HomeMy WebLinkAbout04-25-08
PETITION FOR PROBATE AND GRANT OF LETTERS
CIl9.~ex\~C)
COlJNTY, PENNSYLVA:\[A
REGISTER OF WILLS OF
Estate I)t 5fJj/I.., J? 6-...et:J'4~
I ., , -
a so ,mown a, _
File Number
1 \ 0 '6" 6'-\ l!l r
, Deceased
Social Security Number ~ $- -
Petitioner(s), \\ho is/are l~ years of age or older, apply(ies) for:
(CO:HPLEIF '.-I' or 'lJ' BEl.OW:)
o A. I'rollak ;lJlt! Crallt of Lellers Testamentary and aver that Petitioner(s) is I are the
last Wdlor' the [)ec~(knt dated and codicil(s) dated
named in the
r-J
-=
() 5
(-?:~ 0 ...!"~
(State relevant circumstances, e.g.. renullciation, death of executor, etc.) ..-~ ~~ ~2 ~ ", . :.))
Except as follows, Decedent did not marry, was not divorced, and did not hale a child born or adopted after execution of ~ IiMnlme~) offe\:ect, ',.:3
for probate, was not the victim of a killing and was never adjudicated an incapacitated person: .J. -;-- '.)!
.._-.~:'::,~; ~
_ :...1'.. "
').,-1
t ;"~~_'
~~. Grant of Letters of Administration
o
Q:)
PetitiJner(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
Admillistratioll, c.t.a. or d.b.H.c.t.a., enter dale oj Will in Section A above alld complete list oj heirs.)
(If appticable. enter:
0-
.D
:"-1
c.t.a.; d.b.n.c.l.a.; pendente lite; durante absentia; duraljJe:minoritate)
5
c
~(.
(COMPLETE IN ALL CASES:) Attach additional sheets if necessary.
Decedent, then if "5
years of age, died on 12ciJ. ~ :JtJ& I at
16 Wc...yJff' f(M {'lttrljJlhlllll-,/7c11
Decedcnt at death owned property with estimated valucs as follows:
(If domiciled in PA) All personal property
([f not domiciled in P A) Personal property in Pennsylvania
(If not domiciled in P A) Personal property in County
Value of real estate in Pennsylvania
$ 2.cXJO, 00
$
:\)
$
situated as follows:
Wherefore, Petirioner(s) respectfully request(s) the probate of the last W,ll and Codicil(s) presented wirh this Petition and the grant of Letters in the '<11 to
the undersigned:
c
IJfm
Typed or printed name and residence
Fun" RW-02 rei' 10/J06
Page lof2
Oath of Personal Representative
COMivJONWEAL 1 fi (If FENNSYL VANIA
COUNT1' OF ___~~__
Tilt: ['cti'.i'::licn.! :;h'..i\ ,c'<u::lc'd i''. c';HI.'.Il1f d ''firm(s) that the statements in the foregoing Petition are true and COlTect to the best oC
SS
lh.~ k,/,)\', kd",c ~i!d hd/~r nf Pe[itioner( s i ;\I'.J [11;t[. as personal representative(s) oCthe Decedent, Petitioner(s) will well and truly
administer tbe est:Jte accordlI1g to law.
Swom to or affirmed and subscribed
bdore me the
Signu:un: q/ r'erso!l"i Rc:presentative
n
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1'-.3
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Signuture of PurSOlJo! Representative
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Estate of
File Number: ~ \ ()'6 bL\lO~
~\~ f ~~ ,D"""d
"\~ Date of Dealh: \ t> \ \~\ ol
1.6 ~, iJ\. con; id'''".O n ofl'" fncogoing Pelilinn, "O;f,"ory ,mof
1jdff\\\~
o
(X)
in the above estate
and that the instrument(s) dated
described 111 the Petition be admitted to probate and filed of recor
Supreme Court LD. No.:
FEES
Letters ......'~ .p1);) . . $ lC
Short Certificate(s) . . .l. . . . . :5 i-f
Renullciation(s) :5
JeP $ lb
___'' ~1D $ S-
$~---
$
$
$
$
Attomey Signature:
Attomey Name:
Address:
$
Telephone:
~ JC)
TOTAL. .
r.~".", IHV_IJ! "(~\I 10 I ~_()(j
Page2of2
HI05.905 REV.(G/OG)
This is to certifY that this is a true copy of the record which is on file in the Pennsylvania Division of Vital Records In accordance
with Act 66, P.L. 304, approved by the General Assembly, June 29, 1953.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
~
No.
CfJJA-~ ff~oL ~
u'-:C .=
Frank I~ali ~.
State Regl~~ =-0
.', =s:1 0 :;::;:l
...',- N
DEe G 7W6?2 Ul
Calvin B. Johnson, M.D., M.P.H.
Secretary of Health
4198748
:'--::,C';
Daiti~
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:t::'"
J:.
<2
o
CC
Hl~~NAL
1\ IlIACI< INK
" #31-116
~ 1. Nomeof_(flIIt._."".tuIlbt)
, Sally E
5 AqellJlslBirtl1d.,)
COMMONWEALTH OF PENNSYLVANIA' DEPARTMENT OF HEALTH. VITAL RECORDS
CORONER'S CERTIFICATE OF DEATH
(See Instructlons and examples on reverse)
2\ 08 otttof}104838
11.OIcedenrslJull l'l"IOIId 1Ife.00not_
K>fof- Kn1~_{lnWs1ry
Homemaker Her uwn Home
16'~~n8lmotyl_,_.Z\>-)
Camp Hill, PA 17011
'8~~'~~ht
2IlL-.*'1" (TlI!"/PrioJ)
Kenneth u. ueorge
12. Was Oecedent f\I'8f in the
o.s. Armed Forces?
Ov.. I2llNo
-,
Actual Residente 111. Slate
STATE FilE NUMBER
Vrs.
George
8. 00Ie of _IMonth, , ,
April 10. 1962
45
Bb, County of Do"'"
Cumberland
ed. FaciIi!y Name (W""_. give..... and """""')
16 Wayne Road
13._,E_ISC>eoty"""hlghestgrada~
EIemenIary I Socondary (1).12) College 1'-4 '" 5+)
12 2
171>. County
PA
CUMBERlAND
~~ 17C~V...~lMd"
T"""""'? 17<10 No.DocadontLNed_
Ac1ualLimllsof
Twp.
atyl-
19. JAothe(s Name iFlrst. rnidde, maiden sumlllTIe)
Judith H. Hendrickson
2U>1"~."'t1a~Tok~, oty~'iliii, PA 17011
a
~
~
~
~1Ioms23lH:""'_cortifylng
phljIi:iIrlisl'lOl8YlllllbleattlrneofdMthlo
ClII1lIy....of_.
220. ..... and -... of Fo:illy
FACKLER-WIEDEMAN FUNERAL lD1E,23rd & Derry
230. To""""'ofmyla1owledge._~al"''''''''.dllIaandplaoo_.ISignaIurs and"") 231>. Ucense_
211. MIIhod of DiIpoeItk)n
21C.Placeof~INameof_._",_plaoo)
Hoover Crematory
2'd.~tCkyI_._.q,_1
Harrisburg, PA 17112
-_.........-.,.".....,
""""""""""'_'
25. Dolt """"""'" Dead t-, cloy. year)
7:00 A. M. October 18. 2007
CAUSE OF DEAlH rs. __ _..........)
1Iom11.Partt EnIar""~-_........",_-1heIdIrsdly_""_.OONOT____asCllldlac._.
t'IIIPirIIory...... or't"l!lf'llrlcUlbIII8tion dlCd showing Iht 1Iic*lgy. UIIcriy one ca.. on lI8Ch IinB
204.Timeof~
26. Was Case Referred 10 MMIcaI ExamIner I Coroner for 8 Reuon Olher than Cremation or Donallon?
V" ONo
Approximate 11teNaI: Part II: Emr oIher lIionIIicant oordIions cnNrhJlnn to dMIh, 28. Did tobacco Use ConIrtJute tl DM1h?
Qnset\oDootll ""'''''_"'''' undorIy;ngcausaglvenm Partt 0 V" O"'-Y
o No DJ:-
=.m-==I~ .. Mixed Dru2 Toxicitv
Due to (01' M aCOf1llllqU8l'1Cof):
I
l!s
I
32<. Dolt ~ Injlay 1_. cloy. year) 321>. 00aaIle How Injlay Ocarrsd
UNKNOWN Misuse of prescribed
32Il._oflnjlay 32o."""al--' 32f.WT__',*",ISpecIIy)
UNKNOWN Ov.. ~No ODrivw/Opers1oo 0"- 0-
M. ~'SPeCIIY
3:k c.-...I_ "'" _) 331>. SignaIurs and
. :=..~..:'==:..~.."':..~':~~_~~~~_________________ 0 ~ Coroner
. -..............."..,... ~ boll pRlI'IIlll'dng _ and 00>Ilylng \0.... ~ _I 33<:. Ucanaa N..- 33d. Data S9* IMonlh. cloy. year)
llI.._at..,--..,__....-._OIldplaoa,.........couaa(.,...-.___________________ 0 N b 13. 2007
. __,_ WI ovem er
011.. -"'_...,............. In..,......... --....- _...pIaoa,......... couaa(.)... -. ---"\ 34.JloG>eaod_ of,faBoniMlo ~ Cauao.ol Ooalh (110m 271 Type 1 Plinl
~~cnaeL L. ~orr~s. ~oroner
- 3S.......'.9IgIIPfII~O f'r 6375 Basehore Road! Suite fl1
~ ...,..,.. y Mechanicsburg. PA 7050
D!{"'" [] No
)It"'" ONo
0- 0-
~- O-.gl>waolllgalion
0- OCoUdNol..__
29. W Female:
o Nolprllp1Mt_pastyaar
o ","",,",","""'of_
0..._...__",..."
of_
o ...prIIp1Mt...._43...,,\o'...r
---
o _'__""pasl\"""
32c.Plateof.....:_......-.F-"
medications OIlIo:aBlilllnil.aIc. (SpecIIyI Home
32g.LocalIonoflnjlayl_.ctryl_._)
Wayne Road. Camp Hill. PA
=l:lItccnlllonl,"~,
10 1::IUItlilledonlnea.
Enlor ___
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