HomeMy WebLinkAbout01-13-09PETITION FOR PROBATE AND GRANT OF LETTER
REGISTER OF ~~IILLS OF C ur~~e~'~01+`~ COtTNTY, PE~~SYLVAMA
E.stateof 7`Obel"C~ ~VG~NIE ,~Q~-mE1'
also known as 2O ~ ~. ~. ~'i r-"1 a f"
. Deceased
File Number ~ ~ ~ ~ ~~~
Social Security Number
Pe~;itioner(s), who is/are 18 years of age or older, apply(ies) for:
(CO;YIPLEI'E 'A' or 'B' BELOW:) rva
n °
_ ~a -t-t
..n
^ A. Probate and Grant of Letters Testamentary and aver that Pe*.itioner(s) is /are the ==- ?:7 ~.-named i{a: the ~
....a -
last Will of the Decedent dated and codicils} dated ~-~ ~ .;
~.
. .. ,
1.Y_ GJ ._ ~ t
~~ _..
(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 ot~t~insttumet~ offeiEd
-1 .. ~.
fcr probate, was not the victim of a killing and was never adjudicated an incapacitated person:
N
B. Grant of Letters of ?,dministration ~ t ~ `
(lfappiicable, enter: c.t.n.; d. b. n. c. t. n.; pendente lire; durance absentia; durnate nunrnitntej
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: (~j
Adnrinistratiat, c. t. a. or d.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.)
Name Relationship Residence
K ~ ~ z~'~ E Gc1 lbra i-~M- M o thEr' 837 ~p w t/r ll~ R C_dr~r~le. P(+
(COMPLETE IrV ALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in ad ~~r ~ tl Y9(~ _ County, Pennsylvania with his /her last rincipal residence at
_S 3 7 N@ ,~, y r ~ t E ~L~C:«---r ~~ I- P~ i 7 o t~ /~. ~''~; ~ d le t v
(l.iSt;treet address, [own/city, township, cotuth~, state, zip code]
Decedent, then ~ 3 years of age, died on ~ 0 3 0 ~ 9 a[ O ~ 7 N~'~// v r ! I ~ ~ C ~ rl1~tC Pf'~
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
situated as follows:
~_~~O
- - ---
S
Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(;) presented with this Petition and the grant of Letters in the appropriate form to
the undersigned:
Signature Ty ed or tinted name and residence
// k t z; e E, C a l br Ftl~
2,~ao /~~. G%1 ~~~,~' 837 /~/ev~/v+'tle . R~ Cc~l~-1r~~E ~da t7~13
Form RI-V-O? re~~. 10.13.06 hflbe I Of 2.
t~V
~~
Oath of Personal Representative
COM~IONW'EALTH OF PENNSYLVANIA
SS
COUNTY OP C vw~bQrl acn~
'The Petitioner(s) above-named swears} 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. J~
Oy .~~ Q,7 ~/ e
Sworn ~e or affirmed ai:d subscribed
~~
before me tae __~~ day of
_ ~~~ ~
~ er the Register
tore A~Personal Representative
Signature oJPersonnl Representative
Signatw-e oJPersona! Representative
:V
n ~
.-~
_~ ~
?~~
r_ j..~.
~, ; -,
;., _ ;
l ~ ` F ~ 1 {
~.i
_~J --i ~ ".
~- ~
tV
File Number: ~ ~ U~~ ~~~
Estate of ~~ O/ b ~- h'~ pE y' q f? ti~ ~ (' Y- -"-1 e y` , Dece/aced
Social Security Number: ! ~ ~ ~ 6 S ' ~~ ~ 6 Date of Death: ~o / 3 ~ ! d
r
AND NOW, 1 J ~ `
having been presented before
are hereby granted to
Register
in the above estate
Attorney Signature:
Attorney Name: ~~~~
and that the instrument(s) dated
described in die Petition be admitted to probate and filed of record as the last Wi>{~ (and Codicil(s) of Decedent.
FEES
G ~j 1 j ~~
Letters ...... ! ~ .I ~... $ i ~
Short Certificate(s) .. ~.... $ `~~
Renunciatio(~(s) .......... $
~l ... $ ~~
... $ S".
... $
... $
... $
... $
... $
... $
... $
TOTAL .............. $
i
Supreme Court LD. No.:
Address:
the foregoing Petition, satisfactory proof
Telephone:
Form RDV-0_' rev. 10-13.0( Page 2 Of 2
~V~~ ~~~~V~O! f~9is~' A~~A~~~R'~~H~JJ~ ~ grit d~ 3 D 5
9NA1~lVINC: It is illegal td r~u~lvCate ih6~ ~~,~y by ~hoto~tat Or ~hcatcac~r~~~;.
_ ~~~~~~
1 --..--
~~~ ..C if it7t;_tt t r 11'..il'' .~1 ,... ,{.
..3 1 ~
! (t ~., 1(CI~ ~2i, ilL' ~ 1i ll.''i)_ t )
•~'
f,~~A :rte,." ~~~~ `
BT~,~ ~ 3~ ~~ 1r ~
~ ~ . ~a.c~~~-a~X~ NO1U ~
~ ~~
_
l
N
_= Q t.q
~
~
_
t
~ ~
/-
W ~
'
- _
~.~
J ~--. t.--. _
~~ ~ r
~-
~
-
tV
,
H105.144 REV 11/~tl06
TYPE I PRINT IN
PERMANENT
BLACFCrrvK X631-384
0
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CORONER'S CERTIFICATE OF DEATH
(See lostructiorts acrd examples on reverse) ,._.__ _.. _ ......___ ~ \ r . c-. ~ . r ' s 1 f
_ __ __ __ _ _ ~. t ....- ~.
1. Name o1 Decakenf (FUS1, mddle, !azt. suMx) 2. Sex 3. Social Sacuriy Number 4. Date of Death (Monty, day, year)
Robert E Lehmer Male 182 - 68 - 6706 October 30, 2008
5. Age (Last Blrtnday) Under 1 year tinder i day 6. Date of Binh (Month, tlay, year) 7. Birthplace (City and state w fore'
country) Ba. Place of Death (Check only one)
Momma Days Have Mlnurae Haspiral: Other:
33 Yra May 8, 1975 Carlisle, PA []Inpatient ^ER/Outpatient ^COA ^NUYSirg Fiume ®Residerlce ^Other-Specify:
86. County of DeaN &. City, Bor Twp. f DaeN ed. Facility Name pf not insfitulkn, give street and number) 9. Wes Decedent of Hispanic Origin? ®No ^ Yes 111. Race: American Indian, Black, WNife, etc.
Cumberland North Middleton (x ras, aped!y Cuban, IsvauM
837 Newville Road Mexican,PuenoRican,Bm.) White
71. Decedents Usual Occ Ikn KiM of work done tlunn moll of world life. Do rKK state retired 12. Wes Dacetlenl ever In the 13. Decedent's Education (Specify Doty highest greoe Canplefed) 14. Marital Safus: Merced, Never Married, 15. Surviving Spouse (d wife
9k'e maiden name)
KIM of Work KiM of Busuress / IMUStry ,
U.s. Amred Forces? Elementary / Secondary (0-12) College (1.4 or 5+) Widowed, Divorced (Spedry+l
Cook Restaurant ^Yea ~p 12 Never Married -
- 16. Decedents Mtiling Address (SreaL city I town, style, zip coda) Decetlenl's Ditl Decedent
PA
837 Newville Rd. Acoral Reaitlerlca t7a. Sete
Live in a t 7c. [~ vas, Decadent uwd m North i ddl On
Twp
Carlisle
PA 17013 TBwnahip,
,7b cpanry Gtmlberland i7d.^ No, Decedent Uvad within
, Amual Lillis of CBy I Boro
16. Fathels Name (First, middle, IasL suffix) 19. Moffrer's Name (FlraL middle, maiden sumema)
Robert L. LetmTer Kitzie E. Marquiss
20a. InformanYS Name (Type I Pdnq 2Ub. InlormanYS Mailirg Address (Seel, city /town, stale, zip code)
Kitzie E. Galbraith 837 Newville Rd., Carlisle, PA 17013
21 a. Method of Ofsposifion ~ Cremation ^ Wnaapn 21b, Date M Disposit~ (Month, day, year) 21 c. Place of Disposition (Name d cemetery, crematory w other place) 21 d. Location (City /town
state, zip cotle!
^ Burial ^ Removal from Sate i Was Cremation a Denalion Authorized ,
^ ocrrer spenM ! byMeakalExamlrxr/coroner? f~crea^No
- 11 5 2008 Evans Cremation Services Leola, PA
22a. signature of Funa Ca Ucensee w ass 224. Lkerrse Number 22c. Name vk Adtlress of Fadlky
- - ~ FD 012633 L Ekaaing Brothers Funeral Home, Inc., Carlisle, PA 17013
Complete aema 23a<onry when prdrying 23e. To Ne best pl my k ,death oavrtetl at Na 6me, date all place sfatetl. (SignaNre all fine) 236. L'ICense Number 23c
Dale Si
d
M
d
ty
phyekMn is tort axadada m rime w tleaN fo .
gne
(
ay, year)
on
.
tlNNly cause of death.
Items 2426 must be completed by parson 24. time of Death Ap rx 25, Dare Prwxxxrced peed (MmN, tlay' year) Z6. Was Case Referred fo Medical Examiner /Corone r for a Reason Other than Cremafkn or Donation?
_
wnpwDnwncesdaaN. 1:00 A M. October 30 2008 ®Yea ^Np
CAUSE OF DEATH (See InatruMbna arM exemplea) r Approximate interval:
Item 27. Pan I: Enter die charn m avenb - dseases, inrynes, a compicefiona -Nat tlireclry ceusetl Ne tlpN. DO NOT enter terminal events such as pniiac anesl Part IL Eller other simi6pnf Ixur6fions coot tutira fo deeN, 26. Did Tobacco Use Conmdne to Death?
, Onset to Death
raspietory aresl, a ventMularfibrifhtim nilxM shawng pre atlWogy List oMy are cause ar sell Noe. fxp not resuhirg in kre unoerrying cause gNen In Pan I. ^ Yes ^ Probaby
^ Nc ^ Unl:rrown
IMMEDIATE CAUSE~iral dsease or
conbTlon reauamg in aN) _)r a. Pending Investigation zs.uFamak:
DUB to (or as a Consequence O(): ~ ^ Nw pregnant wdht past year
Sequentiaity list caknbns, d any, 4_
Iaad~p to tl1a pose listed pn litre a. r
^ Pregnant of tlme of tleaN
Enter lie UNDERLYING CAUSE Due to (or as a Consequence oQ: r
^ Not pregnam, Olx pregnant within 42 days
tfisease or inNry Nat m t the
~, ryy ad
enb resuWng m death) LAST. of doom
Due to (or as a consequence ot!: ^ Nol pregpnT but pregnant 43 days l01 year
d. ^ belknownaf pregnant wihin Ne past year
30a. Was an Autopsy
Performed? 30b. Were AuNpsy Fina'Ings
Availabk Prkr to Completion 31. Manrrer of Death 32a. Date of Injury (Month, day, year) 3ffi. Describe Flow Injury Occurtetl 32c. Plop of Inury: Home, Farm, Street, Factory,
of Ceusa of Death? ^ Homxyda
^ NeNrW Deice Buiking, etc. (Speciy)
® Yes ^ No ^ Ves ^ No ^ Aunt ~ Pentlmg Mveelnpdan 32tl. T of t!ury 32e. Injury al Work? 321, a Tmnsponafion Injury (3pedtyJ 32g. Location of Injury (Steel, city /town, state)
^ sukke ^ Cook Not t» Determined ^ vas ^ No ^ Dmer /Operate ^ Passenger ^Petleslnan
M. Ottler _ SAeu~ry'
33a. Certifier (check Dory Dire) 33b. signaure and 'fi
CeMtying physkkn (Physician ceNfying ceuea o/ deeN when another physician FMS pmrrounced death ell mmPreted Item 23)
To the bestd my knawladq, tlaatlr acurred due totM auae(a)end menrcrnsMed_________________________________ ^
• P
onam
i
azM
dh
h
i
ki
P
i
M
~ Coroner
- ,~
,
c
ng
ce
y
ng p
ya
an (
den b
hys
l prmourlckg tleeN and ceNfyirg to cause of tleaN)
To the hest Of my knowledge, death attuned M the tNra, date, all ace, end due ro the
pl puaelsl uM manrreru ebled__ _______________ ^
33c. License Number
33d. Data Signatl (Month, day, year)
• Metlkel ExemNx /Coroner
OnfM bWe oreaaminetlm and/or MVestlgedan,mmy opkdon, aeeN aaaumadxme rime, ama, era plxe, end aue io ttx eau k~
as(s) &Itl manrwr e9 dated
/rv
November 2 2008
- 34 Name and AddrBSS of Person Wiw Completed Cause of Death (Ite m 27) Type 1 PMF
35. Registrar's s' r MDldrkt NUmgar~l
C
` 36, to Flied (ManN, day, year Michael L. Norris, Coroner
-
I,~ 11 I ~~ I I I (
f I ~ a 637 Base ore Road u to 111
Disposition Penntt No. ~yC~_~ I J~