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ttR~,GISTFR OF `Y;-ILLS
am hPf-1Q11~ COL~iTY, PE~~SYZVA\TA
Name of Decedent:~~~, ~' ~ ht ~ i ~
Date of Death:__ ~ c_ 1' . ~~ File Number:_ '~ (j Cj ~ ~ Q ~ a
Late i,ci[cis VPilnted:~ C f ~ I ? ~ QV~ M
To the Register:
I certify that Notice of Estate Administration required by Pa. O.C. Rule 5.6(a) of the Orphans' Court
Rules was served on or mailed to the following beneficiaries of the above-captioned estate on
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Name: Address:
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(If more space is needer~ attach separate sheet.)
Notice has now been given to all persons entitled thereto under Pa. O.C. Rule 5.6(a) except:
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Signature of Person Filing this Forn
Capacity: G~ersonaI Representative O Counsel
Name of Person Filing [h!s Form
.4ddress
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Telephone
~ormRiv=GB rev. i0.1i.G6