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HomeMy WebLinkAbout07-23-09 (2)PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF WILLS OF ~I f1~If IQn~ i COUNTY, PENNSYLVANIA Estate of x I !,[~ 1(~l ,( ( ~~~ File Number 6 ~~ also known as Deceased Social Security Number Petitioner(s), who is/are l 8 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 of the Decedent dated and codicil(s) dated named in the era ....~ - ~ = ~~ ~~ `~ (State relevant circumstances, e.g., renunciation, death of executor, etc.J `- j ~- fin,. t""" ` ~., ~_ ~ .__ ~ rn N 4 _ ~ .. Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the ~~t s o `~ O wed for probate, was not the victim of a killing and was never adjudicated an incapacitated person: ~' -~~:~~ -,~ i ' . ;.:J ~ ; . ` B. Grant of Letters of Administration ---I V? '' (If applicable, enter: c.t.a.; d. b. n. c. t. a.; pendente life; durante absentia; durante r>i`inoritate) tw3 - 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: (If Administration, c. t. a. or d. b. n. c. t. a., enter date of Will in Section A above and complete list of heirs.) 1~©~3 at de in l.U,l -11~ Il~ I ~(~ Cn~ty, Penns~,vaui~ with his /her last principal residence at (Lrst street address, town/ciry~ township, county, s te, ., p code) Decedent, then years of age, died on at 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 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: (COMPLETE INALL CASES:) Attach~ddition`al sheets if necessary. Form RW-02 rev. 10.13.06 Page I of 2 Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA : SS COUNTY OF 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 affirm~ed-1~a..n~d subscribed before me the CJ day of .~.dL.. For the Register x ~--_ SigngtaXe ojPersonal R ~ ( UCC,~~ Signature of Personal Signature of Personal Representative ~ -_~ ~~ ~~~ ~ ~.... __~ w ~ €~r3 N _~C.7__ ~ .~ W File Number: ~ ~ Q~ ~~~-+ ~ . bhes ~ `~ Estate of ~ Deceased Social ecurity Number: Date of Death:_ 05 ~ ~ ~~~ AND NOW, ~ l0 ~~ in considera 'on of the foregoing Petition, satisfactory proof having been presented be a e, IT IS DEC ED th Letters are hereby granted to ,~ ~~,/ r ~ i rtylt rlno_ and that the instrument(s) dated described in the Petition be admitted to probate and filed of FEES Letters .......,,~?~.... $ ~ • ~~ Short Certificate(s) ... a ... $ ~ , G~ Renunciation(s) .......... $ P ... $_ ~e ...$ ~ ... $ ... $ ... $ ... $ ... $ ... $ ... $ TOTAL .............. $ ° "U'60 in the above estate as the last(''~Il (and Codicil(s)) of Decedent. 'stet o Wills ~ Attorney Signature: Attorney Name: ~ - Supreme Court I.D. No.: Address: Telephone: ~' - a, ~=' _ _r:_~ ,~ l ,~ , . ; Form RW-Ol rev. 10.13.06 Page 2 of 2 I (~-<'~~ ] 05.905 REV.(3/09) 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. Linda A. Caniglia State Registrar .5049305 JUL152009 No. Date p,~ ~ ~~ ~ ~`~ " ~l~ F~NI~L H105.024-REV. 12/06 COMMOWWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS ~O ~~~~-C~~j CERTIFICATE OF FETAL CEATH ttI6AGK nxt 3 SEX (M/F/Unk) 4. DATE OF DELI ERY (Mo/Oay/Yr) 1. NAME OF FETUS (optbnN - at the dlspetbn of tM panne) ~ ~ ^ Q 2. TIME OF DELIVERY Q ~ a ~ (24hr) r/ TQ...` L7~r ~ov f7~ t 9 I . 6a. IF DELIVERY OCCURRED IN A HOSPITAL, ENTER HOSPITAL NAME 6b. IF DELIVERY DID NOT OCCUR IN OSPiTAL. CHECK THE TYPE OF PLACE BELOW AND COMPLETE #7 & 8. ~ / r _ /_ ~ ~ / : C~Q ~n -~~ ' O Freestanding Birthing Canter { Cu ~- / ~/] ~JlA ~j 1 O Home DelWary: Planned to deliver at home? O Yas O No I I 131 ~1 ~ J O Clinic/Doctor's office Facility ID (NPI) O Other (Specify) BORO OR TOWNSHIP OF DELIVERY 8. 21P CODE OF DELIVERY CITY 7 , . 6 COUNTY OF DELIVERY MOTHER'S CURRENT LEGAL NAME (First. MktdN. Lest, Suffix) W OF BIRTH (MWDay/Year) E 9b. DAT . rr ,, f"~ ~) oe. MOTHER'S NAME PRIOR TO FIR T MARRIAGE (First. Mbdb, Last, Suf(Ix) 9d. BIRTHPLA E (State. erritory, or Foreign Country) ~ YtLL ~ ' WHERE DOES MOT~•IER ACTUALLY LIVE? 10 DOES MOTHER LIVE IN A TOWNSHIP? ~ ~ t ~ 1 ~ ' . - IrJ 1-1 10a State -c wP~ n ~ c Nor ~ti 1M toe, Yes, mother lives In city/boro. tOb. Count ~ L-~~C tOd. No, mother lives within limits oT ~n r ~ Apartment Number: t f iJ' toe. Complete nu^mber and street 1 ~ ~ 10g. Zip Code__ ~ 7 U I ~ t Of. City/Bon ` d r t ~ ~ 10h. If not United States. a~owtb!• 17 •.FATHER'S CURRENT LEGAL NAME (First, Mk1dN Laat. Suffix) 11 b.DATE OF BIRTH (MO/Day/Year) ttc. BIRTHPLACE (State, T~rntory, or Forofyn Country) • 12a.METHOD OF OISPOSmON: ' Burial O Cnamatbn O Hospital DlsposHbn O Donetbn O Removal from State O Other (Spec? 12b. PLACE OF DISP081TION (Verne of oametery. crematory or other platy) 12e. LOCATION - CHy/7own, State, Z{p Code Cvr••be r larc( ~m.1~ty Wltrrtoc •~ ' ~ ~cle ~ U l5 CO-r l . le (-~- I . 13a. SIGNATURE OF FUNERAL SERVICE LICENSEE OR. PERSON 13b. LICENSE NUMBER e) f Lk 14. NAME AND ADDRESS OF FAQ ILITY l il lL• A TINO UCH xsnss (o ,, r7 /-~r1'C±.~CII-(C [ l f~ l0e. r t_ _ O i 18. NOA I E, AND NPI: NPI: NAME: TITLE: O MD ~ OD O CNM/CM D OTHER MIDWIFE O OTHER (Specify) 18. REGI TRAR'S SIGNATURE AND NUMBER ` 77. DAT FILED ~~/ ~~ / V+ ~ DD YYYY ~ s, eo~vn~o To FeTw~ DEATH 18a.INITIATING CAUSE/CONDITION 18b.OTHER SIGNIFICANT CAUSE/CONDITION (Among the ohobes below, please select the one whk#t most likely began tM segwnoe of want t>•iultlnp In 1M death Of Ua fetus) Material CondiUona/Diseases (SPectly) Material Conditbns/Disaassa (Specify). Complleatlons M Placenta, Cord or Membranes Complieatfons of Plapnta, Cord or Msmbrenss O Rupturo of membranes prbr to onset of labor _ O Rupture of membranes Prbr to onset of labor fff//~11\))) ~~~' •^ ~ O AbruPtb Pleeenta . O Abp PIS ~ l O Plaoertfa InwflbNney iv(1/. O PlacenL Insufficiency w. !" 1 • 1~ D Prolapsed cord ( ~ ~ O Prolapsed cord ~ ~.~ .. i ,~, O Chorloamnbrtitls + _ , O Chorbamnbnitis ~ ~ r':.~j ~ ~ - r~ j ~ { _~ '' _ti e S S-{' ~ I l .~x,rn o Other (Speciyy) Other (BpeotfY) ~ ,_t,,,~ ~ ~ _ '• i ~ `.'1 J ~ Neatlorts (Speolly) OtMr ODStetrical or Prepneney ComPlicatbns (Specify) C .i .. ~.~ Omp Other ObeteVleal dr Propnarley _~ ~ ~ X' ( Fetal Anomaly (SPacIN) Fetal AnomeN. (SPedfY) " ~ ~'^~ .,..J f ~. "' ~7- ~:..f~: Fetal Injury (SpeeHy) Feral Injury (SPeeMy) ~~-- ~aa--. -I.7 ~ -7-~ ,,:.~ - Fetal Infection (SpeeHy) Fetal In}sctbn (Specfy) ~ h -A•/ . ~y s a ^, r ~ OtMr Fetal CondKbns/Disorders (Specify) OtMr Fetal CondHbnWDisordsre (Speciry) ~ / ~ ' p --y ~ :.) O Unknown O Unknown 180. WEIGHT OF FETUS (grams preferrod, specify unit) 1Be.ESTIMATED TIME OF FETAL DEATH 78f. WAS AN AUTOPSY PERFORMED? O Dead at first assessment, no labor ongoing ~ Yes L 8 /.Z ~ ~ O grants ~ Ib/ru oing labor on nt O No O Planned g , O Dead at time of Rrst assessme 189-WAS A HISTOLOGICAL PLACENTAL EXAMINATION 18d.OBBTETRIC ESTIMATE OF GESTATION AT DELIVERY O DMd during labor, after first asaeaament PERFORMEDT ,~/~ (aOmPMtsd weeks) ~ Unknown time of fetal death xYes O No O Planned 18h 1 hereby rtlfY this fetus was tleliwretl dead on tJte dab statetl above (t114) 18i. WERE AUTOPSY OR HISTOLOGICAL PLACENTAL EXAMINATION RESULTS USED IN DETERMINING THE ~ FETAL DEATH? F p j~ CAUSE O / ~ -- ('~~ Q ~ r ~ y. Y~ D O No to ATE 610tVATURE (PYrytNafis/b AriMeo'4sxem/ner/ .. ADDRESS DISPOSITION PERMIT NO. ~,~~ .Z~ CONTINUED ON BACK