HomeMy WebLinkAbout11-10-08PETITION FOR PROBATE AND GRANT OF LETTER
REGISTER OF WILLS OF ~ L~.M ~L ~ h~,JV ~~ COUNTY, PENNSYLVANIA
Estate of J" ~ , ~~i[~~, ,~ 1 5~~~/Y ~~
also known as
Deceased
File Number ~\ U v ,, V<~
Social Security Number ~ ~ ~ - ~'~ ' ~ 1 ~ C
Petitioner(s), who is/are 18 years of age or older, apply(ies) for: ~
(CO;LIPLETE 'A' or 'B' BELOW:) ~''7 ~ `~
- _ ~ cz~
~~
^ A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is /are the ~~' z? E--~ ~+ned to the
last Will of the Decedent dated and codicil(s) dated ^~~ ~-~ -
s~? c~
- '"~ - '--,y- - -"
(State relevant circumstances, e.g., rencuiciatron, death of executor, etc.) , ~;_:~; :_.t ~
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the ifi~tument(sI}effered - _
for probate, was not the victim of a killing and was never adjudicated an incapacitated person: ~' ~
B. Grant of Letters of Administration
(If applicable, enter: c.t.a.; d. b. n. c. t. a.;pendentelite; durmueabseatia; durantemiizoruatej
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(COMPLETEW ALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in L Ut'1BE12.LAN ~~ County, Pennsylvania with his /her last principal residence at
(List street address, town/city, township, counh~, state, zip code)
Decedent, then ~_ years of age, died on o2. L r at ~ {`31~
Decedent at death owned property with estimated 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
sit.iated as Poll
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:
Si~nahire Typed or printed name and residence
,_y~,l
. SAIL"
Fo,m Rw-o r~,< to.l3.oe Pale 1 of 2
Petitioner(s) after a proper search has 1 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.~t.c.t.a., enter date of Will in Section A above and complete list of heirs.)
Oath of Personal Representative
CO'VI~ION~VEALTH OF PENNSYLVANIA
SS
COUNTY OF C t.i"I ~:' L' l~~ L t-l ti~
'The Petitioner(s) above-named swear(s) or affim?(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
admints:~~r tLe estate according to law.
Sw ;rn to or affirn?ed and subscribed ~~ ' ' ` ~ ~ ~"`~"' `"' `-
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Signature of Perm t! Representat ?
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before me the ~ ~ day of l
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~' .~.:
~ Sigrrnture ajPersonnl Representative
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~~ For the Register Signature oJPersonn! Representative ~J
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File Number: +
Estate of ,Deceased
Social Security Number: Date of Death:
in consideration of the foregoin g Petition, satisfactory proof
AND NOW, ,
having been presented before me, IT IS DECREED that Letters
d t
t
b
h
e
o
y gran
ere
are
in the above estate
and that the instrument(s) dated
described u? the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent.
FEES
Register of Wil]s
Letters ......~.-~..... $ a~
Short Certificate(s)~~~.' .... $ ~ Attorney Signature:
ciation(s) .......... $
Renut? Attorney Name:
~
,l~-I' ... $ IlU
~i {-~ ... $ ~
-- Supreme Court I,D. No.:
... $
- Address:
_ ... $
... $
... $
... $
• • $ Telephone:
... $
- cU
TOTAL .............. $ ~3
Page 2 of 2
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Ev nl2oos COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
'RINT IN
1NENT CORONER'S CERTIFICATE OF DEATH C'
KINK (See instructions and examples on reverse) ,~ ~, G ~ ~ `, ~ G
~k'i l -(lR(l creTC Fii F rii ir,~nGo
7. Name of Decedent (FlrN, mMdle, last, suffix) 2 Sex 3. Social Security Number 4. Date of Death (Month, day, year)
M Robert Shenk Male 1 86 _ 34 _ 4951 August 28, 2007
5. Age (Last Birthday) Urcler 7 r Under 1 day 6. Date of Binh (Month, day, year) 7. Birthplace (CRy and stele or fpr dgn country) 6e. Place of Death (Check ody one)
64 "i"~w °ry' "°"' M`""°a Jul 25 1943
Y
echanicsburg
PA Hospital: other
Yra , ^ Inpetienl ^ ER! Outpatient ^ DOA ^ Nursing HomeResidence ^Other ~ Specity.
Bb. County of Death &. C' Boro . d Death Bd. Fadllty Name (II not Insfitution, give street and number) 9. Wes Decadanl d Hispanic Origin? ~] No ^ vas 10. Race. American Intlian, Black, White, etc.
Cumberland New Cumberland (II yes, speciy Cuban. (Specly)
226 Reno Avenue
Mexican,PUeMRican,etc.) White
1 t. Decedents Usrml tlcn Klntl d wok done durm most d worki Ifle. Do not state reared 12. Wes Decedent ever in the 13. Decedent's Education (Speciy Doty highest grade completed) 14. Marital Status: Married, Never Married. 75. Surviving Spouse (If wile, give maitlen name)
d Wart Kind d ine Industry
Civil engineer Dawoo~ ~n U.S. Armed Forces? Elementary / Secrondary (0.12) Coll (1-4 or 5+) Widowed, Divorced (Specily)
~4
g. ~]vea ^Np
Married Melissa Jane Lloyd
t fi. Decedanrs Matling Address (9paM, dry /town, sate, xip code) Deceded's Did Decedent
PA
2 2 6 Reno Avenue Actual Residence , 7a. sale
Live in a rip. ^ vas, Decadent uvetl in Twp
New Cumberland
PA 17070 Cumberland 7°~"'"'p? ,~d ®No.DapaaamLrvadwimin
New Cumberland
77bo°°nN
, AdualGmihol
Cary ! Boro
16. Father's Name (Frst middle, last suffix) 79. MdheYS Name (First midAe, maben sumeme)
Myre1 Robert Shenk Winifred Murdorf
20a. Informant's Name (Type /Print) 20b. Informant's Metliig Address (Sheet oily /town, stare, zip code)
Melissa J. Shenk 226 Reno Avenue New Cumberland, PA 17070
21 a. Method of Disposdion ~ Cremation ^ Donation 21 b. Dale of DisposMOn (Monts, day, year) 21c. Place of Disposi9on (Name of cemetery, crematory or oMer pace) 2'. d. Location (City I town, state, zip code)
^ Burial ^ Removal from Slate j Was Cremation or Donation Authodzed
^ Other-Specily j byMedicalEzaminer/C Doer? Yes^No AU U S t 2 9 2 0 0 7
g r BFH Creme f o r
y
Grantville, PA 1 7028
22a. ~ lure of Funeral Service licensee (or person ling es such) 22b. License Number 22c. Name ant Address d Fadlty
- FO 012342-L Stone & Marra F.H. 408 3rd Street, New Cumberland, PA 17070
e Items 23aC only when certdying 23a. 7o the be y k ~ th occurtetl at the lime, date and place staled. (Signature ant dlle) 23b. License Number 23c. Date Signed (Month, tlay, year)
p ician is rid available at 6me d deem to
cedily cause cl death.
Items 24-26 must be competed by person 24. Time of Death PYX . 25. Date Pronounced Dead (Month, tlay, year) 26. Was Case Refertetl b Medcel Ezertuner r Coroner for a Reason Other than Cremation or Donaticn~
who pronounces death. 7;00 A. n4. August 28, 2007 'Ves ^Na
CAUSE OF DEATH (See Instructions end examples) r Approximate ktterval: Part II'. Emer dher slanifipanl mnmliats cpntri6ut rig b death, 23. Dld Tobacco Use Contribute to Death?
Item 27. Pan I. Enter me Hof events -diseases, injuries, or complicaNans -that directly caused the death. DO NOT enter terminal events such as cardiac crest. r Onset M Death bd rid resulting in the untledying rouse given In Pan I. ^Ves ^ Probably
respiratory artest or venMcular fibnfiation without sfrowing the etiology. Lrst only one cause on each line. t
r
(
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^ Nc ^ Unknown
IMMEDIATE CAUSE
Final disease or
coMdion resultirg in eath) _~ a. Metastatic Carcinoma t
zsnFemale:
Oue to (or as a consequence otp. i ^ Not pregnam within past year
Sequentialty list cmdilions, if any, b_ Cancer O f Rectum ;
to the cause listed on lire a
ba6n ^ Pregnant at time of doom
99
. Due to (or as a cons ante o r
Enter the UNDERLYING CAUSE ~^ ~~ r N
^ of pregnant. but pregnant within 42 days
(evixns resulting mt death~LAST e i of death
Dua to (or as a runsaWance of/: ^ Not pregnant, but pregnant 43 tlays to 7 year
b
f
d ore death
e
^ Unknown If pregnant within the past year
30a. Was an Autopsy 30b. Were Autopsy Findings 31. Manner pl Death 32a. Dale d Injury (Monet, day, year) 32b. Describe Flow Injury Occurred 32c. Plata of Injury. Home, Farm, Street Factory,
Pedormedn Nvailable Pmor to Gompietion
~Naturai ^ Homicide Office Building. etc. (SpecityJ
of Cause of Death?
^Ves ~o
^Ves ^NO ^ Accident ^ Pending Investigation 32d. lime of Injury 32e. Injury at Work? 32f. It Transponztion Injury (Specily) 32g. Location of Injury (Street city /town, state)
^ Suicide ^ Cculd Not be Determined
^Ves ^ No ^Driverl Operator ^Passenger ^Pedestnan
M ^Other ~ Specity~
33a. Certifier (check only ono) 33b. SkgnaMe and Title d
• Certitying physician (Physician cenitying cause of death when another physician has pronounced death and completed Item 23) - C o r one r
Ta the best of my knowledge, death occurred due to the cease(s) and manner as stated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^
• Pronouncing and certltying physician !Physician born pronouncing death and ceritying to cause of death)
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d 33c. License Number 33d. Date Signed (Month. day, year)
occurre
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manner as sta
To the best d my know
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_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ All gll S t 2 9 2 0 0 7
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• Medical Examiner/Coroner
On the basis of examination antl / or investigation
In my opinion
death occurred at the time
date
and place
and due to the causes) end manner as shterL ~
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,
, y N~andAddreses2l Pelson Wr~r~p~~a~ e o~B~t~r~2~lYType r Print
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35. Registrar's Signatures strict NUmbe(r/~ (J~- / '
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" ~ 75 Basehore Road Suite 111
63
PA
7050
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Disposition Permit No. n ~ ( '7"~/ ~ /