HomeMy WebLinkAbout01-16-08PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF ~.yy,~,.La.,ti~,G COUNTY, PEIV'11SYLVANI:~
Estate of p D.Q~~„u,[ Q ~ a.k'e oe~~., ~f ~~JU -~~
---T- File Number _
also Known as
~~ f 9 1Oa7 ,Deceased Social Secw•ity Number_~Jr~- ~ ~` '
Petitioner(s), who is-are 1$ years of age or older, apply(ies) for:
(COMPLETE '.-f ' or `B' BELOW.) c~-a
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^ A< Probate and Grant of Letters Testamentary and aver that Petitioner(s) is /are the j =' ; •
last Will of the Decedent dated named in the
and codicil(s) dated `M1 r. ~-
CJ: ~!-;
(State relevmu circumstances, e.g., renunciation, death of executor, etc.) _ T-~ _
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Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution the insttv~nt(s) offered,
for probate, was not the victim of a killing and was never adjudicated an incapacitated person: `_' ~,,,~
I3. Grant of Letters of Administration
(Ifapplicabte, enter: c.t.a.; d. b.n.c.t.a.; pendente lire; durmue nbsenttn; durante minori[ate)
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.t:.c.t.a., enter date of Will in Section A above and complete list of heirs.)
~_ Name Relationship
~ ~ Residence
~-`y~0 o v
(COtYlPLETE I,'V ALL CASES:) Attac/: additional sheets if necessary.
Decedent was domiciled at death in (ww~.1,-w,(_4,,,~„Jl_ County, Pennsylvania with his /her last principal residence at
(List street address'. town/city, township, co:uuy, state, >ip code)
Decedent, then ~_ years of age, died on ho-~r t qt ,~00a~ /~ 01.E ,4 ~,~/-,,~ /-l e~~'~r.
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property $ .~ CJr O OG ~ O o
(If trot domiciled itt PA) Personal property in Pennsylvania $
(If not domiciled in PA) Personal property in County $
Value of real estate in Pennsylvania $
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:
l 5i,nature Typed or printed name and residence
S~lem~'{,r...TCIz Rd.- h'iac/iarttc5fswr•~{~a. /7oso
Fo~•m RW-0? rein. 10)3.06 Pabe 1 Of '~
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF an-v~- •
The Petitioner(s) above-named swear(s) or affirn~(s) that the statements in the foregoing Petition are true and con•ect 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 ~, ,~ ~1 cQ,Ec.~.v ~
// t~'j Signature ojPersonal Representative
before me the ~CP day of
Signature of Persotinl Representative
i
F r the Register
Signahu•e ojPersonal Representative
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Estate of R.we /~
o--.~,o( l,. ~,L~-C_¢_k.-q~e ~~ , Dec~sed
Social Seeun y Number: Date of Death: ~`r / 4i .~~~ ~ r^.~
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AND NOW, ,~p~~-+~-, in consid ration o f the foregoing Petition, satisfactory proof
having been presented be re , I IS D C ED t t Lett ,/~
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
FEES
Lt>
Letters ............... $
Short Certificate(s) ........ $
Renunciation(s) $
~. $ ,O
... ~
... $
... $
... $
... $
... $
... $
TOTAL .. CX.~
Attorney Signature:
Attorney Name:
Supreme Court I.D. No
Address:
Telephone:
Form R4V-02 rev. 10.13.oe Page 2 of 2
I05.805 REV (01/07)
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LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00
P 13989592
Certification Number
This is to certify that the information here given i correctly copied from an original Certificate of Deatl
duly filed with me as Local Registrar. The origins:
certificate will be forwarded to the State Vita:
Records Office for permanent filing.
~--~ NOV 6 10 7
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Local Registrar Date Issued
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REV 1lnoos COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
lMANENTN CERTIFICATE OF DEATH
ICK INN (See Instructions and examples on reverse)
STATE FILE NUMBER
1. Name of Decedent (Rrst mitlde, last, suhiz) 2. Sez 3. Serial Security Number 4. Date of Death (Month, tlay,'year)
Roland J. Galls her Male 452 - 54- 6858 `~`~ C
5. Age (Leal Birthday) Under 1 year Under 1 de 8. Date of Birth (MOmh, de , ear) 7. &nhpace (C' aM state a krei country) Be. Place of Deam (Check only one)
Namme flays tfsure twaam Hospital: Other.
75 vrs. Aug. 29, 1932 Evans City, PA Inpatient ^ER/OWpatient ^DOA ^Nursing HOme ^Residence ^Other-Specify
Bb. County d Death &. City, Boro, 7wp. M Death 8d. FadNly Name (Ii rrol instlWlbn, gNe street antl wmher) 9. Was Oecetlent of Hispanc Origin? ®No ^ Vas 10. Race: American Intltan, Black, White, ek.
1 1 • Pf Yes, speclN Cuban, (sP~tM
Cumberland East Pennsboro Ir-1` Meziwn, Puerto Rican, etc.) its
11. DecedenYS Uwal tlpn Kind of woA d are dr' most d Ne. Oo not slate retir 12. Wes Deceden ever in a 13. Decedent's Edu cahon ( onty highest grade compl eted) 14. Marital Status: Martied, Never Monied, I5. Surviving Spo use (II wife, give maitlen name)
Kind d Work KiM of Businms /Industry U.S. Armed Faces? Elementary ! SecoMery (012) CoNege (1-4 or 5.) Widareq Osarced (Specify)
Truck Driver Trans ortation ®res ^No 11 Married Charlotte E. Gardner
- 1fi. Deeedent's Meiling Address lsree4 city /lam, slate, zip coda) DeoeaenYe Penns lvania as Depdem
y
90 Salem Church Road, X400 Actual Residence 17a. Stale
live in a 17c. ~ Vas, Decedent Lived in AaTtmden T
~
PA 17050
- Mechanicsburg Township? 17tl. ^ No, Decades Lived vA1Nn
17b. Couny
GTlmberland
, _
Actual Umiha City/~
18. Father's Name (Fks4 middle, last suhiz) 1S. Moma's Name (Flrst, middle, maiden wmamej
Harve Dombart Ma Galla her
20a. IsarmanYS Name (type / Pnnt) 20b. InlamenYS Mailing Address (Street city /town, slate, zip pde)
1 a
21a. Memod d Disposition i L~Crernetion ^ Donation 21b. Date d Disposition (Month, day, year) 21c. Place of Diepoehbn (Name of cemetery, crematory a Omar place) 21d. Loptim ICity I town, stele, zip coda)
^ Bartel ^ Removal Iran Slate ~ Was Crerrmllon a Donatbn AulMnzed
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^ Other- ;y . byMeMcalEamniwlcoraten
Vea^Na Nov. 26 2007 Cremation Societ of PA Harrisbur PA 17109
- 22a. Sign re L' le person acing as such) 22b. license Number 22c. Name aM Address d fecaity
Auer Memorial Home and Cremation Services, Inc.
- - ,~G• FD 013376 - L 4100 Jonestown Road Harrisbur PA 17109
23e-c arty when certifying 23a. To the best of my kno~Medga, death occuned al the time, dale and place slated. (Signaure acct thle) 23b. License Number 23c. Data Siyred (MOnm, day. year)
physidan ta cwt avaNaGe at fire d deer
cergly cause d tleath.
Nems 24-25 must be cortpleled q' person 24. Tme of DeaM
p 25. Date Pronounced Deed (Nosh, y, year) 2fi. Was Case Retarted to/M¢~aI Ezamirer /Coroner for a Reason Other than Cremation or Donatron?
,- wrq pronoarcces death. /~ (
'YJ M~ 2 '~ Q ~ ^Ves ~IIG
CAUSE OF DEATH (Sera InstYUCtlona end a,emplea) r Approzirele interval: Pan II: Enter other ' ~ 2B. Dkl Tahecco User Catribute W Death?
hem 27. Pan I: Enter me chain d everes -diseases, inrynea, a cenplpikzzs - that dreotly reused der death. DO NOT eser terminal evens such as prtliac arrest i Onset ro Death but not reselling in the underlyirp cease given in Pen I. ^ Yes ^ Prabeby
reapirelor
y
eneM, or vemriptar fibnRetlon witlaul/~showtrp the eFObgy. Ust spy aw reuse on e(a'ch Fns. , ^ No ^ Unknown
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cerrdlbn reardtl USA f entll)deease or (/ ` ^l~ ~ _1 ,z~
rg de _~ a rl ~ l7-CA`
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`(A.IJ 'TZ,A/"I
h ASR 29. fl Femeb:
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Due to la as a arlce (gp:
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Na nt willwn r
Me9na Pest Yea
^ Pregnant et tine of death
SequenFaNy Nst cerMhlons, h anY. b. t
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Io the cause Fated on lire e.
~~adrp Due to (or as a oQ:
UNDERLYNID CAUBE
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9 ^ Na pregrenL ba pregnem within 42 days
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er
le
(disease a in~ that ~nMiated tl~e c r
Wtl m d
th) LASr
t
of death
even
s res
ea
Due m (a es a consequence off: i ^ Not pregnant, hul pregnant 43 days l01 year
d. r bedae deem
^ Unknown H pregnant vn1Nn me past year
30a. Was an Aulopry 30b. Were Aucpsy Rndxgs 31. Meag(.W9eem 32a. Date d Inury (Momh, day, year) 32h. Descrme Haw Injury Occurred 32c. Place s Inprry: Horne, Farm, Slreel, Factory,
Pedamred? Avahade Prbr to Completlon
Natural ^ Flornicide Once Buildng, etc. (Specr~ly)
d Cause d Deam7
~NO
^ Vas .-, // ^ Vas ^ No ^ AcddeM ^ Pending Invessgatlon 32d. 7me d Inury 32e. In(ury al Work? 32f. If Trensponatlon Inryry (Seedy) 32g. Loptbn d Injury (Street ceY /town, slate)
^ Sukitle ^ Could Na be Determined ^ Vas ^ No ^ Ddver /Operate ^ Passenger ^Petlestdan
M Omer - aPedh:
33a. Certifier (died osy erne) 33b. Signature eM T of r
• CerlgYm9 phyakhn (Physkden rastying pose of deem when aroma physkian has Pronwrzred deem an0 competed hem 23)
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To tfK beet of my lmowledge,dwth exerted due to the eauee(a)ark manner ea stead,._____-_'-"_'___________________ ^ V _
• PralounaMg and cxtgying phyektan (Physidan ham pracundng deem grid pnhylrg to pose d deem)
To the boat of my knowledge, rkalh aeuned al the time, MPo, end place, end due to the cwse(a) and manner ere etated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ 33c. License Number ~ \ ~~ 33d. Date S~ ~ ( M, ~Y~ V d
• fiMdkal Examiner /Coroner
On Iha Dads of ezaminetlen end I or Inveatigatiw, in my opison, death oceurred al the lime, date, erM place, and due to the pose(s) and manner ere slated_ ^ ~ Name aM Adtlress of Person Vr,Aw
C~ plated Cause of Death lltem 27) Type I Pnnt
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Registrar
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Diwoeiaon Perron No. 0070672