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HomeMy WebLinkAbout10-19-09PETITION FOR PROBATE ANL) GRANT OF LETTERS REGISTER OF WILLS OF ~~ M1~~.Lf4FV~ COU'~tTY, PE~iSYLVANIA Fctate of M`~~'Nr'~=~'~"\/\ C. R/~'M.C7 File Number ~ ~ ~1~ ~~ v / also known as ,Deceased Social Security Number ~~ "I " ~ C.' _ ~~~C{ ~" Petitioner(s), who is/are 13 years of age or older, apply(ies) for: (CO;~IPLETE 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 relevait circwnstances, e.g., renunciation, death of execitor, etc.) ' - , ~ ~ '.-') Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the-ipst{umen offered `~ _ ~j for probate, was not the victim of a killing and was never adjudicated an incapacitated person: ' r i .-^ ~~~t © B. Grant of Letters of Administration - -~- Qfapplicable, enter. c. t. a.; d. b. n. c.t.a.; pendente lire; durante abseiuia; durante ttirt~oritate) ~J _ J --' • • ` :=, Petitioner(s) after a proper search has /have ascertained that Decedent left no Will and was survived by the following spouse (if any) iOlieirs:~ (If Admitristratiott, c. t. a. or d. b. n. c. t. a., enter date of Will in Section A above and complete list of heirs.) Name Relationship Residem-e ~ (COiYIPLETE IN ALL CASES:) Attach additional sheets if necessary. Decedent was domiciled at death in CUM3~f21-A~st'~ County, Pennsylvania with his /her last principal residence at ~S~ S~ i~r\;•w •X ~=~ t~cL~ ~(~; ~. GI'~l2.L1 ~Z,E r.4 )l7 c'» ~ (List sweet address, towidcity, township, county; stale, zip code) Decedent, then ~ years of age, died on ~ E 'CJ ~ at lfe~-'jl~ 77~F~)~=~L ~-~^"'~ ~_ ~~ ~ ~~ Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property $ '.-1 ~ ~' ~ (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 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: Sisnauire ----~ Typed or printed name and residence- _ PIS ?'~' /~- - 17~' 3 ,~•v~~ a~-~~,,~ )i6 s'?~'w,x cQ ,gyp; 2 ~~s~i.,~'~ Form RYV-0? re». 10.!3.06 Page 1 Of ~ Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF Glf,Mt~~RL~tN i~ 'The Petitioner(s) above-named swear(s) or affirm(s) that d1e statements in the foregoing Petition are five and con~ect to the best of the [cno~,v[edge 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 f ~ ! . ~ra_ or th Register r`~ -.. ? r'--a' -r~ SfgnntureofPersatalReprEsentnrive i ~ r : -) r--- ~ J F-~ ~~.. - -: j 7 ~~ ~ Signature ojPersonal Represeruative ~ ~ - =~' - - .~; Signature of Personnf Representative .~- ti O File Number: ,~ ~ '-~~ ~ ~ ~ ~' Estate of iMEU M~ SAC `~1 i L ~ ~ t"+ ~ ,Deceased Social Security Number: 1'-(~ - C7 - `f ~ ~ ~ Date of Death: ~/ ~ / .~C t~ ~ AND NOW, , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters 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 Letters ......... ...... $ Short Certificate(s) ........ $ Renunciation(s) .. ........ $ ... $ ... $ ... $ ... $ ... $ ... $ ... $ ... $ ... $ TOTAL ...... ........ $ Attorney Signature: Attonney Name: Supreme Court I.D. No.: Address: Telephone: Register oJWiRs Form R4V-0' rev. f0.f3.0( Page 2 Of 2 ,,~~, ~~,~r LOCAL REGISTRAR'S CERTIFICATION 01= DEATH WARNING: II is illegal to duplicate this copy by photostat or phatog:•aph. F~°er~~r ifli~ cclEl#ir,tt~. ~.(~'t(±~ „ ~?!t OF ~ ' Thl~ is [Y, tielril~ l.lt Lhc ini~,rnl I~ ~+r) h lip , ,, ~~~~, E y ~~ L7~ rectl~~ ,,L11~ L L' II n? Sul LJn final ( 11i III I,t Ih.T[i~ ~` ~~ ~ f•' ~ l ~l CjUi~ rtiett \~Il,l '.ls .L> I. Tt .,i IZc I , !E j'}~ ctrl lna ~ ~ c,lutlca[e ti>.)i~ t ;I,r~~ (l~~eei r i~l~° ,fate ~~t~zl z; ~`~ y , 7ta .~ IZect)r CIS {)III<'~ # z~;(ill lt.'1f Ili7n`'-. P 15838308.- _ Q~ , ,I,. ~ !~~k~~~~s ("ertill~~lisOn ~tullhc-~ ~,,,,,~ V "~_ll>~ 9~~u~Li ucal Rc~);,r.lr~ rv _ .... _ ~ J . c,?': ~? 7 ~? - ~I ~ _ ~ -- i., - -;-j ~,.0 i. ; ~ _ -~ ^3 .-fir _I~1 - r au~ -~ .. . _ I - ' 3"_" . q r,m6u~keY umuo COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS TaeFr.t?~,emr" CERTIFICATE OF DEATH BLACK tad (See instructions and examples on reverse) STATE FIIE NUMBER (1~ J 0 I Name of Decedam IFusL middle, lass. wnixJ 2-Sax 3. Sa:ial Security Number J Dale of Death jMonln, tlay, year) Remo Mehmedovic Male 177 - 80- 9694 5 Aqe Mast &nhdayl Under I year Under I day 6 Dala of BIM (Month, tlay. year) 7. &nnplace IGry ant dale a foreign country) Sa PWce of Death IOheck only one) 59 ~ritr' °"' wa~i' kt,,i„> June 25 1950 Hospual Dinar. r M111C1 Bosnia rrs Inpatient ^ ER I Outpaeenl ^ DOA ^ Nursing Home ^ Residence ^Omzr - Speedy. 8b County of Ocalh Bc Clty. Boro, Twp of Dzalh dd. Faclliry Name (lf not inslilulion, give s0ee1 arW number) 9. Was Decedent of Hispanic Origm7 ~NO ^ Yes /g Race. American Inman. Black. Wn4e. etc 111 res. speedy aban, I SpanM Cumberland East Pellnsboro Hol S irit Hos 1 Mexican.PuenoRican,elcl ~r• I I Dscednnrx Usual Gcu tltm KuW of work m aw dim mull W wvAil Ina Lb n.N stale retired 12. Was Decedent ever n the 13. DecedenYC Eduwlion (Specify only hignesl grade compl eted) 14. Marital SlalUS'. Married, Never MarnM, 15. Surviving Spo use 111 wile, give maWen normal Nuid W Wak Kind W Business I Industry U.S. Armed Forces? Elementary /Secondary (U~12) College (7-4 or Sa) WWOwed, Dnorcetl (Spealy, Con9ruction Bulidin ^Y°~ g]NO 12 Widowed 76. D..etlenrs Maibng Address (Slroel. city ;town, state, zip code) Decetlenl's Did Decedent 4 ~~ Slala PA five in a 770 Decedent Lned in Nrnfl+ w-•~+•~ Tw ~ Yes l Resid nce ^a Ad 716 Stanwyck Circle Apt#2 , . p . ua e Cumberland T°w°snip? 77d^N°,oa°¢d¢nlLwadwnnln Carlisle PA 17013 17L Co°°" Adaal Umik°' Cnyy Born IB Famer's Name frn;t middle, last xiAix, 19. Mother's Nyme (First, middle Wen w ) Hakija Mehmedovic Me7ra Me~imec~ovic 2ga Irdormanfs Name IType ' Pnnp 2W. Inlormant's Maikng AtlUress ISIreeL city I town. slate. zry code) Hamid Mehmedovic 716 Stanwyck Circle Carlisle PA 17013 21a MemW W Osposuion j [] Cramatmn ^ Donation 2tb. Dale of DisposiLOn (MOnm, day, year) 210. Place of Dlsposilion (Name of cemetery. crematory or other placer 21d l.ocalion (Gry ll°wn. stale, zp code) L7 ~Bwiel ~ kentoval tiom Stave ~ Was Crsmalion or Dunalion Authorized trier -Spin ~ OY Medical Examiner I Coroner? ^ Yes ^ No g-1 1 -2009 Rovasi Cemetery ROVa$i Bo$nla 22a Signor Funeral a Li ee on aOUnq as such) s > 22b License Number 22c Name and Address OI Facility _ ~ -~( FD-012662- Myers Funeral Home 37 E Main St Mechanicsbur PA 17055 Gom7 to Ito <onry wean cemtying a. To the be' I my knnwletlgz de°m a;curred al me time, tlate and place sorted (SlgnaWre and title) 23b. License Number 23c Date Signe0lMOnth, day year) pnyxician is iwl avadaae et rime of death la ceniry ca se W loam person hems ,~ 2ti Torsi lie roinplztzd b 2°. Time °t Dealn 25 Dale Prorwuriced Dead IMonih, tlay, year) 26. Was Case Relarratl to Medical Examuier I Coroner for a Reason Oltrer Than CraAiallnn or Oonauon? y th h y 5~ 1 x F~ /' l k~ 1 l ^Ves '~~Flo o pr°noun~is uza w , / . M. ): 47 ~C IJ Ji' ~'(i it l T CAUSE OF DEATH (S theft 11 d nples) r Ap1u I 't +al Pan II'. Enter wn 5ty1)1n;yr il G41~LSR75 GsnlL4ylln51 IV ilealh 28 O-diTW,acco Use mr bate to Deam? n . r I a1 I t II L~LI VIE s_le d yui es a m ryl I 11 tl e~lly' - J the d- 11 DO NOT a ter Icr ti lal eve M si ' es cardi, c a est. 0 sal to Daalh bur nui insulting in Iha underly ny causn g van in Pan I r sir Yes ~ ably /-' eap ale y ar c>t w vcnlr ~Ula I0i Ilel on writ Dui show ly n v ct: tgY t et ly ari a muse on eesh li te- ^ No ^ U 4 ow IMMEDIATE CAUSE Final d,:.ua>e w r>J1 nmg 3 mi _~ a L/•~11. ~ . vV -2 /. 4 'rC~ I~ ~L S C L t ~ r~ ~ Yl. 29 II Female. l - ^ N - ga ~ ml. Duel ( z ~a b4-Ify asl dl 11~ U ~U(l lti ~ -- 1 ^ ~-/ k~_ ~1.a,. ~y~/ ~ L Z 'i„!L ILS •Mr'L ~ w~`•.+ I~ 9 art n yar Ip V ^P g~ rail l°~tn I JyI Ue isleU.a+lx Dual Sul 1 1 " ' ' ' ~ f"'' ~ ~ ~ Nal 1 ~ 1 ul a Mail in J.'d.iy> C-hitlaUNDERLYING LAUSE , ~T~ ka raay~~~//~L ~~,1, Yank .a,~ ~r ~ r /~ ~ , j ~ itluea>e ur wpry ILat unenic° Thor r ~ L Y/ 4i IA ~ Y , '' y q p 1 Y a-4 i~ ` ~C ~~1/ lC 1 ~ ~ I~ of IlaaO J I +eua rz;,dua u, ik~.do LAST. Duo to lu as e c • +I e %JL /~, /J T~~/ y~ ~ ~ ~/ ~ ,{ 4 1--IF , a~-,~,4 .( ~ ~ ~ r ^ Nul praynanl. bur pioyiwnl JJ days lu 1 yore before deem d. _ r'/) ref V l W ! ~ ~ Y / 1 I4% 7• \ I-~ UnkMwn it pregrienr wilhiri the past year 30a Was do Autopsy 3(Ib Were Aubpsy Fntlings' 71. Manner of Death 32a. Date of Injury (k7onih, 09y, year) 320. Describe How Injury Occurred 32c Place W h9urY Moore. Farm, Street Faaary. PeA„mtad^ A+a~la0le Pnci to Compieuun °t Cda.e UI Dealli? ~/'' ~l~I~~ial C. ~ Honii[ide //~^ Otlice Bunning, etc t5peayyl [ ] 4, lcni ~~ P,. w y In+asligal un 32d Tune of Iryury ffie. Injury al Work? 321 I Trensponal on Injury Spea7yl 32y. La:el on W Inlury ISlrael, city/ town. stale) tors ~NO ~ ~ Yes ~,~ N° ~ Could Nut b ^ J udz ~ e Determined ^ V°s ^ N° ^ Dr vzilOperalor Berger ^Pedcsuwn ~u . M Omer ~ SVealy: 3" G H a Icne k - ly ~ I sa 330. Signalwe r. Vile I Bar e - • LenilY 9 Phy lPl y. - f q - t d an yr, t p -d d~elh a td co. pletetl Ilan 237 e d Ih cu add f In s l) d ScMt d. _______________________________ k led To theb 1 1 , g Y • Pronouncing end cenilymg pnycWran jPt yoca bolt I r° l w g Teeth ar d mly rig to cause of dealhJ ^ 33c License N .Dale Siynetl IMmm, day yeah 6 To IM bast of my knowledge, death ocwned at Ina umo, dale.. and place, and due I C lO lne causals) and manner as sblad_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ~ n a I ~~ ~ •/r ~ ~ •, () (~ ~ r/ • Medical Examirwr uroner On the basic of examination and I or inveshgaU°n, W my opini..n. deem occurred at the lime, date, and place, and a°e to me caueels) and manner as sbtad_ ^ 34 Nnnw arM AcWilS W Pe Who Completed Cause of Deem Iliem 271 Type I Peru ~ ~~x• G •T i5 R . r; Siynalure and Dilna Number l ~ 2 I (I~ I ~ t - i 36 Dele EiWd (Month, day, year) ~. ,e.~.le~ Z u ~n[n,r< ~u~~ rrrr~'2 i w~ N r : n-~c . v ,-. o r , '1/ U Dispr,sninn Perron No Q3 S~ Q ~ O wary-~ trlt ~ I-.~:~ 1?a ) az}-; RENITI°~1CIATIOi~ ~,., -, ;=~ :_ __ _ a.'...5 . ; REGISTER OF WILLS _._.l C~~ M ~~ L r:~N p COUNTY, PENNSYLVANIA ~ - ;~ Z,L, , „ ' l I -~ j ~ - C j ~ ~ \I -v -i `~ / / ~..? 'i ' a"'" , O Estate of f`~1L. l~ Nib ~~,.~.tC ~AM~ ,Deceased I, T`REI~N~L:. L~ ~w ~ r_ ~A2 ~N\ ~ , in my capacity/relationship as (Print Namz) ~r~.V C-~WT~ 1~.. of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to j~~ih~1~~t_~,1 L ~A a1Nl ion i~ %:~~c (Date) Executed in Register's Office Sworn to or affirmed nd subscribed befo~r-ey m~e this ~ day Deputy for l~eg>ister Wills (Signature) ~1~ `~rfi~'vy~X Ct~CLE Ali ~ _ (,Street Adrfre.cs) Ci'r QL.\ Sim P~ ~-1C; 13 (City, stare. zip) Executed out of Register's Office purposes stated within on this day of Before the undersigned personally appeared the party executing this renunciation and certified that he or she executed the renunciation for the Notary Public My Commission Expires: (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission.) Form R;~-06 rev. 10.13.06