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PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF r::-~.. '" J"" <' /...# cf
COUNTY, PENNSYL V ANL\
Estate 0 f
b'o/~/.p
c.
If /.J;?~q 8-/1/
File Number r2/-0g- - ClA /
also known as
, Deceased
Social Security Number
/9?-/6'-o?4
.
Petitioner(s), II lIe is,are 18 years of age or older, apply(i s) for:
(COMPLETE '.1' 01' '8' BELOW:)
I)(j A. Probate and Grant of Letters Testamentary al d aver that Petitione..) is / aile the h J,"i' ( Ii' ::;J.jIjzE'If6Ii~amed in the
~a~t Will of the Decedent dated 1- 2 ~ - g' and codicil(s) dated /Yo IVQ
(State relevant circumstances, e.g, rellullciatioll, 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(s) offered
for probate, was not the victim of a killing and was neverladjUdicated an incapacitated person:
I
o B. Crant of Letters of Administration
(lfappli able, enter: c.I.a., db.n.c.t.a.: pendente lite; durante absentia. durallte minoritate)
Petitioner(s) after a proper search has / have ascertained t at Decedent left no Will and was survived by the following spouse (if anY),lI~d heirs: (If
Admillistratian, c.t.a. ar d.b.l1.c.t.a.. enter date af Will in ectian A above and complete list of heirs.) C) ;0:-:
Name
Relationshi
.~ _, I
(CO/'-IPLETE IN ALL CASES:) Attach additional sheet ifnecessary.
--I
County, Pennsylvania with..m:,./ her last principal tesidence at ~
Elf 5,:f Pc<'N/II.5'~O.ld ruy< CC/N.h"";/$-A/d" ;0,4 /9(/2..{-
, towl/lcity, township, COlll/ty, state, zip code) I
Decedent, then '/f yearSOfage,diedon-2-r J.1}-C7? at ft,Jy SI'J'K',r 110.5'/,""'#/ Cd"V'#/ ~
Decedent at death owned property with estimated values as follows:
(If domiciled in P A) All personal property
(If not domiciled in P A) Personal property in Pennsylvania
(If not domiciled in PA) Personal property in County
Value of real estate in Pennsylvania
J 00' 0
.,
situated as follows:
Cq
$
$
$
$
BOO
Wherefore, Petitioner(s) respectfully requcst(s) the probate of the I st Will and Codicil(s) presented with this Petition and the grant of Letters in the appropriate form to
the undersigned:
Ty ed or rinted name and residence
~
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Furlll RW-OJ rev 10./3.06
Page 1 of2
I .
Oath of Personal Representative
COMMONWEAL TH OF PENNSYLVANIA
SS
COUNTY OF
The Petitioner(s) above-named swear(s) or affi (s) that the statements in the foregoing Petition are true and conect to the best of
the knowledge and belief of Petitioner(s) and that, s personal representative(s) of the Decedent, Petitioner(s) will well and truly
administer the estate according to law.
Swore to or i';6rmed and subscribed
. . .. /) c:---t-k--
before me tbe 0\ ,J day of
, Q()J ~ Signature of Personal Representative
~
For the Register Signature of Personal Representative
AND NOW,
having been present
are hereby granted to
File Number: ~l -0
, Deceased
Date of Death: q Zl 0,
in the above estate
Letters ............... $ \ 3S . c::c)
Short Certificate(s) . . . . . . . . $ g. oD
Renunciation(s) , . . . . . . $
h.)l\\ $ 1s-.tD
~ CP $ \D .()i)
(" \ /::'" -
~~,^7\III'r-... $ ..J.O\)
$
$
$
$
$
$
TOTAL.............. $ ll3-dD
and that the instrument(s) dated I - d-.s- - 11(
described in the Petition be admitted to probate andifiled of record as the last Will (and Codicil(s)) of Decedent.
Ji'b~~11Mu1 cAt!o.d:>ai~~f(t
Register 0 ills ~j-
l~, ~
~.JLfl-t" ll.,
FEES
Attol11ey Signature:
Attomey Name:
Supreme Court 1.D. No.:
Address:
Telephone:
Forlll RW-IJ] rev !IJ, !3.IJ6
Page 2 of2
LOCAL REGISTR R'S CERTIFICATION OF DEATH
WARNING: It is illegal to uplicate this copy by photostat or photograph.
Il'l' ,ll t'li" "lTtllicatc.<;'h.OO
('crti ficatioll ;\Iumbcr
1111~'~(W'otp;:;.....
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"""UNIIII11
This is to certify that the informatioll 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
Records Office for permanent filing.
,2wn /J?~.,.
P 13858950
Local Registrar
0CT 0/1 1007
Date Issued
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COMMONWEALTH OF PENN YLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
ERTIFICATE OF DEATH
tructions and examples on reverse)
REV 1112006
PRINT IN
AANENT
CK INK
Cumberland
Twp . 1-\0\
STATE FILE NUMBER
3. Social Security Number
197 - J 0
4. Date of Death (Month, day, year)
0716 &!-fmtx'v con, 2GG-1
5. Age (lasl Birthday) 6. Dale of Birth (Month, day, year)
89
Minlllel1 Other
10/10/17
o Nursing Home 0 Residence 0 Other. Specify
9. Was Decedent 01 Hispanic Origin? IKJ No DYes 10. Race: American Indian, Black, White. etc
(If yes, specily Cuban, (Specify)
Mexican, Puerto Rican, etc.} Wh 1. t e
14. Marilal Status: Married, Never Married,
Widowed, Divorced (Specify)
Widowed
Yes
11. Decedenrs Usual Occu hon Kind 0\ work done durin most of world life. Do no! state retired
Kind of Work Kind of Business I Industry
Laborer L.B.Smith Club
. 16. Decedent's Mailing Address (Slreet, city I town, state, zip code)
13 High St.
. Enola, PA 17025
Decedent's
Actual Residence 17a. State
17b. Coun
PA
Cumberland
Did Decedent
live in a
Township?
17C}tJ Yes, Decedent Lived in Eas t
17d. 0 No, Decedent Lived within
Actual Limilsof
Pennsboro
Twp
lB. Father's Name (First, middle, lasl. suffiX)
William Fealtman
Cily/Boro
19. Mother's Name (First, middle, maiden surname)
Sarah Workman
2Ob. Informant's Mailing Address (Street. cily / lown, Slate, zip code)
1055 Allendale Rd. A t I Mechanicsbur
21c. Place of Disposlhon (Name 01 cemetery, crematory or other place)
PA 17053
Chestnut Grove Cemetery
22c. Name and Address 01 Facility
Richardson Ftmeral tbne Inc. 29 S. Enola Dr. Enola P
23b. license Number
26. Was Case Referred to Medical Examiner I Coroner for a Reason Other Ihan Cremation or Donation?
DYes DNo
~~~~n~~~ ~~~ dise:;
CAUSE OF DEATH (See Instructions and examples)
Uem 27. Part I: Enter the ~ - diseases, injuries, or complicatioos that directly caused the death. DO NOT enter terminal
respiratory arrest, or ventricular fibrillation without showing the etiology. Ust only one cause on each line.
1='oU.-lwl4
Approximate interval:
Onset to Death
Part II: Enter other sianificant conditions contributino to death,
but not resulling in the undenying cause given in Part I.
28. Did Tobacco Use Cootribute to Death?
DYes DPIO".bly
o No ~ Unknown
~~n~i~~~o:,~~~ a
Ente~ UNDERLYING CAUSE
(disease orif.ljury lhat initiated lhe
Mots resulling In death) LAST.
b.
Cl-tF
A tfrrJ ~:hM.. ~
29.lfFemale:
~ Not pregnant within past year
o Pregnant at time of death
o Nol pregnant, but pregnant wtthin 42 days
of death
o Not pregnant, but pregnant 43 days to 1 year
belore death
o UnknOWfl il pregnant within the paSl year
32c. Place of Injury: Home, Farm, Street, Factory,
Olllce Building, elc. (Spedfy)
321. If Transportation Injury (Specify)
o Driver J Operator 0 Passenger DPedestrian
M. DOIher. Specify:
338. Certifier (check only one) 33b. Signature andTrt~e of . ...
- -
Certifying physician (Physician certifying cause 01 death when another physician has pronounced death and completed Item 1 ... --I c:::>-"l /
To I~ best of my knowledge, death occurr8d due to the ceuse(a) end manner as stalfKL _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0 I
~~~:u:~~~,.~ :=~tJ::a~~a~c~~:::~ t~~I~~~~~n;~e:::c:~~~~~:~ot~h~~::~~~~~ manner as stale _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ~ 33c. LicSflse Number 33d. Dale Signed (Month. day, year)
Mod'co' t"'mlner I Corone, fYl t> l.t U~ " _ 27- 0
On the basis of examination and I or investigation, in my opinion, death occurred at the time, dale, and place. and due the cause(s) and manner as statecL 0 34 Name and Address of Person VoIho Completed Cause 01 Death (Item 27) Type I Print
-rAPASbrP ~~R.. I MD
DYes DNo
31. Manner of Death
o Natural D Homicide
o Accident 0 Pending Investigation
D Suicide 0 Could Not be Determined
32a. Dale 01 Injury (
32g. Location 01 Injury (Street, cily I town, stale)
3Oa. Was an Autopsy
Per/ormed?
3Ob. Were Autopsy Findings
Available Prior to Completioo
01 Cause 01 Dealh?
DYes .k\NO
32d. Time of Injury
35, Regislrar's
~
Disposition Permit No
"
LAST WIlL ANjJ 'IESTAMENT OF GOLDIE E. HAR'IM!\N
i
I
I, GOLDIE E. H.foo.MAN, of the Township of East Pennsboro,
County of Cumberland and state of Permsylvania, being of sound and dis-
posing mind, rrarory and understanding, do make, publish and declare this
my Last Will and Test:aI'ra1t, hereby revoking and making void all fonner
Wills by me at any time heretofore made.
l.
I direct the Pclyrnent of all my just debts and funeral expenses
as soon after my decease a~ the same may conveniently be done.
I
I 2.
!
All the rest, leSidue and remainder of my estate, real, per-
sonal and mixed, of whatso ver nature and wheresoever the same may be
situate, I give, devise an bequeath to my daughter, JUDITII E. STAZEWSKI,
of Enola, Permsylvania, absolutely and unconditionally.
3.
LAS'ILY, I nominate, constitute and appoint my daughter, JUDITII
E. STAZEWSKI, Executrix of this, my Last Will and Test:aI'ra1t.
~SfA
IN WI1NESS F, I have hereunto set my hand and Aeal thi~:2
day of January, A. D. 1988 . c~; ~5
c_
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/ JJi!.d/-- C. ~ a,^Vt;;;l41~v~ ~<
Goldie E. Hartman
~~SEAL)
c
Signed, sealedJ published and declared by the above-~d
GOLDIE E. HAR'IMAN, as and tpr her Last Will and Testament, in the presence
of us, v;ho, at her request and in her presence, and in the presence of
eac..'l other, have hereunto subscribed our names as witnesses.
/ '_/ I///f./ /(..- . ~ /
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OATH OF S BSCRIBING WITNESS(ES) ~,
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REGISTER OF WILLS
(LA COUNTY, PENNSYLVANIA
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Estate of 6-0 Idle. [. fkr+tUl
J ko bee!- Sb, ufHr (tAd (Joh fl )1. bet JG~
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, Deceased
(Print Name/f)
the 0 Will 0 Codicil(s) presented here wit , (each) being duly qualified according to law, depose(s) and
say(s) that she l he l they was / were present and saw the above Testator / Testatrix sign the same
and that she / he / they signed the sam and that she / he l they signed as a witness at the request of
the Testator / Testatrix III her / his
, (each) a subscribing witness to
(Signature)
Ww-
(Street Address)
.d~~ . (/0.... [70 j-'J~
(Ci~~are,Z~) , //
AIla rite {--_S~ Hfttl
(Street Addres;)
~/sS~11Ls17~lJ
Executed in Register's Office
Sworn to or affirmed and subscribed
Executed out of Register's Office
before me this
day
Sworn to or affirmed and subscribed
:tM
day
of
before me this
of ~hlAj{f~1 , 200fi,
J
~_.~.~
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,)
Deputy for Register of Wills
NOTE: To be taken by Officer authorized to administer oaths, Please have present the original or copy ofinstrument(s) at time of notarization,
FormRW-03 rev, /0./3,06
HOtMW. 11M
HIIOI M NIUON
NotoIy NMIo
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My CornmIIIIon ..... Juft 27. 1011
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