HomeMy WebLinkAbout05-30-08PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA
Estate of Francis E. Czajkowski File Number ~/"~QvU ~ ~l`,CI~
also known as Frank Czajkowski*
,Deceased Social Security Number 144-42-4882
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE 'A' or 'B' BELOW.)
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A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is /are the r = O naj~d in the
last Will of the Decedent dated and codicil(s) dated =~
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(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 e:Kecution of the i~trument(s~ffered,
for probate, was not the victim of a killing and was never adjudicated an incapacitated person: '~ •• ;
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® B. Grant of Letters of Administration
(If applicable, enter: c. t. a.; d.b.n.c.t.a.; pendente life; durante absentia; durante minoritate)
Petitioner(s) after a proper search has /have ascertained that Decedent left no Will and was survived by the fallowing spouse (if any) and heirs: (If
Administration, c.t.a. or d.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.)
Name Relationshi Residence
See attached Schedule
(COMPLETE IN ALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in Cumberland County, Pennsylvania with his /her last principal residence at 533 State
Street, Enola (East Pennsboro Township), Pennsylvania 17025
(List street address, town/city, township, county, state, zip code)
Decedent, then 56 years of age, died on January 28, 2008 at 533 State Street, East Pennsboro
Tnwnshi~t~ Cumberland County, Pennsylvania
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property $ 15 , 000.00
(If not domiciled in PA) Personal property in Pennsylvania $
(If not domiciled in PA) Personal property in County $
Value of real estate in Pennsylvania $ 60 , 000.00
situated as follows: 533 State Street, East Pennsboro Township, Cumberland County, PA.
Form RW-02 rev. 10.!3.06 Page I of 2
*a/k/a F. E. Czajkowski, a/k/a Frank E. Czajkowski, a/k/a Eddie Czajkowski.
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:
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Part B. Grant of Letters of Administration
SCHEDULE
Decedent never married and left no issue to survive him.
Decedent's mother, Yolanda M. Czajkowski, died o:n November 5,
1992. His closest relatives are as follows:
Father: Frank Czajkowski
90 Union Valley Road
Monroe Township, NJ 08831
Brother: Robert Czajkowski
104 North Beverwick, Apt. 12
Lake Hiawatta, NJ 07034
Frank Czajkowski has renounced in favor of Petitioner.
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Oath of Personal Representative
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COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND r
The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true and ~f; t}re 13~ 4t
the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decedent, Petitioner(s) w~lJf ~e11 and tnily ' ~'n
administer the estate according to law.
Sworn to or affirmed and subscribed
before me the ~~~ day of
May 2008
~ { ~ ~~~~
For th Register
Signature of
Marlin R. McCaleb
Signature of Personal Representative
Signature of Personal Representative
File Number:
Estate of Francis E. Czajkowski* _, Deceased
Social Security Number: 144-42-4882 Date of Death: January 28, 2008
AND NOW, May ~~ 2008 , in consideration of the foregoing Petition, satisfactory proof
having been presented before me, IT IS DECREED that Letters of Administration
are hereby granted to Marlin R. McCaleb
and that the instrument(s) dated N/A
described in the Petition be admitted to probate and filed of
FEES
Letters ...............
I C'i..
$
Short Certificate(s) ........ $ 1
Renunciation(s) . , . ?..... $ ~~
r
... $
... $ o
... $
... $
... $
... $
... $
... $
... $
TOTAL .............. $ 9'60
in the above estate
Attorney Signature:
06353
Supreme Court I.D. No.:
Address: 219 East Main Street
Mechanicsburg, PA 17055
Telephone: (717) 691-7770
Form RW-02 rev. 10.13.06 Page 2 of 2
*a/k/a F. E. Czajkowski, a/k/a Frank Czajkowski, a/k/a Frank E. Czajkowski,
a/k/a Eddie Czajkowski.
Attorney Name: Marlin :R. McCaleb
~ S ~~~
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
\NARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate. S6.OO „rr%%% - fhl, n to cattily that the Information here given is
•1r' ~,TH OF p
1,,11' ~,P, ,Ey`= colrcct;y espied from an original Certificate of Death
,;1`~o~~i \~~~ dull fi':ed with me as Local Registrar. The original
r~~' `;y~ certificate will be Forwarded to the State Vital
~~°; ~ naj IZeconls Office liyr ]permanent filing.
- ' -1MENT OF,~;r~11
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C'ertifir_ation Numher ""'~~~~~~~~~r ~,~
[.,oral Re ~ISU~ar Date Issued
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Ev 112006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS ~
>r"4ENr" CORONER'S CERTIFICATE OF DEATH ~
KINK See Instructions and exam les on reverse
~E 71 .7 7 7 ~ P ~ STATE FILE NUMBER
1. Name of Decedent (First, mitltlle. last. six) 2. Sax 3. Social Security Number 4. Dale of Death (Month, day, year)
Francis E Czajkowski Male 144 - 42 -4882 January 28, 2008
5. Age (last Birmday) Under 1 year Under 1 tlay 6. Date o18iM (Month, day, year) 7. Birthplace (Chy and state or for eign country) 8a. Place of Death (Check only one)
56 Many ~" "Wn M1nu1B July 13, 1951
Bayonne
NJ Hospital: Other:
Yra. , ^Inpelienl ^ER; Outpatient []DOA ^NUming Hnme Residence ^Othe• Specify
eb. Courry of Death 6c. Clty, Bor Tw . f Death 6d. Facility Name (II rid institution, give slre9t antl number) 9. Was Decedent of Hlspanc Origin? ~ No ^ Yes 10. Race: American Indian, Black, White, etc.
Cumberland East Pennsboro 533 State Street pr yea,apecirycuban,
Mexican, Puedo Rican, etc.) (speriM White
11. DecedenYS Usual Occu lion Hind of work done d un most o(workin life. Do not state retired 12. Was Decedent ever In the 13. Decedent's Education (Specity only highest grade completed) 14. Marital Status: Married, Never Married, 16. Surviving Spouse (If w'rfe, give maitlen name)
Kind of WorN Kintl of Business /Industry U.S. Armed Foroas? Elementary /Secondary (U12) College (1-4 or 5+) Widowed, Divorced (SpeciM
Engineer Rail Road ^vea ®No NK Sin~~le
16. Decedents Mailing Address (Street, city I town, state, zip code) Decedent's Did Decedent East P e n n s bo r o
533 State Street AdualReaidence na.SYale Pennsy~Vania uueina 17c~]Yea.DecedenlUvedin Twp.
Enola PA 1 7025 ro Cumberland Tawnahip? ,?d ^ w°,D~ademLroadwimin
1Ib. Coon
Actual Limns of Clry I Boro
~6Famer'aName(Firat,midtpe.iasl.a°fox) Frank J. Czajkowski 'eMotner'Name(Firsl,middle,maidenanmame( Yolonda M. Gerenscer
zoo. InrormanY, Name (Typo / Print) Frank J . Czajkowski 20b. Informant's Meiling Atldress (Street, city I town, state, zi codes
90 Union Valley Rc'~• Monroe Twp. NJ 08831
21 a. Method of Dispositon []Cremation ^ Donation 21 b. Date of Disposition (Month, day, year) 21 c. Place of Disposition (Name of cemetery, crematory or other plaix) 21 d. Location (CM /lawn, sWta, zip code)
^ Burial ^ RamovallromSlate WesCrematlonwDOrladonAu[horizetl 5/7/08 Evans Cremation Service Leola, PA
^ Other -Specify: i by Medlcel Examiner I Coroner? 05'es ^ No
22a. Sgnature of Fun mlEerv C (or pe actkg such) 22b. License Number 22c. Nama and Address of Facility u 1 V a n u rte r a ome
~ ~ ~~~ FD014993 51 N. Enola Dr. Enola, PA 17025
Compete hems 2 only when certitying 23e. To the bell of my knowledge, Beam occurred al Cre time, date and place stated. (Signaure and tlde) 236. License Number 23c. Date Signed (Month, day, year)
physician is rid stable at time of death to
cemfy cause of am.
Items 24-26 must he completed by person 24. Time of Death 26. Date Pronourrcetl Dead (Month, tlay, year) 26. Wes Case Referred to Medical ExamineN Coroner for a Reason Other Than Cremation or Donati°n?
who pronarMes deem. UNKNOWN A. M. May 2, 2008 Yes ^No
CAUSE OF DEATH (Sea instruetlons end examples) r Approximate interval: Pan II: Enter other simitican,. caalitlons mnlnhuting le death, 26. Did Tobexo Use Comnbule Ie Death?
Item 27. Pan I: Enter the chain of events -diseases, inpdes, a complications -met direly caused the death. DO NOT enter temunal events such as cardiac artest, s Onset to Death but rat resuhing in th s underlying cause given in Pan L ^Ves ^ Probably
respiratory artesl, or ventrkular fibrillation without showing me etidogµ Ust Doty orre cause on each line.
^ No ^ Unkrawn
IMMEDIATE CAUSE (Final tlisease or ~
wMition resultingm deem) _~ Occlusive Coronary Artery Disease ~
a
Remote MI's w/stents 29. II Female'
^ Nol
re
nant within
ast
ea
Due to (or as a consequence of): r p
g
p
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SequentialN ksl mntlilarl5, if any, b t ^ Pregnant al time of death
lea~rp to d1e cause listed an line a. Due to for as a cons a of 1
NDERLYING CAUSE eQu rice ).
m
E ^ p g p ego t within 42 da
Nol re nant, but r an ys
nter
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d m of death
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(disease or inlury T
al
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events resulfing In death) LAST
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Due to for as a consequence oQ~
^ Nol pregnant, but 143 de 1 1 e
pregnan ys o y ar I
d. hefare tlealh
^ Unknown it pregnant wdhin the past year
30a. Wes an Autopsy 306. Were Autopsy Rndings 31. Manrrer d Death 32a. Date of Injury (Monet, day, year) 32h. Describe Maw Injury Occurted 32c. Place of Injury: Home, Farm, Street, Factory,
Pedanned? Available Prior to Completion ~ Office euilding, etc. (Speaty)
M Cause of Deam? NetUrel ^ Homicide
^ Ves ~No ^ Yes ^ N° ^ Accident ^ Pentling Investigation 32d.lime of Injury 32e. Injury al Work? 32t. If Trensponalion Injury (Speciy) 32g. Locadon of Injury (Street. city / tarn, stale)
^ Suicitle ^ Could Not be Determined ^ Yes ^ No ^ Driver /Operator ^ Passenger ^ Pedaslnan
M ^Omer - Specity~
33a. Certifier (check only one) 336. Signature and Title of Carte'
Certdying physmien (Physidan certifying cause of deem when another physician has pronounced death and completed Item 23) , C O r One r '
To the heal of my knoMetlge, oesM oeeurretl due to the wuae(s) and manner as stated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^
• Pronourlcing and wnlyfrg phyaklan (Physkian bom pronouncing death and certirying to cause of deem)
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xeminer
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On the heels of eaaminatfon and I a Investigation
In my oplnbn
deaM occumed at tM Ilme
date
and place
and due to the wuse(e) sod manner as stated
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_ 3d. Neva apdAddrgsyof Parson WTa ComplEtad Gauss oFDSam (I gpr~71 _TYPe I Print
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RENUNCIATION ~ ~ ~=~~~ ' ~-
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REGISTER OF WILLS
CUMBERLAND COUNTY, PENNSYLVAIJIA
Francis E. Czajkowski, a/k/a F. E. Czajkowski, a/k./a Frank Czajkowski,
a/k/a Frank E. Czajkowski, a/k/a Eddie Czajkowski
Estate of
Deceased
I, Frank`~Czajkowski , in my capacity/relationship as
(Print Name
father and next-of-kin of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be iss~zed to
Marlin R. McCaleb
,, • A / ~ I / /. ~
May Z, L~ 2 008 ~~'~.~ ~ p ' i`G-4~-Z~ ~1.~
(Date) (Signature) Fran JC2: k wski
90 Union Vallee Road
(Street Address)
Monroe• TownshiF~, NJ 08831
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this day
of 2008
Deputy for Register of Wills
Form RW-06 rev. 10.1.3.06
(City, State, Zip)
Executed out of Register's Office
Before the undersigrled personally appeared the
party executing this :renunciation and certified
that he or she executed the renunciation for the
purposes stated within on this z. day
of ~ ~ ~~ ti o v 1,~
Notary Public J _
My Commission Expires: 9/22/2009
(Signature and Seal of Notary or other official qualified to -.
administer oaths. Show date of expiration of Notary's Commission.)
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