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HomeMy WebLinkAbout03-05-09 (2)PETITION FOR PRO/tBATI,E AND GRANT OF LETTERS REGISTER OF WILLS OF l ,U,YYI -JP~~Q-~ COUNTY, PENNSYLVANIA Estate of TO /a , ~ Cl. File Number -QC~~ / 5 also known as e4 C~ •~ . 5 ~;o.,t t ~ I I - l y - ®~~~ Deceased Social Security Number Petitioner(s), who is/are 18 years of age or older, apply(ies) for: (COrY1PLETE 'A' or 'B' BELOW:) ^ A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is /are the named in the last Will of the Decedent dated and codicil(s) dated ra '-' ..~ '-1 ,~ -~• -s-t '~pA '..-- -'t'J (State reievmt! circumstances, e.g., renunciation, death of executor, etc.) ;~ ~ ~ i0 ~': + ,.~ Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of~g~st1?T3rtent(s~ffered~ ~:.t for probate, was not the victim of a killing and was never adjudicated an incapacitated person: ~"~ "O ""? ~~U -c't N 7;'t ,~ B. Grant of Letters of Administration ` ~_~. r (Ijapplicable, enter.• c.t.a.; d.b.n.c.t.n.; pendente lire; durante absentia; durnnte ua?7i Iritate) J (COMPLETE IN ALL CASES:) Attach additional streets if necessary. 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: (!f Adrnittistration, c. t. a. or d.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.) Name Relationshi Residence 'C ~~~- ' ~' I 1.~1111am G~e% R~ ~ ~ Gha~~ ~cs-~,~~q~~o~ CC,c~, ~: „~c~r} ~{1 ~ F ~b5 ~i~r ~r\®~0. PA 1lt~Sf was domiciled at death in , ~ n10 I CL County, Pennsylvania with his /her last principal residence at 3~ ~~ (Y) Cj (List sh~ee[ address, [own/city, township, county, state, zip code) --11~ ~ ~ Decedent, then years of age, died on ~F17t"kCr ry )y~t3M / /, y`^~ ~ Decedent at death owned property with estimated values as follows: ,l.11 (If domiciled in PA) All personal property $ 1 ~ O ~ V (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: 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: Signature Ty ed or rioted name and residence Form RW-0? rev. 10.13.06 Page 1 of 2 r 7 yd t~ `'~~ Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA COUNTY OF The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are rice 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. Sworn to or affirmed and subscribed before me the ~~~ day of For e Register Signature ofrersonal Representative Signature ojPersonal Representative tV Signature of Persa:al Representative o C w ~ ~ ~ r~ -~-rt n• Via: , f~~~rn- ~ `;~ nn l ~~S ~~~ (~ ~C ~ ~ ~ r; ~ cn '~1: f ~=~ C File Number: % JO , ', ~ //~~ ~ ~ ~ C ~ -. Estate of V , Dec~as~ ~ . ? Tl ~ ~ p ~~ ~' ~ ~ ~ ~,, ~ ,._~ `' Social Security Number: Date of Death: i1 (.(J . ,~ AND NOW, ~~~ D(l ~ Y(~l, ,~ , in consideration of the foregoing Petition, satisfactory proof having been presented bf~ore me,~YI' InnS~,~DEC/R}E /D~th~atjL/emitters are hereby granted to ('f11.U IVl • (', ~l.t-Y ItL~ and that the instrument(s) dated in the above estate described in the Petition be admitted to probate and filed of recor the last Will (and Codicil(s)) of Decede FEES ' (~ D~ egisterofWifls •~~/~' Letters ............... $ ~`"~ Short Certificate(s) ........ $ ~ •d Attorney Signature: Renui~~ Iciation(s) ....r ..:.. $ ~ , (r)~p-~ $ /~;~ Attorney Name: ~~ ~ V~~ • • $ ~h'•~/ Supreme Court I.D. No.: ... $ ... $ ... $ ... $ ... $ ... $ ... TOTAL .............. $-111L_ Address: Telephone: Fam RW-0_' rev. ro.r3.oh Page 2 of 2 LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $6.00 P 15187378 Certification Number This is to certify that the information here given is correctly copied from an original C ertificate of Death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Record, Office fpr permanent filin g. ~~ yy~ ~ ,l FEB 21 2009 / / • Local F:egistra~ e~ ° Dat~,,Issued - n G p _ ~ ~ a° ~ r't C7 "10 . .. - ~ ~ ~ ~~~ i _ ~7 ~ _ s i _~ -~ ~,--~ 3 ~,"i -.. ~„ .C ;: + W t REV 112W6 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECONDS !PRINT IN ,~~K CERTIFICATE OF DEATH (See Instructions end examples on reverse) CTdTF FII F fJ11aaFFR t. Name d Decedent (Full, midde, last sulfixl 2. Sea 3. SoGal Searily Number d. Date of Death (Month, day. year) Joyce A. Stewart Female Ill - 14 "'--0114 February 18, 2009 5. Age (Wst Bk1May) UrMer 1 year Untler 1 tla 6. Dale of &M (MOnlh, day, ar) 7. Binhplace (City aM dale a f cardry) Ba. Place of Death (Check onl one) Mantua Gays Hours Mimosa MOSpHeI: Dlher. 84 Yrs. 10/ ]4 / 1924 Colrain, Mass. ^InpatieN ^ER/0utpaliem ^DOA ^Nursing Home Residence ^Other-Speciry Bb. Coalty of Deem &. City, Boro, Twp. d Dedh 80. Feddry Name (Ii not InatlHnial, gNe sireel and number) 9. Was Decedent of Hispanic Origin? ~] No ^ Yes 10. Race: American Intlian, Black. While, etc. Oberland st Pennsboro Ttap. (II Yea, specHy Cuban, ~s~ciM 32 Adams Street Mexicen,PUedaRican,etc.) White i1. DaaderlYS llsud ICKId d work dae moll d tile. Do nd state reliretl 12. Was Oecedenl ever in the 13. Decedent's Education (spedfy oNy highest grade compbletl) i4. Marital Safus: Memed, Never Martied, 1 S. surviving Spouse Qf wife, give maitlen name) Kntl d Work Kintl d Business / Intluslry Houseduties U.S. Arrtwd Forceal Elemen~ry ! Secondary (0-12) Colbge (1-d or 5+) Wb°w'~~ Divorcetl (Specilyl ^rea 57ND 12 2 WidowEK~ 16 Decetlent's Mailing AdNess (Sireel, dry /town. slate. ziD cotle) Decedent's pA Did Decedent EasC Pennsbo o 32 Adams Street r AcNal Residence 17a stale Live n a nc.YFl Yea, Decadent Lived in Twp Enola, PA 17025 Towrrship? 17d_ ^ No, Oecedant LMetl within fro. Caunry Ctmberland Achral LkNlS Of city/Born I6 Fattler's Name (Pest, middle, lest aKxl 19. MoUa'a Name (First, mMde, maitlen surname) Edward C. Potter Elizabeth M.I. Lu le 20e. Informants Name (Type /Porn) 20b. InfamanYa Meiling Address (Street, dry I town, stele, rip cote) Qty M. Clarke 1115 SunT3yside Road York, PA 17408 21a. Method d Disposition Cremation ^ Donation 216.Oate d DEm (M oNh, tlay, year) 21c. Race d Disposgion (Name d cemetery, aemelory a o6ter flats) 21d. L°caf (CAy I lavn, sate, zip coda) ^ Banal ^ Removal from Slate i Was Creine6on a Duration AuNwrized ^ other ~ spent': ; M Yedcal E:amore, / cormeff ~ Yea ^ No M n t 2 /2 1 /2w7 Hull in er g Cr®atory MC . Holly Springs PA 17065 22a. Siglature d Funeral Servicy.j.icenaee (a person acting as such) 22h. lkronse Number 22c Name and Atltlress d Faddry ~ // - f/ ~-T~ ~ FD 012774-L Richardson F1u3eral Home INc. 29 South Enola Drive Enola, PA 17025 Carlpkte Hems 23at oily when cer6lying 23a. To t of my knowledge, death occurred el tlw lime, tlele and place dated. (SlgnaNre and tithe) 23D. License Numha 23c. Dale Signetl (Month, tlay, year) physidwl s nil evadable al tans of Death to Ldtiry causeddBem. /( / ~l ~.. l}ra /~c'-'. ..- -. a.l- ~/ ~ P /•-~~ /X..'Z.J~.") %'~a ~~l J~~- Hsms 2426 root ere wrrlPldetl R' person 26. Time of Death 26. Dale Praneunce0 Deed (Month, day, year) 26. Was Cese Relaned to Makcat Examner /Coroner for a Reason Other Than Crematon or Donation? who pronourxxa tleeM. %~ TAM. ,~ :. /' _. ~~~ ^Ves ^No CAUSE OF DEATH (See Instrudione and examples) oximete inlarvel: Item 27. Pen L Enter th dwin d events -diseases, njunes, a calplicatlons - tilat caused the death. DO NOT solar 1 ~ rel events such u cardiac arest, i ~ duecal' Onset to Death Pad II: ENa other djppj(~amt conditims canyibi ° to death, but nil rewlAng in the untlerrying cause gNen in Pan I. 26. Did Tobago Use Cmlmute to Death? ^/ Yes ^ ProOady respretory arrest, a vaninadar fldidatian witlwut showkg the etiology. UM only aw cause on each line. r i IMMEdATE CAUSE (F~mal disease a ~ r ^ No ^ Unknown mrxkaon restlHng n deem) _~ a C .'Y.i .1.~. (" USJ %":.r r r:.' :' ~- c .ter u.: n,.• -,% ~iUf <IS-E ~ Y /.- A,~ ~ 29. If Female. Due to (a as a consequence dl: ~ ^ Not pregnenl witnn past year Sequentladl(v~Ad eontliliorw, H anY• b. % ~~..i' fl... c :-7 .~ J ~c ~ ~ J'. " T J (.:. ° Z ~ S r ~„ C pa~Iq la ..._ cause ligetl °n Ina a. ~ ^ Pregnant al kme of death Due lo (or as a cons Finer UNDERLYING CAUSE epuence o I ~ x e gnenl, but pregmanl wndn 42 days ^ ' Idsea a eylay that inHiatetl the c_ evenLS resulting n death) LAST. i h d d~ Due 1° or as a con ( sepuerxx og: N°I pregnam, but pregnsm 43 tlays to t year d. i r bebre tlealh ^ Unknown it pregnenl within the past year 30a. Was an Autopsy Pedamed? 30b. Were Adapsy FindiM,)s Avadade Prpr to Camplelion 31 Manner d Deem ~,,//, 32a. Dale d Injury (Manor, tlay, year) 32b. Describe Haw In Occumd Wry 32c. Place of Injury-. Home, Farm. Sired, Factory. DHke Builtling e1G (SpeciN) d Gau58 of Death? L'J maWral ^ Hanicltle , ^ Yes ~No ^ Yes ^ No ^ Accltlenl ^ PeMkg Investigation 32tl. Tore of Injury 32e. Injury at WoM7 321. II Trenspmlation Inury (Spedly) 32g. Laatron of Injury (Street, city I lows. dalel ^ Suitide ^ Cab Nol be Ddemkrletl ^ Yas ^ No ^ Dover / Operala ^ Passenger ^Petlestnan M ^ anar - speaN 33a. Cedfier (dleck Dory one) 33b. Signalae antl Tole d Cenifwr • cerntyiM phyaklan IPhysidan cenitying cause d deaM when another pnysicien has pronouncetl deem antl canpetetl Item 23) To the heal of my knowledge, death xarred due to the eeuse(a) arM mamw m stNad. _ _ _ _ _ _ _ ~ ________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~ -ei. ~ i •.'e.~... _ "-'R - , • Pronoundrl9 and CeNhJfltg pityskhrl (RryaKMn botll pmnalmxlq death and cenilyirg b tease of deaml To the heel of my krlaHM e loth occurted at the time date and l d d t H d ^ 3&. Ucense Number 33d. Dale signetl (MOnN, day, Year) g , , , p xe, an ue o ,e tease(s) an manner as ehterL _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ • YadW ExaMrrerlCaawr ~~ y~.f '~,.7 ~, /:~~;• Dn the basis d examination and / a Investlgatbn, In my opinion, deem occurred at the time, dale, and pNro, end due b the cause(s) and mariner ee steled_ ^ 34. Name and Address d Person Who Canflleuxl Cause d Death ptem 271 Type I Print 35. RegiWreYS Sgnalure Numoer L~~ ~ I v21 ~ I r~ / I / I 36. Dale le'd der , r ~ o a ~) ~..y ti / f7 /'. ra-):' c, c. TS,.I 4r v) I fj~ 0 Csbc,Li i+ ~, ~:, H'r4 . 2 , a v Disposition Permit No. ~' `» .Z,n r 3 ~ N o RENUNCIATION c ~ ~ f=~-~ ~. ' _.. 17 .f i "~ ~ ~ C ~ REGISTER OF WILLS ~`> cn x ~ "' "' `~"' °~' ~' -iat~1 "~_ COUNTY, PENNSYLVANIA ~p ;' ~ r_: ~ . ,_,. °~ -..! Estate of _,~ ) 4 Cl; ~ c .7 _-.. l~. ~ ~ _ ~, ~~_.~;~~ k ~ ,Deceased I, -~ =~ ~ L~ ~' ~~-- Z- ~~ ~ ~~~, ~ , in my capacity/relationship as ~ (Print Name) ~~~ of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to (Date) Executed in Register's Office Sworn to or affirmed and subscribed before me this day of Deputy for Register of Wills +. V (Sfgnatur (Street Address) ` Cil~, Skr?ts'"ZipJ r 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 purpo/~/s~~e-s~stya~te~d within on this a y day of _--~--~-~ .~•-_ ~ .ten 4 Notary Publ'c My Commission Expires: f'/~~~ COMMONWEAL~M 6F F"z,;,, ~ nature and Seat of Notary or other official qualified to Notarial Sea' __ s. Show date cf expiration of Notary's Commission.) Robert J. Reese, Nofr,ry public Silver Spring Twp., Cumberland County My Commission Expires pug. 10, 2012 M~~. Pennsylvania Assar:~tian of Notaries Form RW-06 rev. 10.13.06 RENUNCIATION N REGISTER OF WILLS ~ ~_ --,; c,a,~~_ COUNTY, PENNSYLVANIA ' ~ ~ ~- ~x~ ~ it ri ~ u`i ::~ : t, a -~-; ~C7 ~ %~ r x i Estate of _ / o t-/ ~f ~ ~ S rt £ (n/ f} l27'' ~ -~ ~-~' ceased • '' I, _ ~ 0 N -~_ C L ~ ~k ~' , in my capacity/relationship as _ (Print Name) 0~ of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to (Date) Executed in Register's Office Sworn to or affirmed and subscribed before me this day of (Signal e) ~ R ~f ~ ~jx 1 ~ (Street Address) /Ylt~f~~(~v`~ow~~ ~9- t 7US~q (city, state, zip) Executed out of Register's Office Before the undersigned personally appeared the party executing thi:> renunciation and certified that he or she executed the renunci ion for the purposes stated within on this day ~,, -~PbY~rc,~ (~00 1 Deputy for Register of Wills Form RW-06 rev. 10.13.06 Notary Public My Commission Expires: (Signature and Seat of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission.) NOTARIAL SEAL DENISE R. PETERSON, Notary Public Walker Twp., County of Juniata My Commission'Expires Feb. 24, 2010 Estate of I, ewu S Q n (Print Name) of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to YY1 (~ ~ ct f ~~.~$~ ©~ (Date) (Signature) 3 ~ ~ ~~ fik .~ ~~ (Street Address) ~'y~q ~Q ~ 7~~~ (City, Slate. Zip) Executed in Register's Office Sworn to or affirmed and subscribed before me this day of Deputy for Register of Wills Form RW-06 rev. 10.13.06 RENUNCIATION ° ~ ~_, -T' CO _ ~ _ ~~` ~° ' REGISTER OF WILLS E~~ '-'~~ ~ ~ L ~~` ~' Cwrh .e cI ~-„ / COUNTY PENNSYLVANIA ~'~~~ ~ ~ ~ , , ~ ~~::?, , ,~-., 4/ -a ~..;.~ F ~ ~. t: ~ ~ N i"t" 1 C7D G y C e_ ~ S~ e L~ u ~' ~ ,Deceased Executed out of Register's Office Before the undersi~,>ned personally appeared the party executing this renunciation and certified that he or she executed the renunciat o i or the purposes stated within on this ~. $ day o f Ft h r ..~ E-~. r ~_ a.~,r, ~i otary Public [y Commission Expires: /1 Uv 1 s o~ y (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission.) COAi1MONYVEAL'fFf OF PENNSYLVANIA Nolerfel Seel Tina NL RObafleon, Notary PubNC C-aef Prrnrborp Tw{s.. WrntoeNandCwNy My O0fr1r1'7i6flOrt E~Irae Nov.1S.2011 Membfar, Pennsylvania Assoei~tlon 1f PbtMte~ in my capacity/relationship as