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HomeMy WebLinkAbout11-20-08PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF WILLS OF ~'-t~rn~,~..r~ C1~YZC?~ COUNTY, PENNSYLVANIA Estate of ~ ~ 1 a ~ l~ . ~i~' _ r° _~. ~ t° 1,l File Number ~, ~ ~ (1 ~~~'J O also lrnowtt as h Deceased Social Security Number r~~ (~ -- ~~ - ~~ 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 last Will of the Decedent dated and codicil(s) dated named in the -~ -x~ (State relevam circumstances, e.g., renunciation, death of executor, etc.) ~- ~% „r`".- - . r'- - r; Except as follows, Decedent did not marry, was not divorced, and did not have a child bom or adopted after execution of the mst~t~ent(s) ced , , i for probate, was not the victim of a killing and was never adjudicated an incapacitated person: - - ,, ,-r ~, c - ~,7 ~ ' B. Grant of Letters of Administration _,~ -~ -... (Ifappticabte, enter: c.t.a.; db.n.c.t.a.; pendente life; durance absentia; durante minorttate) ,~-.. CA Petitionet~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 dote of Wilt in Section A above and complete list of heirs.) Decedent was d miciled at death in ~ County, Pennsylvania with his /her last principal residence at (List street address, town/city, township, county, state, zip code) l 1 \ _ Decedent, then ~ years of age, died on S,L-~ ~ - ~~ at ~~-!' ,~ ~~ l~ E--1.t'~~J i ~Y(~ ~, Decedent at death owned property with estimated values as follows: Ca ~ (If domiciled in PA) All personal property $ \ h ~ C~7t'`~ (If not domiciled in PA) Personal property in Pennsylvania $ (If not domiciled in PA) Personal property in County $ Value of real estate in Pennsylvania $ situated a:> follows: Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) pmsented with this Petition and the grant of Letters in the appropriate form to the undersigned: ~,. ~. i 7~ Z`~ Form RWd)2 rev. 10.13.06 Page 1 of 2 (COMPLETE !N ALL CASES:) Attach additional sheets if necessary. Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA COUNTY OF SS The 1etitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true and correct to the best of the knov~rledge 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 before mie the ~~ ,_ d y of ~ ~ ~ ~~ ~~ ~~ ~ ~~ b- "1~ (' Signature of Personal Representative a ~- `~"`' For the Register Signature of Personal Representative ~ i J i ~~ ~_ t~ :~ r--- "- -'ri File Number: ~ \ ~ ~~ ~~~~ ,~, ~~` _ -~ ~ ~~ ~ ' Estate of , Deca~sec~ - ' ~.. ~-- ~ ~- ~- Social Security Number: Date of Death: ~ ANI:- NOW, , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters are hereby granted to 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 ............... $ Short Certificate(s) ........ $ Renunciation(s) .......... $ ... $ ... $ ... $ ... $ ... $ ... $ ... $ ... $ ... $ TOTAL .............. $ 0.00 Register of Wills Attorney Signature: Attorney Name: Supreme Court I.D. No.: Address: Telephone: Form RW-O2 rev. /0./3.06 Page 2 of 2 iU>B(H RGV 101/u'~ FOCAL REGISTRAR'S CERTIFICATION OF DEATF~ WARNING: It is ilSegal to duplicate this +:opy by photostat or photograg~h. Fee for this certificate ~6.OO _P 1480701 _ Certification Number ;,~~'"'~~ZN OE p ~=~ t~~tiA ~ E,Y,y~~\ G ~ ~ ~9rN1ENT dF~~`~" Ihi~ i; t1t t_crtif~ th,lt (h~ intormalicrn lcr~ riven is ccurectly co~cd Eros; :±n o)i~~intfi ~'~.I-titi~ate f>f Leath duly filed ~~ ith me a~ Lt1ra1 Rer I~n:;r. Tl,e uri«i(rYl ce~ntirue wlfi he for~~_Lrdcd i i rile ~(21te Vita! ReL,Trc~. (~i1 .~ nor ;;~~~1,Lr:nt filing. d`' NOV 1 8 08 - - _-L__- ~° _- L kcal fZtri~trar !~;)te l,~ued d 1 0~ t\~`~ 3~ 11Y21bfi COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS PRIM IN :^"E"~ CERTIFICATE OF DEATH .K INK (See instructions and examples on reversal ra C> ~-' O ~ `x' a , :.~ ~' ~. 7~ c.:.. ~ , .~ . r- a7 ::_ ~a ® :J; ..J , ~, .__ -' _.1 ?„ .I ~.-- __~ ~.. _ -- ~ .T3 --i ~ ., y ~'~ j . 4;~ i. Name of Decedent (Rrsl middle, last, suffix) N a n e y L , She 11 e y 2. Sex 3. Social Security Number V r V q. Date of DeaM (Monts, day, year) emale 210-58 +2302 p~e(yy~ ~- (~ 2~©~ 5 A L U d r 1 . ge ( ast BirtMay) n e year Under 1 day 6. Data of Birth (Monts, day, year) 7. BiMplace (C' and stale or breign country) 8a. Place of OeaM (Check only are) 4 5 xex,~ oars Han knows Hospbal: other: 6/9/63 Enola PA Y , rs ~ ^~A ®Inpatient ^ ER / Om bent ^ Nursing Home ^ Residence ^OMer ~ Speciy: Bb. County of Death Bc ~ Boro, Twp. of DeaM 6tl. Fealhy Name (It not insthutbn, gNe street and number) g. Was Decedent of Hispank Origin? ~] No ^ Yes 10. Race: Amenwn Indian, Black, White, etc. of ee a ecd ° Dau b hin H i b y , p y p u arr s a"' (spec'M Whit urg Ostepathic Hospital e Mexkan, Puerto Rkan, etc.) it. OecetlenYS Usual bon KiM of work done Dunn moll of world Ibe. lb not state refired 12. Was Decedent ever in Me 13. Decedent's Education (Specify only hghesl grade completed) 14. Marital SmNS Monied, Never Married, 15. Surviving Spouse (It wile give maiden name) , Kmtl ork Kind of Business / Indust U.S. Armed Forces? Wklowed, Divorced ry Elementary /Secondary (412) College (13 or 5+) (SPecd11 Di ~ d sa e ^Yea ~1Np U NK Divorced ifi. Decedent's Mailing Atltlress (Street, city /tam, stale, zip code) Decedents Did Decetlen! d S e s,ata Pe nn s y 1 va n i a Liv ApNal Residence , 7a i 9 S a 1 t R d . e . n a 17c. ~ Yes, Decedent Lived in Twp T hi ? • owns p Eno 1 a , P A 1 7 0 2 5 17b. Coanty Cumber 1 a rid 17d. ^ No, Decedent Lived whin Aduel Limits of City I Boro 16. Famers Name (Frst, mitldla, lad, sulAx) Robert M . M e a dowc ro f t 1S. Mother's Name (First middle, maiden surname) Irene C. Rhoades 20a. Informants Name (Type / Pdn;) M a 11 o r y K . She 11 e y 20D. InformanYS Mailing Atldress (Street, city /town, stela, zp code) 9 Salt Rd. Enola, PA 17025 21 e. Metlpd N Disposmon ~ ^ Cremation ^ Donation (~ Burial ^ Removal from Slate i 21 b. Date of DispcePoon (MOnM, tlay; yea) 21 c. Place of Dispositon (Name of cemmery, creiretory or other place) 21 d. Location (City /town, slate, zip code) Wes Crematbn or DOnatlon AlzMorhed ^ Other - Speah: by Medical Examiner I Coroner ^ Yes ^ No 11 /21 /08 Perry Heights Cemetery Marrysville, PA 22a. SlgneNre of Fu Service U (a Ong ~- FD 01"4 9r9 3 22c. Name aM Address of FadlMy S U i va n F u ne r a Home 51 N. Enola Dr. Enola, PA 17025 Complete It c oNy when cerityiig physidan u available at fime of tleaM to 23a. 7o the best of my Imowledge, deaM occurred at Me erne, date end place slated. (SgreNre and title) 23b. License Number 23c, Date Signed (Monts, tlay, year) certby of tleeth. Items 24-28 must be wrtpleled by parson wYq Vranouncea deaM 2<. Time of Deets U 25. WI Prorolmced Dead (Month, day, year) ~ 26. Was Case Raterted to Medkel Examiner /Coroner for a Reason Other than Crematbn or Donation? . , a ~ a 3 !t M. l7 y ~I~'~ I ~ © - ^ Yas ~'~ CAUSE OF DEATH (See Instructions antl exemplea) mximate Interval: Item 27. Pad I: Emer die cflaln of ev911g - Ciseases, injuries, or canp8catpns -Met 6 r ~ reedy ceueetl the deaM. DO NOT amen tenr4nel evens such as cardiac anent, r Onset to DeaM Pad II: Enter other N Mcent conrntlons Vfi wrltribl"-kw to deaM but not resultln in Me untl l i i I 28. Did Tobacco Use Conirihule (o DeaM? V P respiratory arrest, or ventrkWa IMdlladon wahoul showing dre elpbgy. Usl ony one cause an each Ihra. i g y er ng cause g ven n Part 1. as robaN ^ ^ Y ~ /' ~ry IMMEDNTE CAUSE (Flrel disease or .(i /E /J ^ NO ^ Unknown . -..~ / l~ /yam / ',1 ~t condemn resuNng M deaM) ~- a. 5' V' -e 1 "' ~ 2 V Vim` ~ ~a Y1 (.a/ 1 tQ r i 13 y~Y ~ 29. If Femylp: Due to (or as a censequence off: ~ ^ Not pregnant within past year Saqusndalty Iist oxldl6ons. N any, b r ^ Pre nam at ti f d to the cause listed on Nrre a. r g me o eath Emer UNDERLYING CAUSE Due to (or as a consequence oft: i r ant, but pregnant within 42 tlays ^ o (disease or iryury Ihafirilialed Me o events resureng m deaM) LAST. i of deaM Due to (or as a consequence of): . ^ Not pregnant. but pregnant 43 days to 1 year d. ~ ~ before deaM ^ Unknown d pregnant within Me past year 30a. Was en Autopsy Pedortred? 30b. Were AWOpsy FlMinga AvaIW61a Prior to Completion 31. Manner of DeaM 32a. Date of Injury (Momh, tlay, year) 32b. Describe Fmw Injury Occurred 32c. Place of In'u 1 ry~ Home, Fann, Street Factory, of Cause al Death? ~Nrel ^ Homicide Office Builtling, am. (SpecAyJ ^ Yes ~ ^ Yes ~ ^ Acckfent ^ Pend'mg imestigetlon 32d. Timeol Inury 32e. Injury at Work? 321. If Trensponaeon Injury (Spenly/ 32g. Location of Injury (Street, dry /town, state) ^ Suicide ^ Coum Not tre Determined ^ Ves ^ No ^ Driver /Operator ^ Peseeiger Pedestrian M. OMer ~ Speah: 33a. Cerefien (check onh ore) 336. SlgnaNre end TNS • Certllying phyaklen (Phys.ldan cenihing cause of deah wnen arKKher physician has pronounced deaM and completed Item 23) To tM beatMmy knowNzlge, deaM Occurred due to tM ceueefa)and manneraateted_________________________________ (~ • Pronouncing eM carthying phyekkn (Ph skian horn ronoundn deaM nd ti M t d d M Tj~ r t/(r~`~ ~ / J' y p g e cer ty g o cause ea ) To the bets of my ktoMezlge, death occurred m the time, dek, and place, and due to Me ceuaeta) and manner ae sated_ .. _ _ _ _._ _ _ _ _ _ _ _ _ _ _ ^ • Medical Examner I Coroner 33c. Lcense Number ^/ ~~ r/AO ' / (/'! rfJ C~ 33d. Date Sg~1etl (MOnM, ay, year) /, / / ~ 9~ OO On the baele of ezeminabon and I or Inveetlgatlon In my opinion deaM occurred et Me time date end lace eM due to die ceu a ts d ^ / / , , , , p , se(s) r manner as alate _ 34 Namepnd Address of Person Who Com ple ted Ceua a/f ~eath (I~a ~ 27) Type I Print m 35. Reg' ' naWre and D' ~ I r~l l I °Z1 ~ I rl 3/~ F/J~OGP~ 1 w / l 7~ (/~ ~~ S. s' V~ ` l ! ~J~ r Y~ •3GlOl l1/. i~~r~n1E S~i~ t'/f t/v/~f5 ~ I'Il(D Disposition Permit No. U~~ V 1• I U ~~ v~ ~\5~ `o RENUNCIATION -r~ ~~_ ~ ~ -- - ~c ~' • N REGISTER OF WILLS ~p ~ _ ~ ~ ~ ~; ~ I~, C M ..> ~ ~ ; . y /~'- r- ~rx ~ ~ COUNTY, PENNSYLVANIA ~ : ~ ' ~c~ ., - ; _. ~ --t - c~ Estal:e of 1 ~/ A./V C r L 0 ~~ s L'~ Jl-l C L ~~ Y Deceased I, ~ D 15 c (~ T C U~9r L C 5 ASK C L L L-"Y .J v ~) f d ~ , in my capacity/relationship as (Print Name) ~ rv of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to ..--~ (Date) (sire) ~,~.- (Street Address) Executed in Register's Office Sworn to or affirmed and subscribed before me this of day Deputy for Register of Wills Form12W-06 rev. /0./3.06 (City, State, 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 purposes stated within on this I ~ ~ day of ~ C~ ~~~~ ~Y~ ~ r .~ ,~C% ~ ~ T7 rotary Public My Commission Expires: ~~G°' G•' ~ ~, ~o~/l (Signature and Seal of Notary or other official qualified to administers ' ~ ate,pf~~dti,4~ of N'oLtary's~CAmmission.) AL - r1N0~'191 SeAIPtNN~ V Tina M Robermon, NMary public East Pentatuxo Twp., Qitwedanq a ;ottrth, MY ~t E>rpires Nov.15, tot 7 MMMsr, Pennsylvania Assoctation of Notuks `~\ c~`6 It 5~ ~; ~ ~~ ~ -,_ ~ ' .- ~ ~ ~ RENUNCIATION ~_~Y ~ ~' ~ ` ~ _~ tV , p --, %, REGISTER OF WILLS ~ = ~`} ~ y-' PENNSYLVANIA ~ COUNTY Wt ~ ~y I u t;Ul h = " ~ _ _ _" .. ~" , , . . ~ :~ -~' co Estate of ~ CUB L~ l t) U I S P ('~ l".[ l (,~i ,Deceased I, f~4.aG9;'h F R.C.lrl Sh0 i1~J , in my capacity/relationship as (Print Name) d (~,l_~ h I- ~ V of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to ~~ I G ~V K q~-c 3~ E I I ~,~J ~~ I~ - 0~ ~~te) Executed in Register's Office Sworn to or affirmed and subscribed before me this day of ~~,~ ~ (Signature) i13 ~ J r u~c, S1 ~ ~ r (Street Address) (City, State, 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 purposes stated within on this I ~_ day `--~ ? Depuity for Register of Wills 1<lotary Public My Commission Expires: ~~ ~ ~- 1 'A; ,Zc ~ (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission-) C?OMMONVYEALTM Of PEt~VSYLY Form RW-06 rev. 10.13.06 f~otarta! S~ai Tina M. Robertson, f~k+tary PuhYc Ea51 PC'a~bD1D Twp., Cixnberlarld OOlfky My vonar~efon E.~+es Nov. 15, 2011 AAembsr, Pen~uytvaMa Associadort of NotsFes