HomeMy WebLinkAbout12-14-09PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSYLVANIA
Estate of CHAD E. BANJAK
also known as
File Number ~, - 0 Q - ~ ~ ~ o~
__~ Deceased Social Security Nttmber
Petitioner(s), who is/are 18 years of age or older, apply(ies) for: ~ ~ :~
(COMPLETE A' or 'B' BELOW.) ~ p r~-z.,-! - j
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^ A. Probate nerd Grant of Letters Testttmeetary and aver that Petitioner(s) is /are the ~' ~_ ~~ ~::-;;
last Will of the Decedent dated and codicil(s) dated rr=r' ~=~ _" ~ri `'~
~-it
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_ (SYare relevmn circwtrstrnrces, e.g., reraarciatiorq dearth of execator, etc.) -.~ -~-t W r s F~ i
Except es follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after exewtion of the iostrumcet~offered -~,
for probate, was not the victim of a killing and was never adjudicated an incapacitated person:
I~ ®B. Grant of Letters of Administration Decedent died without a Will and was survived by his nattttal parents Allan E. and Lisa S. Banjak and
Ali M. Barijak, sister. Ali an~/'appJicable,erUer: c.t.a; db,nc.ta; pendentehte; dmuueobsentia; awmuenrinorirate)
AlJ~.n n ak renounce Admin~s ~a or inav~and Lisa. S B k., tf and heirs: (If
Pehhone~s~ai~er a p~ seatrdt has ~)Save no was survtved by t~~~owmg spouse (~ any)
Ad-ninistratron, c.ta. or db.n.c.ta., eater date of Will in Section A above and complete list of heirs.)
Allen E, Banjak Father 1837 Lisburn Road, Carlisle, PA 17015
Lisa S. Banjak Mother 1837 Lisburn Road, Carlisle, PA 17015
Ali Michelle Banjak Sister 304 Stephenson Ct, Fuquay Vatitta, NC 27526
(COMPLETE WALL CASES:) Atitach gda&dortad sheds $/'necessoy.
Decedent was domiciled at death in CUMBERLAND County, Pennsylvania with his /her last principal residence at
219 WEST MARBLE STREET MECHAMCSBURG MIDDLESEX TOWNSHIP CUMBERLAND COUNTY PA 17055
(List sleet ad~ess, town/city, towaehip, coiorty, stye, tiP code)
Decedent, then 28 years of age, died on NOVEMBER 25, 2009 at MEDICAL tJNIVERSIT'Y OF S.C., CHARLESTON, SC
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property S 20,000.00
(If riot domiciled in PA) Personal property in Pennsylvania S
(If not domiciled in PA) Personal property in County S
Value of real estate in Pennsylvania S 125,000.00
situated erg follows: 219 WEST MARBLE STREET, MECHAMCSBURG, PA 17055
Form RW-02 rev. /0.13.06
Page 1 of 2
Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presaNCd with this Pdition and the grant of ]:.afters in the appropriate form m
the undersigned:
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF C[JMBERLAND
The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true and coned to the best of
the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decadent, Petitioner(s) will well and truly
administer the bstate according to law.
Sworn to or affirmed and subscribed
before me tan: ~ Yl day of
''DYYI~Pr .
For the
Sfgnahve ofPtrsalal Repreunt~ive
SYgn~oe of'Psrsonol Repnse~ua~ive
Siignatto~e ofPaaona! Represemative
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File Number: ~ ~ _ U ~ - ~ ~~? a ~ ~ W ~ :~?
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Estate of CHAD E. BANJAK ,Deceased
Social Security Number. 17462-8397 Date of Death: l 1!25/2009
AND NOW, ~P (' 0 VY1 ~ ~ _ _ ~ ~~ , in consideration of the foregoing Petition, satisfiwtory proof
having been presented before me, IT IS DECREED that Letters ADMINISTRATION
are hereby gnmted to LISA S. BANJAK
in the above estate
and that the inshvmeat(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 ............... S Reg-ster .
Short Certificates) ....... S Attorney Signatwe:
Renunciation(s) .......... S~,(~Z
. \ ~ .. ~ Attorney Name: WII.LIAM A. DUNCAN
c1~ It ~ /Yl (L ~C1Yl .. S ~ Supreme Court I.D. No.: 22080
... S 1 IRVINE ROW
... S Address:
$ CARLISLE, PA 17013
..a
..$
•• S Telephone: 717-249-7780
..S
TOTAL .............. Q~:69'
Fon» RW-o2 m. 10.13.06 Page 2 of 2
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State Df South Carolina
s7arid air H NWnJeeN Department of Health and Environmental Control
CERTIFICATE OF DEATH
uxs:.. .,X: , .(a .:.
STATE FILE NUMBER
.5 1 DE CEDEIJT'S LEGAL NAME (InWUde AKAs, If any) (First Middle, Lasp 2. SEX 3. SOCIAL SECURITY NUMBER
___ Chad E. Banjak ale 174-62-8397
4t~.. AGE-La: t 9irihdey 46. UNDER 1 YEAR 4c. UNDER 1 DAY 5. DATE OF BIRTH 6. BIRTHPLACE (City and State or Forego Coun4yj
(Years)
Monms
Days
Hcurs
Mlnules (MM1D0/VYYY)
28 05-20-1981 Camp t-Till, Pennsylvania
0 7n. RESIDENCE-STATE 76. COUNTY 7c. CITY OR TO ~ ~~
c~
1?~,s v is Cumberland
~ anicsbur
Me
~ 7d. STREET AND NUMBER
7e. APT. NO.
219 W st M rble Street _ 71. ZIP CO 7g. INSIDE CITY LIMIT67
~~7055 ~LYas ^No
e. EVER IN JS
ARMED FORCES? 9. MARITAL STATUS AT TIME OF DEATH
C Merriea ~ Married, but separated ~ Widowed 10. SURVIVING SPOUSE'S NAME (If wife, glue name prior to first marrrlage)
~ [] Yes ~$] No ^ Divorced ~Nevar Married. ^ Unknown
LL 1'. FATHEF'S NAME (Firs(, Middle, Last) t2. MOTHER'S NAME PRIOR TO F1R5T MARRIAGE {FGSt, Middle, Lest)
9
~ Allan Banjak Lisa Sa for
z 13a. INFORMANT'S NAME
Lisa Banjak 136 REIA IONSHIP 70 DECEDENT
Motiher 1 c LWG ADDRESS (Sire t and Number, Cil , Slai .Zip Coda)
~$~3~/ West Liseburn Road, C~arlis
14. PLACEOF DEATH (Chock Doty one:.see Incvdcnona) Penns lvania 17013
c IF DEATH CCCURRED INA HOSPITAL: ~ lFDEA7H OCCURRED SOMEWHERE OTHER.THAN: A:HOSFfTALY QHospica
reGliry.
u .
$1 Inpattsnt (] Emergency RoomlOulpetienf Cl Dead on Arrival. [~ Ntasmg homeR.ong term care Ndlily ^ Decedent's home ^ Wrer(Spec.Ay)
r 15. FACILITY NAME (If rql institullon, iva ~sfree and number)
Medical Uni
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~ SC t CITY R TOWN, STA7E ND IP COb :
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~ 17. OWN OF DEATH
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16. METHOD OF DISPOSITION ^ Suds ~ Cremation 19. PLACE OF DISPOSITION (Name of cemetery, crematory, Diner place)
E ^Danatt~
0Enlortibmant ORemovathwn,atate J
Henr
Stuhr
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Northwoods Cr
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y
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a
ory
U.LO TION-CITY. TOWN, ANDSTATE 21. NAME ANO ADDRt=_SS eery U , nC.
~
' a es ton, S. Carolina OF FUNERAL FACILITY.FOT: Tho(aas .J. Geisel F.H.
N U pt1.NERAL3ERVICELICENSEEOROTHERAGENT 23.110 R(OTLicanseeJ 3.33 Falling Sprin
23e. EM L Sgnelure) 23b. EMBALMER LICENSE NUMBER 23c. LICEN5E NUMBER Of Fed
_ None None- 67
615 2 U37-. COGPLETED BY PERSON 24. DATE PRONOU CED DE (MM/DD/YYYYj.
~ 25. TIME HRONOUN Eb' DEAD
WNO O U
;$OR CHRTIFlES OEATa LL 2S 2C3C7 ,?j ~ ~ Pm
2G. 5 ~ NATURE OF AERSON PRONOUNbINCs DEATH (Doty wheh appaceble) • UCENSENUMBER 23. OA SIGNED (MMIDDIYYYY)
Sc 31.~'~ ( I l ~ .Z~ c7
29. A TUAL OR PR i1MED D tE OF TH J(~CT. ~-k
30. ACTU OR PRE MEO.TIME OF DEATH ,34.: WAS CORONER Oft MEDICAL
~
Iilb/Qnil r:J~: LVa17 2:~ / 1 Z. QO .fiRAMINSR~CONTACTED7 ,Yea No:
CAUSE t)F DEATH{See lnslrudlons ono examples) -: ~ Approxlmtlle inleivel:
32: PAR71, Enter the melt, of events-tliuaesa, Inludes, or compdcaeoru-Ihel directly cauxtl Ina death. DO NOT amer tertninel evanle such ac - Oneet to death
carotaa arrest, re4pNalory anaN, pr ven4lcWar abrilleaon without showirp lha ecology. DO NOT ABBREVIATE: En(sronly ono gauss ati a Yoe. Ado -
eddigoerel Anas9 nbwasdry. ~ -
1
IMMEOIAIE CAUSE (Final" C".}~
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d{xasa ar oondttion_~ a .JJ 1 'C. : _ '
euXieg In death) Ow W (or as a Lonsaquen a ufr.
Seq(JeeaeAy Xcl condiltonp,~it b. - -
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ih say, leading b the ®use ~ - Due to (or mm a consequwrce ot). -
fisted on IMe a. Enter the :
UNOFJYLYING CAU6E c - -
~22-- lJeeex or inl~' Ihet _ o or m a c saq ante o
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Jq PART 11. Enter other t not roaWlhg in the undMying cause ga'an In PART I. 33. WAS AN AUi Y PER Wr1ED7
: Yee No
34. WERE AUTOPSY FaiDtN0.4 AVAILABLE TO
: COMPLE7ETHE CAUSE OF DEATHS Yea No
35. DID TOBACCO U5E CONTRIBUTE 33 IFFEMALE: - 3F. MANNER OF AEATN~
. TODEATH7 ^NPl prepnanl vdlMn peal year
~
~ :NaWf91 t~
Homkida
^ Yes ^ probably - ,.
^ P!egnenl al Wm~d death _
'. ^ Nd pregnant, butpregrient within 42 tlays OfgeaN -. ^ :ACddenf - ^ Pending inveat#gapon
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~ay ~ No ^ Unknown ^ Not pregnant, but prepnanl 43 dari m ono yaw tielNa deaW -
[}
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^ Unknown 11 nent w6hin Ihs eel 9er Sukdde .
Could not be detemiinsd
38. i]ATE OF INJURY(Spsll Monih) 39. iIMEOF kVJDFYY 40 PLACE OF INJURY (eg, Darsdenfa lwrrre, consw Um axe, reateurwt4 wooded wee) 41.INJURY AT WORK
^ Vee ^ No
42. £OCATION OF INJURE: State ' Edy or Town: COUNy:
Street&Number~ - - ~ Apeomenl NUmbEy. ~ ZIp COde:
43. DESCRIBE HOW fNJURY OCCURRED: ~ : - ~ 46. IF TRANSPORTATION INJ4AZY, SPEGFY;' :
. - ~ DrNar/Operolm ^ PatleeNm[
^ PaaeeAge~: O olher(Spedyj`
: 45: CERTIF[F.R (Cheok~only~one) -
[]: Certllylnp physkl8n•TO u(~: Wal el my knowledge, deatn eeeuned tltro to the cevea(e) and mannw stated.
arMGaalytrg plryskJan-To dta WNdmyluiwvA+tlgr; detlarinaned e{~gglYrtq,ggia,ytd plea, end duB lolM WUta(a)aM marvar staled.
^ Co[oner/Medkyl Examiner-On NabMY da~VAlnaBOt1NW~IMaallytiGn~Inmyoplrlun, death occu~mdelNSYme,dW,endppp, widtlrxrb awpUUlp)iW mannaralaktl.
Stpneture of COrtifler:
46. NAME, ADORES$ AND CODE OF R2RSON PLET1Nb CAl15E OF f3EATH (Ilerir 32) 4Be. NAME OF ATTENDING PHYSICIAN IF OTHER THAN
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47. TFTGE OF CERTIFI R: ' 48.41@ENSE NUMBE {6. GATE CERTIFI D (MM/OD/YYYY) 50: FOR R0613774ATTOMLY-PATE FILEFJ }Itt6YDp/YYYY)
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SC 0077743
e
iSSU~D DEC Q 1 2D09
This is s true certi#icatien of the facto; on file in the Divisloe of Vital Records, SC Department of Health and
. Environmental GontroL
X~
C. Earl Hunter Guagg Zbao = D H E ~ (
Commissioner aed Mate l? fret. ,
Assista+it State Registrar
:_ ~ ~
This;copy is not v$Iid unlessltrepared oe as engraved Iwrder displaying the.stste seal and issuing agency logo.
PRrr4(llY PR(1 I'Y f.T PRf14'
tevision Dete: 9.4/01/2008 ~ ~ : ~ i
' '. -.: : ~~ Sn,tth Carolina Depenmrnt of Heahh
' "': - and Nnwrmtmrntal (.nninil
RENUNCIATION
REGISTER OF WILLS
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CUMBERLAND COUN'T'Y, PENNSYLVANIA ~ rn ~ ~ `:
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Estate of CLAD E. BANJAK ``
-Y .1'~ce ~
ased ~''
I, ALI MICI-IEL.LE BANJAK . in my capacity/relationship as
f~-N~I
SISTER of the above Decedent, hereby renounce the right to
administer the Estate of the Ikcedent and re,Spectfully request that Letters be issued to
LISA S. BANJAK
~~
~~
S.
~~ - ~ ~ ~
/~bs Simre
Extcated In Register's Office
Sworn to or affirmed and subscribed
before me this ~~ v q , ~' day
of _
Deputy for Register of Wills
Eau RW-06 nn. 1Q 13.06
Executed out ojRcglster's O~'ice
Before the undersigned personally appeared the
party executing this renunciation and certified
that he or she executed the renunciation for the
Purposes stated within on this U'~ day
of ~eeem bEr 200 9
,8'al,G~. Yj~~~,~---~~u
Notary Public ~
My Commission Expires: ~pv~ ~ (~ ~ 20 ~ i
(Si~apoo and Seal of Notary or other otra.W
admiahita oedia. Show data oracpieuioa of !
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RENUNCIATION
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REGISTER OF WILLS ~, ~
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CUMBERLAND COUNTY, PENNSYLVANIA ~~<-~~] c~, ~-~
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Estate of CHAD E. BANJAK • Deceased
I, ALLAN E. BANJAK _ , in my capaci~ly/relationship as
(1'rlnt Nmre)
FATHER of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
LISA S. BANJAK
rn~)
Executed in Register's O,~ce
Sworn to or affirm, ed and subscribed
bef re me this ~h day
of T ...•
uty for Register of Wills
r~~)
1837 W. LISB OAD
{Street dda6 ass)
CARLISLE, PA 1701 S
(City. Stye. Zip)
Executed out of Register's OJ,~3ce
Before the undersigned personally appeared the
party executing this renunciation and certified
that he or she executed the renunciation for the
purpt-~P~ sta*~ within on this _ ,_ _ day
of=~.~~
~----
Notary Public
MY Commission Expires:
(Sim aad Seal of Notary or otlier official qualified to
admieialer oe8a<. Slaw date of expnation of Notary's Commisaioa)
Forrw RW-06 rev. 10.13.06