HomeMy WebLinkAbout11-07-08~~ ' `~ Register of Wills of s Co~ty, Pennsylvania
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~~~~~. -~y~/1 PETITION FOR GRANT OF LETTERS
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Estate of (~r~ ~ ~/_.. , a~ ~ ~ ~.%-~ ~~_ No. ~ _ Vi
also known as
,Deceased Social Security No. t ~ !~ ; ~-~ ~ "~ ~,<;
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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 execut named in
the last Will of the Decedent, dated and codicil(s) dated
_ __
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
documents offered for probate; was not the victim of a killing and was never adjudicated incompetent.
'. B. Grant of Letters of Administration
_ 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 following spou~e (if
any) and heirs: ;~ ` =~
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Name Relationship Reside
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(COMPLETE IN ALL CASES:) Attach additional sheets, if necessary. ~
Decedent :vas domiciled at death in Cr ~. ~) ~. r~c~ /v ~~~. ~ County, Pennsylvania, with his/nor last
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family or principal residence at ~~•L , L ( /~/~ ~ Z "~ ~~1 j C f~~}/(, /c ;~ ~ ~ f~_ I. `_ r r ~ > ( ~
,(List street, number and muniapality)
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Decedent, then ~ >l years of age, died ~ ~ ~-j~)~3~/~ ~ , 20~ ~ at .; ~,{;~,, t~ ~*~l!~~
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-- (Location) = _ ,. _. i~~~ ~ ~
Deceden± at death cwned property with ettated values as follows:
(If domiciled in PA) All personal property $
(If not domiciled in PA) Personal property in Pennsylvania $
(If not domiciled in PA) Personal property in County $
Value of real estate in Pennsylvania $
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situated as follows:
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.
`~~~~' Signature Typed or printed name and residence
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Oath of Personal Representative
Commonwealth of Pennsylvania
County of Berks
The Petitioners} 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(s) will well and truly administer
the estate according to law.
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Sworn to or affirmed and subscribed ~ '- _ -
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L''~..~-''~T.+
before me this ~ l day of
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For the Register
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Estate of ~~ ~ ~~/ ~ ~~ ~ f" ~ ~'"r j-- ~" ~ ,Deceased
Social Security No.: Date of Death: N~'i'L-n~/~~c ~ ~«~
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AND NOW, L-v~ ~~~, ~ , 20_~~, in consideration C7 ~' -;
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of the Petition on the reverse side hereon, satisfactory proof having been presented before me, j ~ ~-
IT IS DECREED that Testamentary of Administration = r~ ,J
Letters _ _' ' ~ ' _ __ •~ 3 h; -
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are hereby granted to ,f; L /„~ ,S. ~~ /~~~/{~A }tL `_t
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C..J ~ ~`r
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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 of Decedent.
FEES
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Letters .............................. $ ~ l] ~ ~) ) - - _,-
ShortCertificate(s)...~... $ (~ ~ ~ ~i~,~--~ ~ ~'~~. '~
Renunciation .................... $ Register of WiNs ~~ 4 4- ' t-
Affidavits(s) .................... $
JCP Fee...`.:. ~c-'..... $ } ~ , ~
Inventory ......................... $ Attorne : ~j/C/~~L J.~r -~~f71///k~/~ l7, ~-f
Y ~7 ,
Tax Return ...................... $ I.D. No.: / ~~ ~~ y
Commission ..................... $ Address: •~J~7a1 (G ~C'UQ ~ -~ ! /~'c`~' ~`
RIF Fee ............................ $ /`7 fit /N~~ /'.~ I ~E,~`/
Other ............................... $
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TOTAL ............................. $
Telephone: ~/~ - r~iT~~ __ ./,_7f.5'_S'_
Form #RW-1
Prepared from Pennsylvania Bar Association, 1991
Standartlized Probate Form RW-t with
PA Register of Wills Automated Docket System,
Copyright 2001, E-ware, Inc., Reading, PA 19606
uos~)n; I:EV.Ir)ulsl
This is to certifi that this is a true copy of the record which is on file in the Pennsylvania Division of ~~ital Kecords 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.
F~ fi~~o~C~~~_
Frank Yeropoli
State Registrar
472203
No.
H105.144 Rev. 1191
TYPE/PRINT
IN
PERMANENT 130-112
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS =~
CERTIFICATE OF DEATH f~ ~ 2852
(Coroner)
NK NAME OF DECEDENT (First, Midtlle, Last) SEX SOGAL SECURITY NUMBER DATE OF DEATH (Month, Day. Year)
ler
D Zei
Cl
d Male
November 3
2005
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y ,. _ _ 4.
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2.
AGE (Last BrcMaay) UNDER, YEAR UNDER 1 0AV DATE OF BIRTH BIRTHPLACE (Ctly and PLACE OF DEATH (Check only one -see Insaucsons on Omer sidel
Months Daya Hours Minule5 (MOmh, Day. Year) StalewForeign Country) HOSPITAL. OTHER:
May I9
1 9 18 Unknown
8 7 Yra InPetient ^ ERlOUlpatient ^ DOA ^ Home 9 ^ Residence ^ Specify)
,
.
g, 7. fla.
- COUNTY OF DEATH CITY, 80 FDEATH FACILITY NAME gl rza institution, give sired antl number) WAS DECEDENT OF HISPANIC ORIGIN? RACE-American Indian, Black, White, etc.
Cumberland
Silver Spring Conodoguinet Parkway @ Willow
Mill P
k R
d No ~ ^Ifyes,speciycaben.
Me n,PUenoRican,dc. (spe°~'y)
White
9b. ac ar
oa
Bd. 9. 70.
DECEDENT'S USUAL OCCUPATION KING OF RUSINESSIINDUSTRV WAS DECEDENT EVER IN DECEDENT'S EDUCATION MARITAL STATUS-Married SURVIVING SPOUSE
(Give kind d work done duringg a
d U.S. ARMED FORCES? If on h hest radec Never MarrieQ Widowed,
Di
rt
S (II wife. give maiden name)
of working lire; do not use ret1re
.) Vas ^ No ~ ElenrentarylSecontlary Coaege y}
vorced (
pec
1,.. M 116. i2 13 ` 12) p4w5" ,.Married ,S.Sara Jane Sei ders
DEDEDENT'S MAILING ADDRESS (Skcet. Ciryrrovm. State, Zip COde) DECEDENT'S S i 1 v e r
p r i n q
AL ,T
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t
P A Dm n
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Ui
di
ACT
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2 D D e w a l t Drive ,~.
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RESIDENCE decedent
Mechanicsburg P A 17 0 5 0 `~, ofn~ ~d ; s Cumber 1 a n d Nve in ap? No. decadent INad
townehi
16. i7b. Coun iTd.^ w4hin actual limits °1 cilylboro.
FATHER'S NAME (F'nsl, Middle. Lasq MOTHER'S NAME (First, Mitldle, Maiden Surrame)
4lilliam E
Zei
ler Ida Davis
.
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INFORMANT'S NAME (TypelPnnl) INFORMANT'S MAILING ADDRESS ($Ireel CilyR ,State, Zp COde)
20. Nanc J. Del l i n lob.
METHOD OF DISPOSITION GATE OF DISPOSTION PLACE OF DISPOSITION ~ Name °I Cemetery, Crematory LOCATION ~ GryROwn, State, Zip Coda
Kuria! L~ Cremation ^ Removal Iram Slate ^ (Month, Day, Year) or Other Place
20onatlo^^ r(5pecily ^ 21611-11-2005 2,c. Mechani csbur Cemeter Mechanicsburg PA 17055
SIGN/(t FUNER RV EN PERSON ACTIN SUCH LICENSE NUMBER NAME AND ADDRESS OF FACILITY
- 22 ~6FD-012662-L 22~1YERS FUNERAL HOME MECHANICSBURG PA 1705
Complete item only en c ing T >n of my knowledge, death occurred et the time, date and place stated. LICENSE NUMBER DATE SIGNED
physician b n aveilBWe e! lime of death to naWre arW Title) (Month, Day, VeaO
canny cau%ol death.
23s. 23b. 23C.
Items 24-28 must be completed by TIME OF DEATH prX , DATE PRONOUNCED DEAD (Month, Day Year) WAS CASE REFERRED 70 ME I L EXAMINER/CORONER7
' peraonwlwpronounc9atleaM. November 3
2005 Yes N°^
1 D A
11
,
`
. M. 2a. 26. "
24.
27. PART l; Enter the d5aeaes, in)uries or complications which Causad,he death. Do rwt enter lire mode d dying, such as cardiac or respiratory arrest, shock or hewn failure. ~ Approzimete PART II: Other signilicanl conditions comributing to death, but
List onN one cause on each line. ~ interval between not resuaing in the underlying cause given in PART I.
neat and death
IMMEDIATE CAUSE (Final
diaaasew`°"°itinn Multi le Traumatic In'uries
resufling in tleafh)--- a. ~
DUE TO (OR AS A CONSEQUENCE OF):
Motor Vehicle Crash
sewenkaly ust corKalions b._
if any, leading to immediate DUE TO (OR AS A CONSEQUENCE OF): I
, ceuse.Emer UNDERLYING ~
CAUSE (Disease oriryury c.
Mal initialed events DUE TD (OR AS A CONSECUENCE OF):
restating in deaM) LAST
d
WAS AN AUTOPSY WERE AUTOPSY FINDINGS MANNER OF DEATH DATE OF INJURY TIME OF INJURY INJURY AT WORK7 DESCRIBE HOW INJURY OCCURRED.
PERFORMED? AVAILABLE PRIOR TO
I
OF CAUSE (Monfh,Day,Vear) A rx.
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OF DE H Nataral ^ Hnmicme ^ Nov. 3,2005 11:10 A ve ^ "°~ impacted 3
vehi~les
Accident ~ Pending lnvesllgallon ^ 30a. 30b. M. age. 30tl.
Yes No ^ Yes ~ No ^ PLACE OF INJURY ~ At home, farm, skeet, fagory, odice LOCATION (Street, CiryR n, State)
sukide ^ coddndbeeelerminea ^ building,ela(Specey) Hi
hwa tPkw
Me
hanicsb
r
PA
29e, tab. 29. g
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30e. y,
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CERTIFIER (Check °nly one) SIGNATURE AN TIF R
'CERTIFYING PHYSICAN (Physician certifying cause oI death when another physcian has pronounced death arW ttxnpleled Item 23)
^ CO tone r
T° the beat of my knowledge, death Occumod due to Ma caeae(ej arW menrteras atatetl ..................................................... 3
_ LIC S BE DATE SIGNED (MOnfh, Day. Year)
'PRONOUNCING AND CERTIFYING PHYSICIAN(Physician b°M pronouncing deaM antl certifying to cause of deaM)
To the beat of my knowledge, death ocerrrrad al the Ome, date, and place, end due to the cause(s) end manner as stated .......................... ^
31c. November 9, 2005
31d.
NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH
Qtam 27)Type or Pri"'Michael L. Norris, Coroner
'MEDICAL EXAMINERlCORONER
On the tlesle d examinagon antllor Investlgetlon, In my oplnlon, death occurred et the time, date, and place, and due to the cause(s) and
6 3 7 5 Bas a ho r e Road , Suite ~~ 1
manner es steted ............. ....................................................................................
Mechanicsburg
Pa
17050
3,a. ,
.
,2.
REf ' SIGNATURE AN M R ~ +~
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