HomeMy WebLinkAbout01-22-09PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF COUNTY, PENNSYLVANIA
Estate of ~ ~ -• - .v /'~
also known as File Number oC ~ ' ~~ - ~(}'~ 3
Deceased Social Security Number ~ t5rc~ - ~~ • ~ ~ Y
Petitioner(s), who is/arf; 13 years of age or older, apply(ies) for:
(CO[LlPLETE A'or F!'BELON!)
^ A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is /are the
last Will of [he Decedent dated named in [he
and codicil(s) dated r_ a
(Slate re(eV(tI(1 C(rCU/Y(StanCQS, B.o., YQnanCta[[On, deal/1 Of eX2C1(tOr, ¢IC.) iJ ~r I l
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Except as fol Lows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of ttt~ i 8 umer~) offeled ,
forprobate, was not the victim of a killing and was never adjudicated an incapacitated person: ~ '
;.~
:,. t _ ~
u iS. Grant of Letters of Administration - ~7
(Ifapplicabte, enter: ca. a.; db.n.c.l.a.; pende[(te lire; tfurante absentin; darmue n:inoritate) ~
Petitioner(s) after a proper search has /have ascertained that Decedent left no Will and was survived by the following spouse (if any) andoheirs: (!f
Adntirtistration, c. t. a. or d. b. n. c. t. a., enter date of Will in Section A above and complete list ofheirs.)
(CO[YLPLETE IN ALL CASES:) Attach additional sheets if ne sary. ,
Decedent was domiciled at death in County, Pennsylvania with his /her last principal residence at ___
(List slreel crctclrec~, tokn/crtp, township, coiuu~{ slate, zip code) - __
Decedent, then ~~ years of age, died on~
at ~ ~
Decedent at death owned property with estimated values as follows: ~~~~~~C y~ ~~v //
(If dom,ici]ed in PA) A]l personal property ~,
(If trot domiciled in PA) $- "~ >
Personal property in Pennsylvania $
(If not domiciled in PA) -~~~
Personal property in County ~
Value of real estate in Pennsylvania
g _ --,1.....
situated as follows:
Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the Brant of Letters in rhP a~,.,~„„~;.,.e ~..._ .-
the undersigned:
Fam RW-0? rev. 10.13.06
Page 1 of 2
Oath of Personal Representative
CO:~~I~IONWEALTH OF PENNSYLVANIA
COUNTY OF
SS
"Tl~e Petitioner(s) above-named swear(s) or afrirm(s) that the statements in the foregoing Petition are hue 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 estai:e according to law,
Sworn to or affirmed and subscribed
efore me the _~f~pZr~ day of
(T--' ~'~=--L-
ve
Signature ofPersoaal Represerrnrive
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For the ReglSteC
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Signafure ofPersonttl Representative -
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File Number: ~ ~ - . -..
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Estate of ~~~
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~ ,IIcceased
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Social Security Number: ~~ - ~ ~-} -
- ~g ~~-~ n
~~ Date of Death: `~ - 11-~g ~
AND NOW,
- OU , in consideration of the fore~~ing rctition, satisfactory proof
having been pcesente before me, I DECREED that Letters
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are hereby granted to
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and that the instrument(s) dated in the above estate
described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent.
]FEES
Letters ...... , ... $~G , r~~ Register ojWills ~
Short Certificate(s) ........ $ ~ 2, . G~ Attorney Signature:
Renunciation(s) .......... $
_~~ _ $ ~~ ,~ Attorney Name:
~
~.~bf`no.+l n~ ... $ 4 C~
Supreme Court LD. No.:
... $
_ , , . $ Address:
- .. $
- ... $
- ... $
_ ... $
- $
_ Telephone:
_
TOTAL .............. $ 4`t •OU
Farm RbV-0? rev. lO. i i.0(
Pale 2 of 2
H105.9D5 REV.r91f1R`
This is to certify that this is a true copy of the record which is on file in the Pennsylvania Division of Vital Records 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. ,.,
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Frank Yerv~Yi N r
State Re Strax ~ c. -_
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4 754426 ~~'0 200
No. ~
Date
H105~143 REV 11/2006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
TYPE I PRINT IN +~~~
/1eE~,"~"INK CERTIFICATE OF DEATHs{I
(See instructions and examples on reverse) STATE FILE Nl1MRFR
r. name or uecexra (HRI, mxlde, last, stafix) 2. Sex 3. Social Secunry Number , / 4. Date of Death (Month, day, year)
5
A
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B
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ast
gee (+
irthday) Under 1 year Under 1 day 6. Dale of Birth (Mont ,day, year) 7. &Mplace (City and state a foreign country) 6a. Place of Death (Check Doty one)
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Morphs Oat's Hours MIMes
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1^L~I ~i n L Cr. S HOeplta: Dther
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In atienl ry
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p ^ERIOutpatient ^DOA ^Nursing Home Residence ^Other-Sped
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. County of Death Bc. C Boro, Twp. of D th Bd. Facility Name pf not instauUon, give sheet and numyb~er) ~ 9. Was Decedent of Hispanic Origin? No ^Yes 10. Race: Ameri an Irdiaq/Bla~ck, Whne, ek.
C ~ ^ ~ ~~ ~ I 2 CrY ~L SG/g,~ r ~ ~~. ' 1 ~ yr ~ pf yes, speciy Cuban. (Specity) ~~~ I , _ "
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exican, Pueno Rican. etc.l `
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11. Decedent's Usual Occu tbn (Kind of work done duri most of workin life. Do not stale retired) 12. Was Decedent ever in the 13. Decedent's Education SSpecity only highest grade completed) 14. Marital Status: Manietl, Never Mardetl, 15. Surviving Spouse (II wife, give maiden name)
Kind of Wonk Kind of Busin
e
ss I Indust U.S. Armed Forces? Elementary /Seconda
dowetl. Divorced (SpeciM
(0-t2
ll
C
ry
)
o
ege (1-4 or 5~)
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y
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of ~n l~ I I R ~ ^Yes (~No ~ Z ~ ~ 1 ,l(~~'E.J
• 16. Deced~elnt' aitirg A s (Street, c'~m1ly I mown, shale, zry cods f,IC 2 Decedent's Did Decedent
' VA; Vle • 7 Adual Residence 17a
Slate ~
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352 ~
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17c ^Yes, Decedent Lived in ~
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ownsh
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C~1 ~.r~n/) p 17d ~ No,DecedentLivedwilMn ~r.0 ~. ~~
( ~ r~• p l ( 1 n. ce~nty_ C+L-
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ctual omits of
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18. Father s Name (First, middle, last, sudix) ~ 19. Mother's Name (First, middle, maiden surname~) / ~~ _ /. f // Iy/a
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20a. Informant's Name (Type I Pnntl /Q~ ~ 20b. Informant's Marling ress (Street city I town, state, zip e)
A i~ert
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21a. Method of Disposition Cremation ^ Donatbn 2 Date of Dispositbn (Month, day, year) 21c. Place of Disposition (Name of cemetery, crematory or other place) ltd L tpn (City I town, state, zp code)
^ Burial ^ Removal from Slate Waa Crematon a Donation Authorized. n[ x 1 _
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.
• ^ Other ~ Specity: ; by Medical Eaaminer I C
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oroner
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22 lure of eral Servk Licensee acting as such 22b Lcense Number 22c Na and Atl ress of Facility/`
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h Items 23a~c only when ceNlyinq 23a. To the best of my krawledge, death occurred at the time, dale and place stated. (Signature and title) 23b. License Number 23c Date Signed (Monts, day, year)
physician is rat available at time of death to
cemry cause d death. ~ , ( ~N ~~~ ~ , / ~ / ~ ~~
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aems 2426 must be completed by person 24. Tinre of Death 26. Date Pronounced Dead (MOmh, day, year)
26. Was Case Referred t M
e
tlical Examiner / Coraier for a Reason Other than Cremation a Daation?
• who prancumes death. ? : rl ~ M
. m I ~ ~ ~ ^
J _7J Yes No
CAUSE OF DEATH (See inshuclions and examples) r Approximate interval:
hem 27. Pan I: Enter the chain °f events -diseases, injuries, or mmplicatbns - that dredly caused the death. DO NOT enter terminal events such as cardiac anent, r Onset 1o Death Pan II: Enter other significant conditions contnbulinq to rn,
b 28. Did To6acw Use Contribute to Death?
respiratory anent, a ventricular F~bdgaticn widrout slwwi~ing dre etiology. Ust only one cause on each tine. r ut not resulting in Ne underlying cause given in Part I. ^Yes ^ Probably
~
IMMEDNTE CAUSE lFinal disease or r
conditim restatin
let aN) r
/ No ^ Unknown
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-~ a. 29
If Female:
D~ue to~ (or as Ia consequence of): //~~t i ~
Sequerrtialiy Nsl cond4bns, tl any, 6
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^ Not pregrnM wiMin past year
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h h Ne cause tinted on line a.
Due to (a as a c
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f ^ Pregnant al tune of death
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er U
DERLYING CAUSE
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~ ^ Not pregren6 but pegnam within 42 days
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Due fo f or as a consequence of): t
t
• d death
^ Nol pregnant, but pregnant 43 days to 1 year
d. r
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betae death
^ Unkmwn 4 preyrant wd"n rite past year
30a. Was an Aut 306. Were Ata Fi
31. Manner of Death
oPsy °PsY nle^9s 32a. Date of Injury (Mmth, day, year) 32b. Descrhe Haw Injury Occumd
Pedonned? Available Pda to Completion 32c. Place d Ir{ury: Home, Fann, Street Faday,
d Cause of DeaM? Natual ^ Homicide Office Buildrg, etc. (Specify)
^Yes No ^Yes ^ No ^ Acddent ^ PeruSng Investigation 32d. Time of Irqury 32e. Injury al Work? 321. b Transpodation Injury (Spea'ryl 32g. Locatan of Injury (Street, dry I Irnm, stale)
^ Suidde ^ Couki Not be DHemdned ^Yes ^ No ^ Driver I Operator ^ Passerxg<r ^Pedesuian
M Other- Specty:
33a. Cerfer (fired ony one)
' ~'le9 DKY~hn IP6y~an cerBMng pose d death when anaher physiaan has
To rite hest of my Wrowhdge, death occurred due to the pronounced death and competed hem 23)
eawels)artdmannerastated----------------- 336. Signature and T Certifier
i /1~/~ M'~
' Praauncing ant cerUlylrg physkiatt (Physician bats prauxxrdrg death and certil
'u
ro cause
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To the beat of mY krwwledge, tkaM oeeuned al the rime, doh, and phce, and due h the cause(s) and manner as stated_ _ _ _ _ _ _ _ _ _ _ ^
MedicNEaamirterlCororra '------ 33c. icense Nurnber
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0 33d. Date Sign (Mon ,day, year)
)
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aah of examMaNon and I a ImesllgaUon, in my oplnlon, death oceurted at the rime, dale, and place, end rice to the cewajs) and manner as stated ^
34. me Address of Pe o Cq)r pleted Cause of De Qte m 27 I Pn
35. Regis Signaure a I 36
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Fl ~ ~ ~~ ° `~" ' e ~a M ~ ' `"~ ! v' C ~ f w
- loI l/ I dl ~- I ate
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ed ( tlt, day, Year)
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yJOt~rtc of C n~i.t~ ~~ '. ~ S, G/~o Ib Qt./t,
f'~el,. ~A 1-in~-r
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Disposition Permit No.
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