HomeMy WebLinkAbout02-25-08
PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF C'UlNI '')..el~( r:tJYlri
COtJNTY, PENNSYLVANIA
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c , <; hd.~'f
SA ~r /)
I
File Number
~ \ o~ a'd..O'S
, Deceased
Social Security Number /83 - I d.- . i :3 Cf 9
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(CO;'\IPLETE 'A' or 'B' BELOW:)
o A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is I are the
last Will of the Decedent dated and codicil(s) dated
r'.',
a:::
~)
Ui 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 instmrii?nt(s) offered
for probate, was not the victim of a killing and was never adjudicated an incapacitated person:
i B. Grant of Letters of Administration
Petitioner(s) after a proper search has I have ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs: (If
Ad/llinistratio/!. c.t.a. or d.bn.ct.a.. enter date of Will in Section A above and complete list of heirs.)
s: i rz~~/~_ tJ
Name
(, c. h P r
Relationship
I rl"" r4/P r
Residence
1/1"'-;; IbrhNL", Au",
I
w , Ic~!; (/4 (
19&11
(COMPLETE IN ALL CASES:) Attach additional sheets ifnecessary.
r r County, Penns . vania with his / her last principal residence at ,;lo / IUor'li/..
a , 17: I
-R:=cedent was dor:1iciled at death in
-t'r (\;\~ St #"
(List street address. town/city. township. county. state. zip code
Decedent, then
'Zy
years of age, died on ..;).. / I .I 0 7
at
ch a WI /:y '-_~ t"9
I
ilc?:>.iLJ1 ted/ 1 dhci. ' ;{],.
I 'iJ
Decedent at death owned property with estimated values as follows:
(If domiciled in P A) All personal property
(If not domiciled in PAl Personal property in Pennsylvania
(If not domiciled in PAl Personal property in County
Value of real estate in Pennsylvania
$ ,.;2 7&'"'0. c'~
$
$
$
situated as follows:
Wherefore, Peutioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant of Letters in the a~propriate form to
the u"dersigned:
c
"p
-7
Ty ed or rinted name and residence
For", RW-02 rev. 10./3.06
Page 1 of 2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF
~\~ 'Der~J.
SS
T,1e Petitroner(s) above-named swear(s) or affim1(s) that the statements in the foregoing Petition are tme 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 tmly
administer the estate according to law.
before me the
~5
day of
Sworn to or affirmed and subscribed
....
Slgnalure of Persollal Represenla/ive
Signa/tire of Personal Representative
~\ O~
RObee--\- e. ~"Cd- p
~~ \d. \~q~
AND NOW, ~\::r.\.)"lL,,-\ ~ 5 ~8
having been presented before me, IT IS DECREED that Letters
are hereby granted to L, 1"\c\.0... r;\~,
File Number:
OdOd
Estate of
, Deceased
Date of Death:~\ \ \ () 1
Social Security Number:
, in consideration of the foregoing Petition, satisfactory proof
\=\6m 'r\\~-\-r~~a''l
in the above estate
and that the instrument(s) dated
described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent.
J1t~ ~~~~~1 ~J..ltp
FEES
~\tX)
Letters ............... $
Short Certificate(s) . . ~ . . . . $
Renunciation(s) .......... $
~~\o ... $
0l~ $
$
$
$
$
$
$
$
$
3D
IIn
Attomey Signature:
s-
ID
Attomey Name:
Supreme Court LD. No.:
r-.--;
Address:
C;..,
(-...,
1" ,
<..n
~-.
<
':.0
Telephone:
c)
TOTAL
<.D\
For,,, R WO! rev 1O.13.U6
Page 2 of2
H!n5_~O"i REV 1/,1:')
This is to certify that the infonnation here given is conectly copied from an original ce11ificate of death duly filed with me as
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
No.
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Fee for this certificate. $6.00
P 13236258
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(J'l
c'"'")
o
H105.1.43REV, 02f2006
1m 1 PRtIT ~
PERMANENT
BlACK N<
1. NloneofOocodont(filsl._.Iast,"'""I
Rober't C.
5.1(je(lasl-~1
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
6 oaeof_
7.
...._or
STATE FILE NUMBER a( \ 0 b 0 do D~
4. Dale of Dealh 1_, day,yuJ
12 - 1399 February 1, 2007
VIS.
183
84
6-18-1922
Shippensburg,
6a Placeofllealh Clled<
HospilaI: Olhoc
[Jl_rrt 0 ERI 0ulpeEnI 0 DCA 0 Nursing Home
9. WasOeoedonlcfHisparicOrigil? KI No OVes
(If l"'. specify Cuban.
Mexic:an,PuertoRical,et:.)
13. Oocedent's_(Spedfyoo~hig-QIBd<>c:ompIeled) 14.IIIJ1laIStOus:_._MIlIliod.
EIlImenIlIyISecondaly(M2) caIege(14 0< 5<J -.-ISpedI)1
8th widowed
[);d Oeoedonl
lMlila
Townoh\>?
17c. El Yes, lle::edenl LiYed in
17d.(g ~~ofUvedwil1in ShinnenshllTq
Twp
\
t\
8b CcluIOy oroe.~
Franklin
11. Decedenl'SUllUal most 01 1Ie.00ootstailJe!le:i.
_of Work _d_IIndos1ry
Bell Hop Hershey Hotel
16 -.Miling_(Shel,cily/_._.2ipO<Xlel
101 North Prince Street Shippensburg
P . 17257
ad FdtyN....(lfnol_g.._and..-}
Chambersburg Hospital
o
!1l
~
12. Was 0ecedeIt eo.<< in be
U.S. Armed Forces?
mVes DNa
-.
Actual R8sidenoe 17a. State P A
17b.County Cumberland
I Born
21b. _d[);,posilion{Monlh,day.l"8'l
Reading Pa.19611
210 Locabon (City 1_.-. "P-J
mithsburg MD21783
~
23c. Date Signed (Month. dlly. year)
_.....l_rriywhenc:eotifp!g
phy8:Bl is notBVIilltJItalimeofdBilltl
cdyCllJl8ddeol1
IlIlms 24-26....1 be,...- by......,
who""""""",_.
~, TlI1eofDeeth
110
CAUSE OF DEATH (500 __.nd uampIool
Iem 'Z/, PART l: Erder1he~' cbBases, iljlries, ucorJ1icabls -lhaldimcltyC&llllld Iledea.1. DO NOT enlerlBrminal ewnts sud1 as ccmac lIlest.
RlllpinIIDry --. Of vermcu. MdaIion VliIJouI fiMilg tie elioklgy.lisI: cdy one cause 00 88th line
_lCCAlJSE(F~lidioeageor .-e e d b
__l~-l _' S CAD (Yyt{JfW"> r-uIV:JU<'
oue1D(or_.~orr
cal,'f I~
: Apprullimalemerval
: Onset.. 00aUl
~c?~h)
I
I
&lh".(rc-
I
,[.t'A ,'Iv.re-
o r 9tq.....
~ ') du...,)
26. DidTobacooUseConlriOOteIoDeath?
OVes Op_
o Na 0 U",,,,own
29. WF<im"':
o Not pregnanl within past year
o PIego1arrtollimeofdca~
o Nolpmgnan~txrtpregnl'f\lwllhin42days
01 death
o NoIpregn"".butpnl9flonl43deysm'year
cfdea1h
o ut*oown if pregnant within the past year
32c. Place of Injury: Home, Farm, Street, Factory,
Oftioe !luting. e' (SpedIy)
Part II: Enterother~mnliImscrnlrb.~ kldealh
bulnotresultingi1tile~ClIlSegiveninPa1I.
=isttoOOilioosoilfflY..
tlCllJ88listl1dooirlea
EnE< UND8lLYIHG CAUSE
(dioeage"?'llhal_lhe
_1OSIi1ing"_llAST.
b.
Due lID (or 115 . a:nseqlJ81lC8 of')
Due to (or _ . consequellOe of')"
d.
o Yes [~
OVes DNa
31. IIovwdlJeolh
~- D-
O- O-lnveoIigab> 32dTmeofkjmy
OSlOclde OColOdNolbe~
319. Locabon oIlnj<>y IS...,. city 1_._1
:1M, W8lilmAuilpsy
Performed?
301>. ....__
A"'aUe_"~
ofCausedDelilth?
M
330. ~ (,""""ooIyooe)
. CortIlJlnlIphyolclon(Phy5icianc:eotifp!gCllJl8d___p.yo;cian""'pronlllIl<Od_....~I1lIm23)
TotbebMtaftnyluJoWltdgl, dIIIlhoa:urmdcMtoa. taIH(.).ndmHlnltl""~___ _ _ _ _ -- - - ----- - - ---- - - -- - - - - - --
P"""'-......atlIIIyIngphyolclon~boIl~_;nl_.......m_)
To'" beoIoI"'l'_ __oIlbe_. _..d .......... duetolbecauoo(.)... --..1llllR<l. _ _ _ n_ _ __ _ __ _ __ - _.D
. IIIMIcII EurniMf I CoI'OOIf
Orlthlt..-al..mnationanclIOf
~
Ill! I ~ I 'PI 36
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