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HomeMy WebLinkAbout04-01-09PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF WILLS OF ~4_-.~ ~... ~o~ COUNTY, PENNSYLVANIA Estate of •K tc],e~,-, .C~ r r. o .L~e.~-K. File Number ~ / ~ 0~ ~ `~ also known as ~ p, ~~~~~,~ ~ ~ 1 g,//5" ,Deceased Social Security Number ~i7 '~ ;~`'7~ ~J ~. ~ 9 Petitioner(s), who is/are 18 years of age or oldec, apply(ies) for: (COMPLETE '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 (State relevact 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 of the instrument(s) offered for probate, was not the victim of a killing and was never adjudicated an incapacitated person: L^J. B. Grant of Letters of Administration (!f applicable, enter.• c.t.a.,- d.b.n.c.ta.; pendente lire; durante absentia; durnnte miitoritate) 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 Adrrtir:istration, c. t. a. or d.b.rt.c.t.a., enter date of Will in Section A above and complete list of heirs.) 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 ~ c~a situated as follows: J~ e,~y ,~ e~~ Q cf~ ~% ~~g_ O~ ~~ /7l~/ ~ 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: ~ Si;nature Typed or printed name and residence __ J 3 Form R6V-0? rev. !0.13.06 RECORDED OFFICE OF REGISTER OF WILLS 2009 APRIL 1 CLERIs OF ORPI-L~1NS' COURT CUDiBERLAND CO., P_~ Page 1 of 1 i, ,y (COMPLETE IN ALL CASES:) Attach additiotra[ sheets iJ necessary. Decedent, then ~_~ years of age, died on /~ at ,~IPf! I C_ Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA hn~f ,/ SS COUNTY OF ~ ~'1.}y~ I ~ 1~Ci The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are hire 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~~a~/nd/~subscribed before me the W '' day of Fort egister Signnture ajPersonnl Represenlntive Signature ojPersonal Represenlntive Signnture of Personal Representative File~~N//umber: ii,~~'' ~ ~ "- ~ % ` ~ 3~ 3 Estate of TeV ~ rl UUf ~ ~ ,~ 112 IA1 P_ ~ ~ S ,Deceased Social Security Number: 173 - ~~ -~~5-1 Date of Death: O~ ' a 8 - ~ 9 AND NOW,15t tX,(,L~ S'~ 1 ~ , 20©p~ , in consideration of the foregoing Petition, satisfactory proof having been presented befo me, IS D CREED that Letters IC~VYI L h 1 S~fl'Q fl 0'V\ are hereby granted to in the above estate and that the instrument(s) dated described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent. FEES i~-~C.~ Letters $ 30. (~_ Register of Wills ~ ~ ~!'X~ Short Certificate(s) ........ $ ~ ~ Attorney Signature: _P Renwlciation(s) .......... $ `i,C~ _}., _ $ fO~, ~~ Attorney Name: ~,a 11°srn~ 1 l_~ul... $~~L Supreme Court I.D. No.: ... $ ... $ ... $ ... $ ... $ ... $ TOTAL . . ............ $ ~?~. ~ Form R6V-0? rev. 1O.13Ati ... $ Address: Telephone: RECORDED OFFICE OF REGISTER OF WILLS 2009 APRIL 1 CLERK OF ORPIL•~NS' COURT CU~iBERI,AND CO., P~1 Page 2 of 2 105-905 12EV.(9/08) 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. 4:784350 No. .n.~- ~~~ w0 ~ `r a W~ H r p w ~ ~ w 0 Frank Yeropoli R i S O O a'+ ~ U Q ' ~ ~ z -zr strar tate eg , q W f-a a ~' ~ ~ ~ U ~1AR 2 4 2009. OC7N ~ ~ o Date ~,,,--,,; Rtv P„z,r,6 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS. 018557 "` PRi~'"`` CERTIFICATE OF DEATH -_-_ ISee instructions and examples on reverse) ray= ~„ ~ ~,,,f,f~:;F F; 0 N N a w 0 w w 0 0 Z t. Name c' Deanenf IFrr. middle, fast. suflixl 2. Sex 3. Social Secwnc Num~r d, Date of Death r'deolh, day, yeaq 5. Age (Last &ntrday) Under 1 year Under I dory 6. Dale of &dh (Momh, day, year) 7. &nhplace (City and state or foreign country) 8a. Place of Death (Cfreck only ate) Mwww Davs Ra.s hNnAes fbspiWl: Omer. t-~pfE~j~t / r ~aQ'^!~ ,UA // Inpatient ^ ER I Outpatient ^ DOA ^ Nursing Home ^ Residence ^Other- Speciry: y ~ Yrs G , . Bd. Facility Name hf noI instiNtion, give Street and number) 9. VJas Decedem Of Hispanic Ongin? ~ No ^ Yee 10. Race: American Indus, BWCk. White. etc. Cooney of Death &. Ciry. 8oro. Twp. o' Death • 86 ISpecity) . ZL pl yes. specify Cuban • Mexican. P~erc Ric e!c. SC =~ fl RU.~LE .t11l~~ra (/ratso~cA( Cc~-kiE> Gc.,'rYS% L- Gf1~e1 1 " . . v~+OERG~f•v0 Divorced (Speci~ylr Marred. 15. Surviving Spouse (I' .vie, give maiden name; tt DEiedent's Usual Ocw orlon ixind of crack done drain mon of aorki^. file Dona state retired 12. Was Decedent ever in the t3. Decedeni s Education jSpeclty only highest grade compietetll t4 Wtlat~etl . Nand of work xind of Busness! Industry U.S. Armed Forces? Elementary I Secondary 1042) College (1-4 or 5rl /c'f~~i /~ /+~ -Q, j ~ /~E' I1CT/f /I ~ ^Yes ~NO /h ~7 R /'~..Z'L-.7 G-T S /~ M,/~ l^ e~ L- i6. Decedent's Maifrtg Address (Sired, city I town, state, ip code) Decedent's ~ Did Dncedertt Decedent Lived in TWP~ 17c ^Yes ~ _ x .3 ~ ~( ~~ ~' ~ Qs Vl~~ ~ ~ . ' Actual Residence 17a. Slate Townshi P? 17d. ©No, Decedent Lived within ~y " C~.e~~G--~~' /Jof - /LL i/n.;J Actual Limits of ( /9Q 1.~3~-G Cdy!Doro t7b. County NU/h /fit - 18. Father's Name (First middle, last, suAixl Iq. Mother's Name IFirst, middle, maiden surname) E'vV.~v~'T/! h/.~ iVL~ ~i/t~L-S ..T/~L /tc~I~rJ .Cicc/ `~iS 20a Infmmam; Warne I'VOe' Prlnll 20b. Informant= Mailing Address iSireet. <~~~. ievc~, 4aL. zip codes //,r/ a h/ 2.i W -LC 1 / 7.3 SFfC 's a rr =" wv-: ~.~ // / "- 7a 2ta. Method of D¢positbn ^ Cremation ^ Donation 21b. Date of Dispostiion (Monet, day, year( 21c. Race of Disposition (Name of cemetery, crematory a other place( 21d. Location (City i town, stale, zip code) Burial ^ Removal from State ;Was Crematron or Donation Autlwdzed ,r ^ No Q 3 ~G ' ~ ~o? C P ? ^Y i l E I C • ~ rl.u~ y /s- ~G t ?/ /1/ f O O C ~/nv ~ -ZZ~ oroner ner es xam ^ . Speury ! by Medica - urprral Service Licensee (or person aptbg~s s~~,~~~11' j 22b. Lkense Number 22c. Name and Address of Fadlity,Jp yoy /~ LE ~ O q HG /L /tid"/I.v L /x~~M4 22a. Sgnature of F / - - c~ GL cis~~1~~ O/.~ 7 7 -L X98 nL0 rP%E~ ii AJ ~L '9r/~9 ./J~/.1~ .Yi re Items 23ac ody wtwn cerlilying 23a. Tome East g4Qiy jgorAedge, death_gaured~atWehrerOate.~d slated. (Signatae ant title) 23b. lkense Number 23c. Date Signed (Monet, day year) physidan u rat avadabk at time d deem to ~-/'f I~ ~ `i ~ 13 J ~' I`z~- ~/7 r k.k - ~ ~j Z Cti t ......... ceratycauseofdeath .._._..__._. r ..... 24. Torte of Death 26. Dale Pronounced Dead (Modh, day, Year) 26. Was Case Referred to Medical Examiner I Coroner for a Reason Other man Cremation ar Datatbn? ~ kerns 2x26 must De completed M persat ,' who pmawces death. 2, (~ ~ GJ ~M. ~Gl~rtvl.G~ 2)l 'ZJ:J: ^Yes ®No CAUSE OF DEATH (See instruetlons and eeampks) r Approxirele blend: Pad II: Eder Omer akvairant caxlilbm rgrttribAim b death, en b Part I i rt i m d 28. Did Tdceaa Use CararblHe b beam? ^Yes ^ Prabady ~E~-diseases, itjudes, a cantp6plins - mat drecily weed me deem. DO NOT enter temwal evens such as cardiac artes4 r pact b Deem Item 27. Part I: Enter the ~Nl . v e urr ng cause g e y but not resullbg ur . respiratory arted, a vednalar fbiation witltod sharing the etiobgy. list a1y one cake on each frw. ' r ^ No mown r ItIIMEDIAE CAUSE Fral dsease a ~ 11 ~ (( f r . I) a-a~T 1-v r+\ 1 vlt,4,t.1 ,~. ~yUtM un- ~u ~-~ ( mrrdlbn resulting b ~eam) 1' Y-c-'~U-1 ('Li,~c~ "'~G"'~ 29. h Female: nant witltin pad year ^ Noe re , , ~ r ~ a. p g d ): Dice b (a a p ~ r (~ ~ (' , ^ pregrart at tine d death v /L ` ~ ] ~ ., i garry tislandtiare y~C twrttial Se \ Ft~i(M 112 M b ` ~ `-~~~r 7Y~~lti. _ , , g y . . . 1 I (.~ r li r ^ Nat Pra9pd, rid pregnad wlhb /2 days re a fearing b the wee (sled an Ftrbr flee UNDERLING CAUSE Due b (a a ~ dt: r d deem r tr~s n e (a ~C '~a L ~ / ` n~ ~T g c. -u ~ ~~ i ^ Ndpregmd,bdpre9~43traysblyeu Due b (a as a omsequence ofl: r before d~lh a ^ Urknuvn if pregltard wits the l~ Y~ . d 30a Was an Autopsy 30b. Were Aubpsy F'rrdngs ' 31. Mamd d Deatlr 3~. Date d Injry (Monts, day, Yw1 32b. Descnbe How Irp'ory Omrned 32c. 0 ~ Bu Q g ~) Street, Fadary, Pedanwd? ari Available Prig b Caryld d D dh? C ~„(_ ^ l alve e d ^ Aaident ^ Peltditg Imestigabat 32d. Time d Injury 32e. Input' d Work? 32t II.Transpatadon Iryory ISpecily) 329. Lacatiat of Injury lam. dh' 1 torn, shale) ^Yes [`~ No ^Yes ^ No ^Yes ^ No ^ Dmd I Operator ^ Passorger ^Pedesbian ^ Suidde ^ Cadd Nd be Dabnriwd M 07ra- Spedly: 3 33a Cedfior (drxk Wt' anal 3b. Sigmlae Tdk d CeNfier ' Cadlryhy phyeibWl (Physidan corMyitg wee d deadr when aglher physidert has praaatced Beam and wrpleted Item 23) ______________________________ ^ deMllomaredduebMecweele)mrdmamaesetoh~ e T fh h k l d td __ my now e g , o e ea • PrawucYg end adlryyy phyekien IRryskian boor praauuing deem and wldying b wee d a1eaM) 3 ^ 3c. Licatse Nurbd ned (Manor, day, year) 33d. Date S g rolhebestdmylapwkdge,dMllaavrtedMthedme,deb, andplaa,alydauebtllewuHslandmamerassMed------------------ v i~~ti1S1 ~S ~. ` _ ~y/V~w 2$ 2t~7~r • MedkdEseminerlcaaler l1n IM Wsk d enminetlar end I a Naaligetiorr, b my opMon, deatlt occurred # the tlme, date, end plea, end dire to the easels) and maxrer as stete4 ^ 3 4. Name and Address d Person Who C Cause d De (Item 27) ,Type 1 Print ~ l ~ ~ S ~ ~ Dale Filed (Monet day year) 36 *~ wl~.~~ u ~ G~bw~c, - Nariba _ I ~ I ~ ~ n I Z-i 35. Flegisbar' and 'L , , . 3 - 4 ro C .td ; j// 91~c?c~f,.oe~~L JPR~ - ~ ~ ~ ,~r~ - 0 ~~ ;,~ ' O Dlspositon Permit No. (~ ~ / T G ~ J