HomeMy WebLinkAbout07-23-09PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF ~~ , _ COUNTY, PENNSYLVANIA
Fstate of ~~~ (} ~'~J~
~-d-~"- File Number ~ ~ } ~-~ ~) ~~~
also known as _
Deceased Social Security Number
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE 'A' or 'B' BELOW:)
A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is /are the
last Will ofthe Decedent dated and codicil(s) dated named in the
tv
~_ c-~
~.7 ~ -.
(State relevant circumstances, e.g, renunciation, death of executor, etc.) ~ ` ~~- C7 r-- -
`~ i-rt R~
Except as follows, Decedent did not many, was not divorced, and did not have a child born or adopted after execution of the instititry~pt(s) o~ed
for probate, was not the victim of a killing and was never adjudicated an incapacitated person: ~-' _
B. Grant of Letters of Administration T7 W
T~ _~{
(If applicable, enter: c. t. a.; d. b. n. c. t. a.; pendente lire; durance absentia; dnrante mmorttate) Cf1
Petitioner(s) after a proper search has /have ascertained that Decedent left no Will and was survived by the following spouse (if any) and hec s: (/f
Administration, c. t. a. or d b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.)
I~C~)3
Decedent, then years of age, died on t ,1.~ ~ ~~T~~-Y-YLL at ~f-~ L (/I . ~ t [- {~-~~ 'Qit ~IJC
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
situated as fol
Form RW-02 rev. l0.13.06
Page 1 of 2
(COMPLETE IN ALL CASES:) Attach dditior al sheQts if necessary.
Dece ent a o i 'le at de in I u ty, Penns Iva ~ with his /her last principal residence at _
(List street address, rown/ciry, township. cnvniv ~ ra -,., ,.,,a„i
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'
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF
SS
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 affirmQe~d' and subscribed
before me the V ~ day of
Jam.
For the Register
~( ~ i
Signature of Personal Represe ative « °
~
~ ~ _.
c~
.:a
_
i7
~~ _
G....
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Signature of Personal Representative ~` r"' ~ "
m tea
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File Number: ~ ~ Q~ ~~ 5 -w
Estate of ~~,~~ ~ ~ ~rleS ,Deceased
Social Security Number:
AND NOW, ,
having been presented be e e, IT IS DEC~r ED th Letters
are hereby granted to ~~Q lrl {~_ ~ I.}l~'C~~~'; J I
Date of Death: ~~ S a y ~ ~r~
~+ ~
c~
C~J
in consideration of the foregoing Petition, satisfactory proof
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
Letters ,.~/.... $ ab - as
Short Certificate(s) ... a... $ ~•d~
Renunciation(s) .......... $
CP ...$ ~o
~~ ... $ 5
...$
ster o Wills ~
r
Attorney Signature: i `
Attorney Name: ~ "~ J
Supreme Court LD. No.:
$ Address:
... $
... $
... $
$ Telephone:
... $
TOTAL .............. $ ~~, "4~
X ~~_
of Personal
in the above estate
Form RW-02 ren. 10.13.06 Page 2 of 2
~~~fb ~~~~~~~~~~ ~
105.905 REV.(3/091
This is to certify that this is a true copy of the record which is on file in the Pennsylvania Department of Health, in accordance with
the Vital Statistics Law of 1953, as amended.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
~~ ~ d ~~- ry~ ~ ~~.
Linda A. Caniglia
State Registrar
J ~ ~ 1 ~ 2009
No Date
/I F~ N~ L ~~ l L ~"~ Uh~~ -
H1~2>-R~ COMMONWEALTH OF PENNSYLVANIA a DEPARTMENT OF HEALTH a VITAL RECORDS ~~~ /~j`_.~_~~,
TTPERRw*IN CERTIFICATE OF FETAL DEATH
PERMANENT
BLACK INK I n. DATE OF DELIVERY (MO/Day/Yr)
t AME OF FETUS (optional - a[ Ina discretion of tna parents) 2. T ME OFD VERY 3- SEX (M/F/Vnk)
. C e 2 J .-,e O o2 ~ % (zahr) "J i I~1Gi..< d !c {GTc' ~:
Sa. IF DELIVERY OCCURRED IN A HOSPITAL. ENTER HOSPITAL NAME Sb. IF DELIVERY DID NOT OCCVR IN OS PITAL. CHECK THE Tv PE OF
PLACE BELOW AND COMPLETE ttJ K 8.
J--~{rte /~7{ // i r/) ~ ~' C i~ ~C/ _ o F omaara ~iyarBirtn~¢nr ctn¢ ¢I~,r.r at r,nr.,e az o No
I D I PI" -d d ~ o Y
J '~ o CGniUDOdor's oIT
Facility ID (NPI) T ~ ~i- O Other (Spacily) __-___
-__- - _
ia,ai ~ CITY. BORO OR TOWNSHIP OF DELIVERY e ZIP CODE OF DELIVERY
8 COUNTY OF DELIVERY
,l~Clcc~~i i n ~ ~r/'y i who ~ '703
,._ ...~ru RO c r^.IIRRENI' LEGAL NAME (Fires. Mitltlle. Last. Suffix) 9b. DATE OF BIRTH (MO/Day/Year)mn
THER'S NAME PRIOR TO FIR T MARRIAGE (First, Mitltlle. Last, Suffix) gd. BIRTHPLACE (Slate. Terr/itory, or Foreign ~.ounu
~~ yl
~1
3c MO ~Q- Yr ~~
F Q • ~
{Y
10. WHERE DOES MOTHER ACTUALLY LIVE? DOES MOTHER LIV
- E IN A TOWNAS~H^IP? 1 `
f ~ ~~ `[•!r~ t ~ }Gri
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~
t ~ -_.-...IwP
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tOa. State I-1 _ 1 Oc. Yes, motn¢r Irv as
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.
f
r:itY/noro
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w ~o.x~lC
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lad. No. mower oye limits o
s wttnin ___..._- -. ---. -
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1ob. cpanty anm¢nt Numbar:
A - __-_._ _.-._..
aveat t I ran r pin ~t
1 oe. complete n~mbe, and_ _ _
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p
- _ log. ziP coda i7 0l3 -
-___-. _---
1of. cay/BOro
t On. If not United States, country
Suffix)
Last
Mitltll
t1b.DATE OF BIRTH (MO/Day/Y
ear) 1tc. BIRTHPLACE (State. Territory, or Foreign
Country)
,
e
1ta-FATHER'S CVRRENT LEGAL NAME (First.
\
1
c"r.e. s
n r D.--,
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12a.METHOD OF DISPOSITION:
O Removal from States
O Other (Space y _ _-
---- - - --
Burial O Cremation O Hospital Disposition O Donati on
PLACE OF DISPOSITION (Name of cemetery. crematory or other place)
12b l2c.LOGATION - Gity/TOwn, Sl ates. Zip Cotla
.
C~-••.be~larr( ~(et.lley Y)ne.-Y,o<:~ ('
)e
l PFF I ?v 15
rc~e ~S
13a. SIGNATURE OF FUNERAL SERVICE LICENSEE OR PERSON ,s
r)-~
tab. LICENSE NUMBER
(of Licensee)
ME AND ADDRESS OF FA/CILITY
/) ~~ ~iZ+~~ ~/UI"y`s~
~-art
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I
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Agp,TI~NG~/A UGH C UL
• n
• ~
• s • •. ~
s
~ TITLE' ~ MD O OD O CNM/GM O OTHER MIDWIFE O OTHER (Spec)
17. DAT FILED
16. REGI TRAR'S SIGNATVRE AND NUMBER ~ '~
B. GAUBE/CONDTTN)NB CONTRIBUTING TO FETAL DEATH
18b.OTHER SIGNIFICANT CAV SE/CONDITION
t Ba.INITIATING CAUSE/CONDITION gan t
(Among tna cnolDes below. Please salad tna one wnicn most like y ne sequence oT
enter reaulbng in Ina Wa[n of the fetus)
aterial Condi[ions/Diseases (Specify) ___
Material ContlitionalDiseeses (Spaciy)
...~~~aas~~~
/~/ ~ /y
DO YYYY
-- ----
Complica[lona of Placenta. fiord or Membranes Gomplicanons of Placenta. Cortl or
embranes prior to
f Membranes
Dose[ of labor
~~
m
p Rupture o
O Rupture of mambrenea Drior to onset of labor ^
/
)
~
O Abrupl~o placenta
~/
~
O Abruptio Dlacenta f "
1
O Placenta insuKCiency ~
~ 7
O Plr.canta InauTlGencY t "\
~
O Prolapsed cord
b ~
~•.J
o Prolapsatl ~
o cnorioamnionlna '; -~ (
o cnonpamnionnls ~
~ `
~~ I ~ S
( ~~I~rn ~e-~-t,t o Dtner «Pa~.) --
.,~• - ;
- -
p( omar (specify)
aciy
S
ti
li r
rte`
_
) tT
Otnar Obstetrical or Pregnancy Co
S
aciy)
b p
ons (
ca
mp IV
-
p
la (
Otnar Obstetrical or Pegnancy Complicat •
1 ,r~1
V _
•
'~
~
t w
J~j _~_
e
A.r
Fetal Anomaly (SpacAy) _. --'
-
-~ ~ 1 ~
~
Fetal Anomaly (Specify)
- _
.-__-.. _ `
/ -.
.~a-!~ ~y--~---.~
\1
T1
if
S _
-_ -_- -
~
-~-.1ai
Fetal Inlury (
pec
y)
Fefal Injury (Spacily) ^.. -
_^
-~V
Fetal Infection (Specify) __..- -- - T
F=~.~__~r!
Fatal Infection (SDacity)
V
r r
omer Fetal condniona/Diaortlars (sPenay) - _.. ~ -------+-.-_
~
Otnar Fatal Conditions/Disorders (SDaclry) ' ^
""~
vl _.... J
O Unknown
o unknown
tBa.ESTIMATED TIME OF FETAL DEATH t
WEIGHT OF FETUS (grams Drafarrad, specify unit)
18c
8f. WAS AN AUTOP
SY PERFORMED?
.
o labor ongoing
n ~T O Daetl at fret assessment, ament.
L Rj ~yc ~ ~ O prams ~ Ib/oi p paatl at bma of frsi assess labor ongoing
fQ vas
WAS A HISTOL
D No O Plan natl
OGICAL PLACENTAL EXAMINATION
OBSTETRIC ESTIMATE OF GESTATION AT DELIVERY O Diatl during labor, after firs[ assessment
18tl PERFORMED?
.
~ Unknown time of fetal deatn
3 jit Yes ~ No D Plan natl
/7 (completed weeks)
/ • WERE AUTOPS
8 Y Oft HISTOLOGICAL PLACENTAL
~ s was delivered dead on tna date statetl above (#4)
f
t
i 1
..
EXAMINATION RESULTS VBED IN DETERMINING TIIE
e
u
s
18n.1 neroby c diN Lo
~
•
-i
~ CAUSE OF FE TAL DEATH?
~
Z ^
~/~
~~
, A~ /~ ~'~Y•/ // / /i' i~ - C• v 1q'Yas O No
N •
- SIGNATURE (Physic/e C xon o~Med Examine/ DATE
0 DDRESS
/ `~(/
CONTIN TIED ON BACK
DISPOSITION PERMIT NO. ys.p~
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