HomeMy WebLinkAbout04-07-09PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF ~r'ri ~ ~ ~ ~' ~~ ~ ~COLTNTY, PENNSYLVANIA
Estate of / ~ e t l ~,.t dL ~ / trC°~
also known as
____ .Deceased
File Number Cam! "' ~~~~
Social Security Number ~~G ` 7 ~` ! ~--~
Petitioner(s), who is/are I S years of age or older, apply(ies) for:
(COMPLETE A' or 'B' BELOW.)
named in the
~ ~~
..A i m_~
(State relevant circumstances, e.g., renunciation, death ojexecutor, etc.) '' ~7 ~ ~ ~`
~ '"~ ' L?
;gin ~ C ~>
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution ol~flt$~~{i}tment(~) offered={ 'j
for probate, was not the victim of a killing and was never adjudicated an incapacitated person: ~ `- - ~> ~ `'t ~ {
J r~ "C?
B. Grant of Letters of Administration ~ ~ [~ r ri
t.. ,_~
(ljnpplicable, enter: c.t.n.; d.b.n.c.t.n.; pendente lire; durante absentia; durant~iaoritate) ~ ~ _
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Petitioner(s) after a proper search has /have ascertained that Decedent left no Will and was survived by the following spouse (if any) and~irs: (!f
Adntittistratiott, c. t. a. or d.b.[t.c.t.a., enter date of Will in Section A above and complete list of heirs.)
^ 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
domiciled at death in
(List street address, town/city, township, county, stnte~zip
~'~ /?vs~
8G`y8
J~~'13
County, Pennsylvania with his /her last principal residence at ~~~67 /~,, k- ~~/~
Decedent, then -~~ years of age, died on J~~f~_ at C,~-~/D ~~ `~ 7 ~
Decedent a[ death owned property with estimated values as follows:
(If domiciled in PA) All personal property $ /~~ ~Q U
(If not domiciled in PA) Personal property in Pennsylvania $
(If not domiciled in PA) Personal property in County $
Value of real estate in Pennsylvania $ ~~ Q 6 U
I ~~ o ~f JJ ~ ,~ 1 S,z, oa G
situated as follows: y ~(/ T r ~r ~~, ~~4Aw! r s L y~'„ ~,~ ~ ~ GL /
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:
or printed name and residence
Fm~m R 6V-0? rev. 10. f 3.06
~~ l7 ASo
Page I of 2
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(COMPLETE IN ALL CASES:) Attach additiotsa! sheets if necessary.
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF~Y~~~
The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true and correct 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 ~ ~~q,,,,~1 a~_
Signature ojPersonal Representntive
before me the ~ day of
Signature ojPersonnl Representntive
For
Estate of
Social Security Nu
AND NOW, ZC~~
having been presented befor~k
are hereby granted to ~~
Ster Signature ojPersorm! Representative
File Number: OL-I - U"
m
_.._ ~T ~ i
'__}
_~ W
p
i ~U ~ L~~~ ~LJIIDII!Deceased
' ~ Date of Death: L 'o~~Q
in considera ion of tie foregoing Petition, satisfactory proof
~~that Letters
and that the instrument(s) dated
described iu the Petition be admitted to probate and filed of
FEES ~~~~~ C
Letters ............... $~,~ '-
Short Certificate(s) ........ $ -~~
Renunciation(s) .......... $ O.
.. $ ~ • ~~
... $
... $
... $
... $
... $
... $
... $
TOTAL .............. $_~~~
in the above estate
the last Will (and Codicil(s)) of
Register of
Attorney Signature:
Attorney Name:
Supreme Court I.D. No.:
Address:
Telephone:
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Form RW-(12 rev. 10.13.0( Page 2 of 2
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FI III~.`t(1512I.\ ;[Il rill t1 ~~_ ~ 2~, I
LOCAL REGISTRAR'S CERTIFICATION OF DE~-TH
WARNING: It is illegal to duplicate this copy by photostat or photograplh.
Fee for this certificate, $6.00
'P 15188243
Certification Number
This is to certify thzt the information here given is
correctly copied from an original Certificate of Death
duly filed with me as Locai Registrar. The original
certificate will be forwarded to the State Vital
Records Office for permanent filing.
O`' MA 18 09
Local kegtstrar Date Issued
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
(See instructions and examples on reverse} eTaTC FII F All MaFFO
7. Name d Deced«lt (Brat, middle, est. sudi,) 2. Sex 3. Social Secuny Number 4. Date of Death (Monts, day, year)
Neil Lynn Strom male 396 - 46 ='7930 March 26, 2009
5. Age (Last &rdlday) lMder 1 year Under 1 tley 6. Date al Binh (Madh, er) 7. BiMplece (Ci ant slate a ~ coumry) M. Place d DeaM (Cherie oNy one) -
Asonsw Days Iw,uw Atnuhe Hospital: Odren
61 vrs. June 13, 1947 Rhinelander, WI ^Inpatient ^ERr Mnt
auya ^ DOA ^ Nursing Home ^ Residence ^Orher - Spedh:
eb. County of Death &. Cdy, Boro, Twp. of Death fid. Facdiry Name (If not irl6laubon, gwe street ant numMr) 9. Was Oeeded d Hispenk Ongin7 ®No ^Ves 10. Race'. Amerkan Indian, Black, Whne, etc.
Cumberland E. Pennsboro Tw
p• Hol S irit Hos ital wya,al>eolhcuba"' (sPe~drl
y p p
Me,kan, Plrerlo Rican, etc.) whit e
11. Deetlem's Usual lion Kind d wont dale d most d life. Do not dale re' 12. Wes Decedent ever in IM 13. Dedftlanl'a Education (Specity ody highest grade mrrlrlpbted) 14. Marital Status: Monied, Never Mewled, 15. Surviving Spouse (If wile, give maiden name)
Kntl d Work Kind of Business /Industry U.S. Amletl Forces? Elementary /Secondary (0-12) College (1.4 « 5+) Widowed, Divorced (Specyly)
Electrical En ineer Rubber Sheeting Mf ^Ves ®Ne 12 4 divorced
16. Decedent's Mailing Address (Spats, dly /town, slate, zip code)
1800 Hunter Drive Decedent's Did Decedent
AcWelRaitlarKe 17a. sere Pennsylvania Live ins t7p. Yea
Decetlenl Lived in Hampden
® T
Mechanicsburg
PA 17050 ,
wo.
TowrlshiP? 17d. ^ No, Decedent Livetl Mdlkl
I7b.Ccuny Cumberland
, AdualL;rdtsa ciryrB«n
LB. Father's Noma (FireL midde, real, sdfa) 19. Mdher's Noma IFlM, mMnre, meben slml0ra)
Ernest Strom Delpha Lamkins
20a. Inlonnenl's Name (Type /Print) 2W. Inlonnent's MalHrp Address (Street, dh /town, able, zip code)
Tatyana V. Strom 504 Hummel Avenue, Lemoyne, PA 17043
21a. McMOO d Diapoai0al ! ®Crema9on ^ Donation 21b. Date d Depailkn (MOmh, day, }art 21c. Place d DeposPoon (Name d cemetery, crematory a orMr place) ltd. Locatbn (city /town. stare, zip code)
^ 131aid ^ Removellromsrete jwa.cr.matlonorDanatloaAamedz.d~ March 27, 2009 Evans Crematory Schaefferstown
PA 17088
Y~^~
^ OMer - Spxdy: t by MMkat EKemkler /coroner? ,
22e. Sige F (« a such) 22b. Lkena Number rn. Name and Address d Fecdity
- ~ FD 013 340 L Parthemore FH & CS, Inc., P.O. Box 431, New Cumberland, PA 17070
CarrpeM Hernc 23ea ady when erdhkl9 23e. Tc tM beat d my krowledpe, dots asurred et the ' ,dab end ~aAe ss/ta/ydI d. (SgneNe pQJAIe) 230. License Nlanber 23c. Date Signed (Monts, day. year)
pfrysiden a nd evadable at time d death b
perrdy rope d dots. ~.~ " c/
p S O l 314 s
Vhr-~~1. 2-1~ , j,-c> c> `(
Mrm 24-26 must M coniWered by person 24. Tme of Death 25. Deb Pmnaxwed Deed (Monts, day, year) 26. Was Case Relerred to Medical Examin« / Gaoler for a Reason Other than Cremation or Oonatbn?
who prala,lces dots. l ~y `I ~ M. Ql L ~ ~ L / 1 D 0 C( ®Yes ^ No
CAUSE OF DEATH ($ea Inatn4ctlons at3d eaamplsa) r Approxkmle relerval:
Item Z7. Pert I: Enter the Nab) d lwems -diseases, kMurres, «complkabons - dial 6redh caused ale deaM. W NOT ed« terminal events such as cardiac awesL r Omel b Death Pan II: Enlar deer ' ~'
but nd resuXin n the u
9 i ndeMin9 cause given M Pan L 26. Did Tobacco Use Contnbule to DeaM?
^Ves ^ P aMdy
respiral«y anesl, «ventdcdar fiMMetlon witlgd shwxkg tM diobgy. List ody one cause «each kne. r
r ^ No
~Unknown
IMMEDIATE CAUSE IFaul disease « /f 11 ~ ~
contlilien resudkg n death) ~"~~( +' J r! ~~ L. ~C-.-~~v ~ ?-~1- / CL;
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~ 29. II Female:
,
. r
~~ a. N/~L rF:+rJ L.
Lri~v~17
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^
Due to (or as a consequence d): ~ '
T Nd Dregnent within past year
Sequentially let candeom, a arty, b, l
I
I~daq b tlr rouse fated an lee a I I ~ /~
/Y~'V r n-'L / ' J' ! . G'f-C ` ~ ^ Pregnant at tlme al death
.
l
Fnler $e UNDERLYpIG CAUSE Due to (or as a consequence aQ: r
^ Nol pregnad, but pregnant wil"In 42 tlays
(dsaa «Mury ~ ~~ ~
events reslAilg m dots) UST. o. ~ of death
Due to (or as a wnsequence of): I ^ Nol pregnant, but pregnant 43 tlays to 1 year
d. ~ belore tlaM
^ Unknown it pregnant within the past year
Spa. Was an Autopsy 30D. Were Auopsy Fk6ngs 31. Manner d DeaM 32e. Date d Injury (M«th, day, year) 320. OescriM Hav Injury 0«wretl 32c. Pecs of Injury: Hans, Farm, SIr9eL Factory,
Pedorrned? Available PMr b Completion r~isgn
YY Natural ^ Homicide Olfke Bu ,etc.
~^9 (SP~~h)
d Cause d DeaM?
^ Ves ~No ^ Yes ~' No ^ Atxitlent ^ Peakng Im~eslkJalkn 32d. Tirtre of Injury 32e. Injury at Work? 321. II TmnspMetpn Iryury (Speedy) 32g. Lorotkn d Injury (Slrlret. dty /lawn, able)
^ Sukdde ^ Cab Nd M Detadnetl ^Ves ^ No ^ Drive /Operate ^ Paservler ^PedeslMn
M Other - Spedfy:
33a. Ceni6er (cnedl onh ~) 33b. Signatae and 7Ae of CMNier
• I;artdying phy,klan (Physkian aaalying cause d deaM when anaMr physkren has praounced tlaM and completed Item 23) - ''''7~ ~' / ~ \1
~~yL~
~
~~
To Ule best of my knowhdge. Oath occurred due to the cauaga) and manner a abbd_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ G' ~
1 4
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• Pronouncing and cerllying physlcren (Physidan bats prorloua:wlg deaM ant cerlihing to cause d tleaN)
Ta the Oat d my knowbdge, oath oauwed at tM lima, date, ant place, and due to 1M ease(s) arld manna a sbled_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ 33c License NlanMr 33d. Date S (Mont ,day, year)
__ ~ ~, (~
~
• Medktl Esamelx I Coroner .3 1 J
i/~/1-.Y G r 7 ~ ' ~
d y /~ G~ /
On the beeb d enminetlon and I « Invest non, in m
Ige y opinion, death occurred el tM time, sate, ad plxe, end tla to tM wwM(6) end manner es shied. ^
34. Name erb Address of Per~on
Who
Compleled Cause of Deals (Item 27) Type / Pnnt
35. Registrar's aNre and Dist 38 De h, day, year) --
n
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Dlapoamon Pemat No. l J-~2'~ L,"7 L iL'L" L .cJ ~ ,/ ~) / ~ Q ~ ' "
RENUNCIATION
/ REGISTER OF WILLS
l~ y t/K ~ ~,r/~ L,~-w ~ COUNTY, PENNSYLVANIA
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Estate of ~,~L~,t ~ ~~ S4`t"a~ ,Deceased
I, ~~ g,rf I nJ ,~ ~~~ ~~a wt , in my capacity/relationship as
(Print Name)
5'0/-/ of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
(Date)
.~
Signature)
(Street Address)
~~ ~~~ ~~ ~.~4 / mil' .~
(City, State, Zip)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this
of
day
Deputy for Register of Wills
Executed out of Register's Office
Before the undersigned personally appeared the
parry executing this renunciation and certified
that he or she executed the renunciation for the
purposes stated within on this ~ ~ ~t day
of lU\.O~n ~- a v -_
. /~
Notary Public
My Commission Expires: '
(Signature and Seal of Notary or other official qualifie:t to
administer oaths. Show date of expiration of Notary's Cramnission.)
Form RW-06 rev. 10.13.06
COMMONWEALTH OF PENNSYLVANIA
Notarial Seal
Marisol Barber, Notary Public
South Middleton T+~P Cumberland County
M Commlasion Euplrea Jan. e, 2013
Member, PennaYlvania Aaeocla on of Notaries
RENUNCIATION
REGISTER OF WILLS
~ N
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/~i1 ~. ~,e d` ~D~-~ COUNTY, PENNSYLVANIA
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ed
Estate of
/I
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e
_
I, ,,, U`~r~/~•~~ .~ ,~`h,~e~//` , in my capacity/relationship as
(Print Name)
~~ ~~if"~'(/` of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
~/~ ~/~ .~
(Dare) _
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
"' ~ 3 z 1 o I , r~ S-~9_~
~-~wc~~v~c~ ~ ~ 11 ~~ ~5 o g~ y $
(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~ex~e'cuted the renunciation for the
purpose tG1~'l ithin on this _~~~ ~ day
d
~~ ,
tary Public
My Commission Expires: ~f~25J~~
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's Commission.}
NOTARIAL SEAL
Jennifer M. Wilson, Notary Public
City of Harrisburg, Dauphin County
My commission expires April 25, 2009 _