.:
Address:
po E?Of. 'Z-3.2-
{)J ew ~ (00'1\A fIe>( J fA- (706r
(7 \7) j?2-23 (7)
Telephone:
0.00
Form RW-o.2 rev. /0.13.0.6
Page 2 of2
H105.112 REV. 1/05
(FEE FOR THIS
CERTIFICATE $6.00)
WARNING: IT IS ILLEGAL TO ALTER THIS COPY OR
TO DUPLICATE BY PHOTOSTAT OR PHOTOGRAPH.
CQMMONWEALTH OF PENNSVLVANIA
DEPARTMENT OF HEALTH VITAL RECORDS
J.l Ot \l~ t
LOCALREGISTRAR'$ CERTIFICA TIONOF DEATH
CERT. NO. T6164078
November 15,.2007
Date of Issue of This Certiftcation
Name of Decedent
Male
John
Burtnett Jr.
B.
Rrst
Last
Date of Death Nov. 13, 2007
Middle
202 - 36 - 7176
Sex
Social Security No.
Date of Birth Oct. 13, 1946 Birthplace
Holy Spirit Hospital
Carlisle, PA
Cumberland
Facility Name
City, Borough or Township
E. Pennsboro TWPPennsylvania
Place of Death
County
Race
White
Armed Forc:es? (Yes or No)
Foreman
Occupation
Decedent's
Mailing Address
Marital Status
Divorced
Mechanicsburg
337 West Green St.
Yes
PA 17055
Number
City or Town
State
Street
Matthew V. Burtnett
Funeral Director
James E. Nickel
Informant
Name and Address of
Funeral Establishment
Nickel Funeral Home, P.O. Box 910, Loysville, PA 17047
Part I:
Immediate Cause
: Interval Between
: Onset and Death
I
I
Q:
~~-
~ . I.. j
l}Ef~
,.; ,:<:r .??
fQo
) .:....; -"
..-.~: !=:i:
..' :Jj)
",.-, .....,.I
:;;;;:
Myoc.ardial Infarction
Part II:
(a)
(b)
(c)
(d)
Other Significant Conditions
Manner of Death
Natural g}{
Accident 0
Suicide 0
Describe how injury occurred:
Homicide
Pending Investigation
Could not be Determined
o
o
o
r--.;t
=
~
........
.U
r~f~~i ,r~J~i
~':-;8
; ~ t-~ :\~r~~
o
m
('"")
N
o
.. :. ,--j
~; c:::>
.. :-"""'1
. . - -'J1
-~
J:ltoo
::J:
9
;" ,'~J (~-)
Name and Title of Certifier
James Thompson M.D.
(M.D., 0..0., Coroner, M.E.)
910 Century Drive, Mech;anicsburg, PA 17055
Address
This is to certify that the information here given is correctly copied from an original certificate
of death duly Hied with me as Local Registrar. The or/ginalcertificate will be forvvardedto the
State Vital Records Office for permanent filing.
November 15, 2007
50-455
Date Received by Local Registrar
City. Borough, Township
St.., New Bloomfield, PA 17068
District No.
Street Address