HomeMy WebLinkAbout10-16-08PETITION FOR PROBATE IAND GRANT OF LETTERS
REGISTER OF WILLS OF C umb~e~ JQ n _ COUNTY, PENNSYLVANIA
Estate of ~ (I~ k~ Cl{~(~(~} ~
also known as
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COttitPLETE 'A' or 'B' BELOW:)
Deceased
^ A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is /are the
last Will of the Decedent dated and codicil(s) dated
File Number ~~ ~ ` ~~~ / t/` ~PS
Social Security Number
named in the
(State relevnnt circumstances, e.g., renunciation, dead: of executor, etc.)
Except as follows, Decedent did not marry, was not divorced, and did not have a child bom or adopted after execution of the instrument(s) offered
for probate, was not the victim of a killing and was never adjudicated an incapacitated person:
® B. Grant of Letters oTAdministration
(Ijapplicable, enter: c.t.a.; d. b. n. c. t. a.; pendeiue lire; durnnte absentia; dacrante minoritnte)
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.n.c.t.a., enter date of Will in Section A above and complete list of heirs.)
~V~~
~8
death
a with~his /her last p =-~cipaT~~ e~i~an~e at ~
(List sb'eet address, town/city, townsJtlp, counh~, state, zip~code) _ -;7 tt.3
Decedent, then ~_ years of age, died on ~ V ._ ~- ~ at l ~ ~ lJ I`~ ~ "~ W
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property $ ~ 0
(If not domiciled in PA) Personal property in Pennsylvania $
(If not domiciled in PA) Personal property in County $
Vahte of real estate in Pennsylvania $
situated as follow
~'d l
cr
Font R6V-0? rev. 10.13. J6 Pabe I of 2
:y
-- _ ,
(COMPLETE L'V ALL CASES:) Attach additional sheets if necessary. `" ''-1~ --
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:
Oath of Personal Representative
COM;vIONWEALTH OF PENNSYLVANIA
SS
COUNTY OF ~ j,LM ~~CIQ ICI
The Petitioner(s) above-named swear(s) or affirm(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
b ore me the l-F-~-~-day of
~f /
~~~ i /
~~M< +n '/
Fort e R gister
Signature ojPersona(Representative
cam,
Signature ojPersonal Representative ~ ~ ~.-:
Signanu-e ojPersonal Representative .,-' <1. ~ C ~
-;~-
-~, r ~ ~~ ,
c_1~._
~~
- ~~ ..
File Number: ~(~- / ~ ~ ' /~~~ V c_..a
Estate of II(,t ~ l.~l (! ~,(~E'i ,Deceased
Social S~e7curity Number: ' `"I -T - ~~~~ -573 Date of Death: ~ Q '' ~'
AND NOW, I~ ~ ~~ , in consideration of the foregoing Petition, satisfactory proof
~ j-
having been presented be^ore e, I IS DECy,REED that Letters ~C'~YYI L I T ~ ~~
are hereby granted to
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
FEES
Letters ............... $ ~~-~~
Short Certificate(s) ........ $
Renunciation(s) .......... $
~' ... $ ~~, C?~
~fZ;> r`Yl eft ~~>~.. $ ,5 -
... $
... $
... $
... $
... $
' ' ' $ Telephone:
... $
TOTAL .............. $--`~s.~~.-
in the above estate
Register of Wills j~/~
Attorney Signature:
Attorney Name:
Supreme Court I.D. No.:
Address:
r-~,„~ RW-o? rev. lo.t3 or Page 2 of 2
~-1- Cis'+~ ~? ~ ~.
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
1 Fee for this certificate. F6.0~
I ~ P 1480799.4
Certification Number
This, i~~~ to certify that thr tnforrnation here given is
correctly copied from an uri~inal Certificate of Death
duly tiled with me as Lural Registrar. Tire original
certificate will he forwarded to the State Vital
Records Office fur herm:u~ent filing.
LG~m ~~~ ~_, ACT 0 8 200
Local Registrar Date Issued
~~
c, '
T C~
-
~
~: F"
D ^ `
1 li
W
I REV ttnoo6
PRINT IN
(ANENT
,K INK
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
(See Instructions and examples on reverse) ~_„_~ ~„ ~ ,,, ,,,,,~„
1. Name of Decetlent (First, midtlle, lass, suRx) 2. Sex 3. Serial Security Number 4. Dale of Death (Month, day, year(
female 194 -36 -11573 ct.5,2008
5. Aqe (Last Birthday) Under 1 year Under 1 day 6. Date of Binh (Momh, tlay, year) 7. Birthplace (City and state or fore go country) 3a. Place of Death (Check only one)
names Days Haxs Minuses HosDilal: Other:
94 Ym Mar. 19, 1914 Sullivan Count
y
^ I
^
[]
~
npalienl
ER / Oulpalient
DOA ]
Nursing Home ^ Resitlance ^Other ~ SpecilV.
Bb. Ceunry of Death &. City, Boro, Twp. of Death 6tl. FacNhy Name (If rrol institution, give mrael and numher) 9. Was Decetlent of Hlspamc Origin? No ^ Yes 10. Race: American Indian, Black, White, etc.
(If yes, specity Cuban, (Specihn
Cumberland Cam Hill Manor Care Meacan,PUenpfiinan,etr) white
11. Decedents Usual Occu tan Kind of work done tlu moss of worxin life. Do not slaw refired 12. Was Decedent ever In the 13. Decedent's Education (Specify only highest grade completed) 14. Marital Status: Married, Never Marrietl, 15 Surviving Spouse III wile, give maiden namet
Kind of Work Klrtl of Business I Industry U.S. Armed Farces? Elementary /Secondary (0-12) College (1-4 or 6.) Widowed, Divorcetl ISpeciryJ
^vea ~"° 2 widowed
i6. Decedent's Mailing Address (Street, city /town, state, zip code) Decedent's Dld Decedent
~, Rd
1502 Lz tc nwo r+ Actual Resaence 17a. Sale P? n n s 1 V a n 1 3 Live in a 17c. "es, Decedem Lrved in
Twp.
~'
^
_
•
C a m ~ H 111
P A 17 01 1 Township? ~
y
, 7b. County Cumber 1 a n d 17d. Ip IJO, Decetlent Livetl whhin ~ ~ m
J i3 1 ] 1
, _
Adual Limks of
Ciry I Boro
16. Father's Name (FrsL mkale, last, suffix) 19. Mother's Name (First, mitltlle, maitlen surname)
[?or3c~ Benjamin Grad Brown
20a. Infomrant's Name (Type /Print)
R~b~cca C. Enn2y 20h. Inlormanl's Mailing Address (Street, cly I town, state, zip code;
1502 Letchworth Rd.,Camo Hi11,PA 17011
21a. Method of Disposition ^ Cremation ^ Donaton 21 b. Date of Dlspositias (Month, day, year) 21c. Place of Disposition (Name of cemetery, crematory or other place) 21d. Location (City l town, stale, zip code) 1 -~ -~ Q 1
Burial ^ R moves from Stale i Was Cremation or Donaton Authodzed
j
^ O C t. 9 2 (
~ ~~ 1'11 1'
~ W O O d C e :n e t e r W l l l l a 1n 3~ O r t ~
her - Specdy:
by Medkel Examiner / CoroneR
Yes ^ No ,
~ .
y ~
IBre W Funerol-Se Licensee (or parson acting as such)
, 22b. Ucense Numher 22c. Name and Address of Facility
a-~t
~-~'~-~~~ FD-013163-L r4us=xelman FH&CS 324 Humm°1 Ava. Lemo na PA. 17043
Hems 23a< Doty when cerlilying 23a. Tot best of ryy knnnooov~~~edddggge, oxurretl el the lime, tlate and place staled. (Sgrelure antl total 23b. Li rise Number 23a Date Slgnetl (Momh day, year)
physictian a nq available at lime of deem to
- carry reuse of Beath. // ~
~{ 7
~ ~ ~ ~ J d ~ ~ /D
O
/
~
O
- Items 2x26 must he competed by parson 2A. Q Q~ ~~~
U 25. Date Pronounced Dead (Month, day, year) 26. W
es Cese Refe
d to Metlical Examiner r Comner for a Reason Other Than Crematon or Donation?
who Omnounces death. 7 M_ /D ` 0 d. ^
C]
Ves No
CAUSE OF DEATH (See instructlona and examples) r Approximate internal.
Item 27. Pan I: Enter the thee of events - dseases, Injuries, or compicalbns -Nat direclty caused Me deaM. DO NO7 enter terminal events such as cardiac arrest, r Onset to Death Pad II, Enter other SgpjQggBLconditans contnhutne to death,
bus not restating in the untledying cause given in Pan L 20, Did Tobacco Use Conlntxne to Death?
^ Yes ^ Probaby
reagrolory arest or ventricular fibrillation without showing the etidogy. Lim ony one Cas138 on each ilne. r
~
^ No ^ Unknown
„
IMMEDIATE CAUSE ((Fetal disease or /~
'n'
r
Y--7, / ~ / f :?~l~. r
~ ,
centlnian resultin deaN
/~ r/•4/1 s
g1° j -- a. l ~-~/l r. L.ru /,/
(/il~i rJ/V/~~• ~ ~~L,~
i'-
`~
~
~
29.If Female:
Due to (or as a consequence of): ~ [
r. ^ Not pregnant wimin pass year
Sequentialty Am corsdlions, it any, b. ~
IeaSng to Na rouse lisletl on lirse a. _
~~` ^ ~ ~ ~'~nJ ^ Pregnant at lime of death
Due to o es a tense )
Enter the UNDERLYING CAUSE (r quence of : t ^ Not pregnant, but pregnant within 42 tlays
(dsease or injury Thal initiated the
events restating in death) LAST. c'
/~ • ~ / ~/~~ ;~ 1` of deem
Due to (or as a consequence op-.
d
~ ^ Not pregnant, Dul pre0nam 43 tlays to t year
before tleath
. .
t / ^ Unknown it pregnant unthin me past year
30a. Was an Autopsy
Pedormetl? 30b. Were Autopsy Findings
Available Prior to Completion 31. Manner of Death 32a. Dale of Injury (Month, day, year) 32b. Describe How Inury Occurred 32c. Place of Injury: Home, Farm, Street Factory,
of Cause of Death? ~ Natural ^ Homidtle OXice Builtling, etc. (Speciy)
^ Yes ~} No ^ Yes ^ No ^ ACCitlenl ^ Pending Inveskgafion 32d. Txne of Injury 32e. Injury el WoM? 32i. II 7ronspodatlon Inlury (Specilyi 32g. Location of Injury (Street city /town, male)
T ^ Sukida ^ Cald Not be Determined ^ Yes ^ No ^ DMer /Operator ^ Passenger ^ Pedestrian
M Omer SpecNy:
33a. Cenreer (check Doty one)
• Certifying phYaician (Physkdan certityirg rouse of death when another physaian has pronouncetl death all corrydeletl Item 23) 33h. Signature all TAIa f Certifier
~~ ~~'
_
To the beat of my knowkdga, deeM occurred due to tla cause(s) and manner as esated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ~ ( ~ 7T.,~/'/
• Pronouncing and certitying phyekian (Physitlan lath pronoundng death and cenitying to cause of death)
To Me bast of my knowledge, death acurtetl al the time, dale, and place, arM due to the ceuse(a) end manner es staled
^ 33c. License Number
- 33d. Date Sgned (Monet, day, yeaq
~
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
• Metlk;al Examiners Coroner
On the basis of examination antl I err investigation, in my opinion, death occurred at Me time, date, and place, and due to the reuse(s) end manner as sated_ ^ ~ ,1 -
~ ~// ,~)~!~/~~`~ ~~~a / 7)
j /~
~ Name and Address of Person Who Completed Cause of Death (Item 27) Type I Print
Regsmrar's S t and Disina Ns~ir~A/q ~ I ~ I / I ~ I / I / I
J 36. bete Filed (Month, tlay, year)
-
~ 1~~~/~Q~~ t~.
Disposition Pertnil NO. V ~ C'' ~ U ~ r ~~~1L,10.;URi~N:aU11~
1NP.CI{islU ~A 11191
C7 -
G ~-~ " ''
,~ -~ {~
RENUNCIATION ~.r ~' ~~
~ ~ t7 --~
~~~ G'~
' Cij . -~
,~ REGISTER OF WILLS ` ~ ~; ~_, ; -^
C, t~vn ~.~rI017d COUNTY, PENNSYLVANIA =~' a { ~~
Estate of _ ~ ~ ~ ~ ~3 , ~r ,~ c/ 2
.Deceased
I, ~ c h n r C~ o c,~ e-- _, in my capacity/relationship as
(Print Name)
S ~ h of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
i ~~ ~~o ~
(Date)
Executed in Register's O, f, jrice
Sworn to or affirmed and subscribed
before me this
of
Deputy for Register of Wills
day
(S lure)
(Street Address)
s r I~a~ ~~~~~^ d, C T ~ r~// rP
(city, stare, zip)
Executed out of Register's Office
Before the undersigned personally appeared the
party executing this renunciation and certified
that he or she executed the renunciation for the
pure ses stated within on this ,~n day
Notary Public
My Commission Expires: ~ ~ ~~i ~ ~ j
COMMONWEALTH OF PENNSYLVANIA
Notdtial Seal (Signature and Seal of Notary or other official qualified to
Dania S. Lutes, Notary Public administer oaths. Show date of expiration of Notary's Commission.)
Lower Allen Twp., Ctxnberland County
My Commission E~ires May 8, 2011
Member, Penncvi"nr~fa ~s~nciation of Notaries
Form RW-06 rev. 10.13.06