HomeMy WebLinkAbout11-06-08PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF
Estate of DORIS JEAN BARRICK
also known as
CUMBERLAND COUNTY, PENNSYLVANIA
File Number 21-- (~-
,Deceased Social Security Number
MELODI B. KOWNACKI
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE A' or `B' BELOW:)
A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the named in the
last Will of the Decedent, dated and codicil(s) dated
State relevant circumstances, e.g., renunciation, death of executoi etc.
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after a+xecution of the instrument(s) offered
for probate, was not the victim of a killing and was never adjudicated an incapacitated person:
SPOUSE PRE-DECEASED
^X B. Grant of Letters of Administration
app rca e, en er c..a.; ..n.c.t.a.; p ante r e; uran e a sen ra; uran a mrno a e
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
Administrahon, c.t.a. ord.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.)
Name Relationship Residence
KOWNACKI, MELODI B. Daughter 185 CRESTMONT DRIVE
Lock Haven, PA 177^'
Q ~~
- i
~
Z
~l
t
C ; ~t7
/h~
(COMPLETE IN ALL CASES:) Attach additional sheets if necessary. ~ ~ ~ C '~ ~~~
Decedent was domiciled at death in Cumberland County, Pennsylvania with his /her last principal resiaP Z ~`_~~?
13 STAMY ROAD, Newville, NORTH NEWTON, Cumberland, PA 17241 ~~ ~ e-,~ `T'
(List street address, town/city, township, county, state, zip code) -~ ~~ = i
Q
Decedent, then 75 years of age, died on 10/19/2008 at GREEN RIDGE VILLAGE, NEWVILLE, PA
Decedent at death owned property with estimated values as follows:
(If domiciled in PA)
(If not domiciled in PA)
(If not domiciled in PA)
Value of real estate in Pennsylvania
All personal property
Personal property in Pennsylvania
Personal property in County
situated as follows: NORTH NEWTON TOWNSHIP, CUMBERLAND COUNTY, PA
$ Unknown
$ Unknown
$ Unknown
$ 100,000.00
Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the ~3rant of Letters in the appropriate form to
the undersigned:
or printed panne and residence
185 CRESTMONT DRIV
Lock Haven, PA 17745
Form
ReV. 10-13-2006
Copyright (c) 2006 form software only The Lackner Group, Inc.
Page 1 of 2 ~/
~~
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA } SS
COUNTY OF Cumberland }
The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true ,and correct to the best of
the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decedent, Petitioner(:.) will well and truly
administer the estate according to law.
Sworn to or affirmed and subscribed
before me this ~ day of
im -er ua~
F the Register
Signature of Personal Representative
File Number:
21--/7~-
Estate of DORIS JEAN BARRICK
Social Security Number: Date of Death: 10/19/2008
.E_.. ~ 'i~~} ~. J
< ,~; > 7
~ ---, c_,
~.._;(I
CT ~_,~~
~ '~"
'[3 ~ r...
,Deceased 0 '-
AND NOW, , in consideration of the foregoing Petition, satisfactory proof
having been presented before me, IT IS DECREED that Letters of Administration
are hereby granted to MELODI B. KOWNACKI
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.
FEES
Letters ............................................ $ c~ ~G ~~
Short Certificate(s) ........................ $ -~.D, D~
Renunciation(s) ............................. $
Auty~mc~i-i ~,~. $ ~ . c~a
$
$
$
$
$
$
TOTAL .................................... $ p,~
Supreme Court I.D. No.: 10264
Zullinger-Davis, PC
Address: P.O. BOX 40
Shippensburg, PA 17257-0040
Telephone: 717-532-5713
Form RW-OY Rev. 10-13-2006 Copyright (c) 2006 forth software only The Lackner Group, Inc. Page 2 of 2
Attorney Signature: r ~.
Attorney Name: Hamilton C. Davis
LOCAL REGISTRAR'S CERTIFICATION OF DEATI-~
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee i~ur ihi~ certificate. $6.0O x]"""'~~~--:
~'' ~ZH OF p "
/~~,P~----~Fiy'_
~ 'I"his is to certify that the mfunnition hEt~~ riven is
c;>Ire.tlr~ c~lpier3 I~run7 an 1r ~it,u, .'ertifi~ tt cf Death
s=
;G'~ ~
„xxo Al
~~
~ ~ ~
duly tiled with m~ is L,r•,tl Re~lstrar the ~ri~inal
~
~
z~ cethttcatc ~+~ill he ior~~~~ude~i I~~ the 5tat~ Vital
o.
I, v. .; ; a,
Rcu>Ids Office for pcrm_m~nt tiling.
p.. . _, L~m~. ~,
,
~
1
P 14999303 ~o~~g9r~
- ~P~?' ~
,~ OCT_212008
~ ~c
k
-- -
' --.. N1ENT ~~ _
.
Vumher
Ccrtilication Local F:egistrar Date Issued
Irv
~ ~
~
*..
3 j-
~ -
C1 T
~~
_
f`, i 3
~ C!
~~ j
. { ;
.Cv
~^~f~ t .
.
~ ~;_~
d ,
H1os1/3 REV nrzo9B COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
PERlMANENiN CERTIFICATE OF DEATH
BLACK INK
(See Instructions end examples on reverse) STATE FILE NUMBER
v'
1~
V
0
a
c
1. Name of Decedent (First, mitldle, mst, sinful ~~'/ ( ~ ~ 2. Sex 3. Snacwll Omy Numher ~I - ~ , / ~~ 4. Date of/D'e~aln (MOnm, day, year) /-1
5. Age (last Biithdey) Under 1 year Under 7 day 6. Date of Binh (MOmh, day, ar( ]. Blmrplap (Coy and smfe or lorei n punlry) ea Place of Death (Check only o1e)
h«
75 "~° 0an "°"' "`"°° July 29, 1933 Carlisle PA Npal~mc 77a
n~
Yrs. ^ Inpetlenf ^ ER / Oulpetlent ^ DOA .~I Nursing Home ^ Residence ^Onrer - Spetlry:
gb. Couny of Deam Bc. City, B«o, ~. of Deem Btl. FadlNy Name gl Iwl insliNnon, give street arm number) 9. Was Deoedent of Hlspenk Ongin? ®No ^Ves 10. Race: American IMian, Black, Whae, etc.
Cumberland West Pennsboro Green Ridge Village Inyea,apecitycatan,
M
P
k
k
Fk Isro;yM
Wh 1 t e
ex
en,
en, e
.)
uedo
11. Decedents lhunl fbn Kira d woA d are du mpl of am. Do rot smle retiree 12. Was Decedent ever in the 13. Oecedenf5 Eduption (Specify Doty Nghast gretle C«np lemd) 14. Marvel SmlUe: Mertied, Never Memetl, 15. Surviving Spo use (II wim, give maiden name)
Kntl of Wak KInO of Business / IMUSIry U.S. Armed Fomas? Elemenmry / SecorMery (0-12) College (1-4 «5+) Widowed, DNomed (Spea/y]j
ZOOl lgl St `LOO ^Yes ~NO 12 2 Widowed
16. Decedent's Mad'mg Adtlress IStreel, dN l town, smte. zip cotle) Decedente Dm Der.Bdenl North N e wt o n
PA Live in a i7
A
t
l R
id
Sml
17
~ v
D
d
l IN
d i
r
13 S t a my Road p
es
erKe
e
en
c
a.
c.
e:,
ep
e
n
wp.
rowneni
?
PA 17241
Newville °
nd^Na,Deceaenluvetlwnnin
,m.ca,nty Cumberland
, Actual t:nue of City I Born
111. Famer's Name (First. middle. last, sWllx) 19. Molfrer's Name (Flrel, mkde, aitlan wma j
ll
t
~
h F
G
Lester R. Moffitt u
s
ia
.
Rut
2oa. mformanrs Name hype r Pang
Melodi Kownacki b. I t ry / mte, zi
~ ~~'°~'9A'~~'°itl `4i'~ 'P7~'. .L`Y4~k Haven, PA 17745
21 e. Memad of Disposition ^ Cranetbn ^ DOnafmn 21 b. Dam of Dieposilkn (Month, day, year) 21 c. Platy of Disposition (Name M cemetery, Crematory a «rar pmca) 21d. Lopdon (City 1 torn, slate, Up rode)
17241
(g a,n~ ^ RemovaltmmSmle jweACrrmrllan«D«l,nenawwd>ed 10/23/2008 Doubling Gap Cemetery Newville PA
^ Olner ~ syery: 1 by Madkel Examimr / Coroner? ^Yes ^ No
z2a. slgnamre p JgYeral ryka 1« rspn ecAng as ouch) zw. license Number ~E~~i~d~Lfiq~ r a 1 Home Inc 1 ~ Big Spring ve
- ~~ T FD 13895 L Newville PA 17241
Complete Items 23ec aMy when pnifyrg
60 al Nma d Oe6ln m
PhYa7~ rs .Tome best of my Nrlowledge, death occu a1 lime, dale entl Dlgc~ smled. (Sign re and title)
/ ~
U 236. license Numf~ n
p'J1~ 12Z k-If
g ~ ~ ~-
' 23c. Date Signetl (Month, tlay,,yyearl
O 1 („
e v I "
zu ° ~''
c t-o
M tl em
pm~paae -
ll~ //l.l
\ IV
! 1
~
~^
Items 21-26 muss be completed 6y person 2<. Tme of Deam
~
~/ ~ 5. Dale P C DeetlfMOn~ , ye~ ~~ ~
D ~rjj Ir 26. Was Case Relerted to McAcal Examiner! Comrrer for a Reason Omer than Cremation or Donation?
~
who pronounps deem. . L
M. 1 ^Yes ~}C
CAUSE OF DEATH (See inehuctlons end examples) 1 Approximate iMervaf. Pen II: Emer ollreralgoif5ent condlllarm pntfibN'no b deem, 28. Did Tobago Use Cantrbule to Death?
rem 27. Part I: Ent« the chain of events - diseases, injures, or camplipbms - mat drecdy caused the tlealn. DD NOT enter mmrpl evenm such as cardiac arrest, Onset m Death hul not resuldrg in the undedying pose given in Pan I. ^ Yea ^ Pra6ahy
resgrelory arteet, a venlrplar fbrNation wilfnN stowing the eliokgy. List only op pose on eacn lute.
^ Ns ^ Unknown
IYMEdATE CAUSE (Fx101 tliseese «
caldtion resullirg k deem) ~ ~ ~ Q~,S~ ~~H C ~~
e.
29. If Female:
^
Due m for as a consequerma op: Nat pregrlanl wimin past year
^ Pre
nant el tim
of dpln
~gM condnom, A ~,y, b.
I
pk
li
t
t
d
F g
e
aa
lq
o Cause
s
e
on
ire a. p~ to «as a
Enter me UNDERLYING CAUSE ( COn~~np o~~ ^ Not pregpnl, but pre9nanl wimin 42 days
Idseese a injury mat nitlaled me
Brame resulleg.n aeem) usT.
C of death
Due to (or es a consequence of): ^ Nat pregnant, bn pregnam 43 days to 1 year
e. i before Beam
^ Unkn«m d pregnem wimin the past year
30a. Was an Autopsy 39b. Were AWapry Findings 31. Manner of Dean 32a. Dale of Injury (MOmh, day, year( 32b. Describe How Inlury Ocwrted 32c. Place of Injury: Moms, Farm, Street, Faclary,
Penomred? Avaimde Prmr to Canplelian r.~
Natural ^ Homkitle Offlce Building, ek. (Specify)
cl Cause of Deem? YJ
^ Ves dNo ^Yes ^ No ^ Acdaem ^ Pentllrg Investigation 32d. Tma of Injury 32e. Injury at Wode7 32f. II Trenspormlbn Inury I~N1 329. lacaf of Inlury (Street, city! lawn, slate)
^ Suldda ^ Coud NM be Demrmined ^Yes ^ Nc ^ Dover /Operator ^ Passenger ^PeG!51ran
33a. Cerefier (dleck only one)
• Cerlilying phyekmn (Plrysiden cenilying reuse of deem wren alrother physiden res pronounced deem antl mrtpleletl kem 23) 396. Sigmlu CerlHier
To the beat al my knawmdge,deem«carrw eue to the wuve(a)and menn«oamle4 __________________ ______ ^
- Y V
a
'
• Pronoundng one urlNYin9 physidan (R,ysicial, hom prawaxing death antl oedilying to pose of death) ~f
To th hest at know p I_I
my letlge,Beam«carretlettllenme,dem,snd Ixe,eneauelomec.ueep>anem.nner.aemme------------------ 33c. Licerwe r
33tl. Date Bignetl (MOnm, tlay, )
pr
_
• Nedkel Examirer/Coromr QO~U ~( S
(_ j0/ Lc CO
On the bash of ezamirmtkn end / « investigation, in my opinion, tleelh oaumed at the lime, date, aM place, and tlw to the causefs) and manpr as smted_ ^ ~ Name end Adtlrese al P~son)Olho Cam}I~Ca~is of Death (Aem 2]) Type /Print
El
b
35. Registrar's S1'~I and Dislr~N~~~r 1
z
_ ~, le Filed (Month, day, year y J ~ S
" ~ • rt 1 ~.
5
~ I I I ~~, I ~ I (> I
-
- L~ks~tvc 4~ ~ - C Ur h t/r /
,q i 7 D/~
Dispositkn Permit No. ~ ~~~-~ t1d~ ~ G ~(),
~s{-~„~, ~ p-