HomeMy WebLinkAbout01-20-10PETITIOI~,T FOR PROBATE AND GRANT Off' LETTERS
REGISTER OF WILLS OF ~~''- ~~` ~~cl~--~ COUNTY, PENNSYLVANIA
Estate of ~, ~e~~IkS'
also known as
Deceased
File Number ~ / v ~ ~/~~~" "~ v
Social Security Number 'Z a ~ ~ 3!0 - ~Q ~~
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COtb1PLElE '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
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(State relevant circumstances. e.g., renunciation, death of executor, etc.) --". L.. i` ~~ '•~.~~'
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execdtu~izlat~e instrtl~'tnent(s)`:offei'ed
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for probate, was not the victim of a killing and was never adjudicated an incapacitated person: ~ .~ ~-- ~ "3
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It. Crant of Letters of Administration N~i¢ - ' " _'
(lfapplicable, enter.• c. t. a.; d. b. n. c. t. a.; pendente life; durance absentia; dur~ minoritnfe ,
Petitioner(s) after- a proper search has /have ascertained that Decedent left no Will and was survived by the following spouse (if an~and Heirs: (If
Adrrriuistration, c.t.a. or d.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.)
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(CONIPLE7E INALL CASES:) Attach additio~tal sheets if necessary.
ecedent was domiciled at death in C~-ti~,.i~-,-.e~ C~rnty, Penns~vania yvith his, /her lad princ~al residence at ~L 3
(List street address, to-wr/city, township, counh~, state, t(p codeTTy ''" ( '
eceden hen y rs of age, died on •~Htl[Q (o a~10 ~/"L~~ ~~~?'-'~
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ecedent at death owned ro ert with estimated values as follows: ~~
P P y
(If domiciled in PA) All personal property $ ~i ~~d `
(lf not domiciled irZ PA) Personal property in Pennsylvania $ ~~
(If not domiciled in PA) Personal property in County $
Value of real estate in Pennsylvania /Vp/l9 ~~~~ ~ $ '~"' s
situated as follows:
Form R6V-0? r~,~. 10.13.06 ~ Page 1 Of 2
named in the
Wl~e~~efore, 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
COMi/IONtiVEALTH OF PENNSYLVANIA
: SS
COUNTY OF
The Petitioner(s) above-named swear(s) or affirni(s) that the statements in the foregoing Petition are hve and con•ect to the best of
the knowledge and belief of Petitioner(s) and that, as personal representati (s) f the ecedent, Pe • oner(s) will well and truly
administer the estate according to law. ~~ ~~.~ n-
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Sworn to or affirmed ai d subscribed
~~(~,. Signature of Personal Rep,•esentnlive
day of
U - ~~
Social Security Number: ~v '' ~~ ~ ~`-~ ~ Date of Death:
1 _ 'l~C ~~ i /~
AND NOW,
having been presented be
are hereby granted to -
satisfactory proof
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:,
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in the above estate
and that the instrument(s) dated
described in the Petition be admitted to probate and filed of record the last Will nd Codicil(s)) ecedent. // ~,~
~~
FEES
~~ Rzgist o •Wills
Letters ............ .. $
Short Certificates $ Attorney Signature:
Renunciations ` ~ ~.~,. ~ ~
$ Attoniey Name:
... $ ~- ~ Supreme Court LD. No.: ~ ~~ d ~ ~
... $ Address: 3 Z C~ a ~/~ V f ~/l~ Y' 1 V ~..
... $ ~
... $
... $
... $ Telephone: ~ ~ 7 ..- Z3 ~ ~~ ~.
... $
TOTAL .............. $
Fur,n RW-D? rev. 1U.13.U(
me the
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Signature of Personal Representative ~' ~ c~ • ~--'
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Signature of Personal Representative
Page 2 of 2
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
hee for this certificate, $6.00
P 16053663
Certification Number
~H10S143 REV 1112006
TYPE I PRINT tN
elra
1. Nara a Decades (Fret, middle, ba, wffbt)
David M. Adams
5. Aga (Lea Brgaey) under 1
fdorrme ~
57 vra.
Hous I asnaee
l,,~t1,,f~~'''a~~H OF pf'
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This is to certify that the information here given is
correctly copied from an original Certificate of Death
duly filed with me as Local Registrar. The original
certificate will be forwarded to the State Vital
Records Office for permanent filing.
~:,,~ y~~ JAN 8 2 1~
~.ocal Registrar~.~ ~ Date issued
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
(See Instructions and examples on reverse) STATE FILE NUMBER
2. Sez 3. Soda Serxuity Number 4. Data d Deem (Morten, day,
M 209 - 36 - 402
1
ttb. Couay d Deem lJc. Cqy, Sor0. Twp. d Dagt
t ~ C,~nberland Mt . Holly Springs
sate retire
i~
I
11, pendant's Vaud eon Kktd d rrork done mat d Mb. Dona
KMtd a watt Icr,e a Swirtas/ Irtdwtry
Foranan Railroads
18. DecedeM'e MeiWtg Addreea (SVeet, sty /town, state, zp cads)
423 Chestnut Street
Mt. Holly Springs, PA 17065
18. Patter's Noma (First, rrwdde, ba, sulfa)
Sylvester C. Adams
2l>0. Irdonnartts Name (Type I Print)
Brenda L. Adams
21 a. Method d Oiepoaition r I~Cremeticn ^ Donation
^ ' Autltaiad
1952 Carlisle, PA
Bd. FaciWy Name (q not ineUtirMort, glw street and amber)
ro. 423 Chestnut Street
12. Was Decerbnt ever in the 13. Decedents Edtaxitbn (Spsdty only
U.S. Amwd Fon:ss7 ElrxnenWY / Sceortdery (D'1~
^ Yea C~ Ne 12
Decedents PA
AcWd Residence 17a. State
17b ~ C1IITlberland
appal: Cher:
HgatlsM ^ ER / OWpegeM ^ DOA ^ Nurskg Hans I~ Realdertca ^ Other - Sparely:
9. wee Decederd d wep.Nc Origin? ~{Ne ^ Yes 10. Race: amedart trtdlart,131eck, wNb, s1c.
(N Yes, epetdly Cuban, (sP•pb')
Mex~art, Pwrb R+~an, e~.! White
is aarnpWed) 14. Marital Stall: Married, Never Mentsd, 15. Survbkg Spares lq ~, 9N• ~^ name)
(1-4 a 5+) Widowed, Divorced (Spedly)
Married Brenda L. Shim)aker
Did I)ecedenl
boa shlp9 17c. ^ Yes, Decadent Lived in T'"~•
_ 17d.C~ t~ adwimin Mt. Holly Springs cny/~
19. Momer'e Name (Fire, nMdMe, maiden surname)
Batt - Strine
20b. Intomrants MdMrg Address (Street, ay I loam, sate, :1p code)
63 ".G" Street, Carlisle, PA 17013
Date a Dbposition (Matra, day, Year) 21c. Place d Disposition (Name d rmtebry, crematory a abet pace) 21d. Location (Cityl kwm, stab, zip code)
^ 13taral RemarahanStab ~ yes ? ~[Yes^ No 1 19 20 0 E<7aI1 Cr ri
^ otiter
22a. Sigrtetirre d Funs ce Licensee (a per ~~ ~ 22b. License NtaMu 22c. Name and Address a FedMly
~ 7 FD 012633 L Ekain Brothers Funeral Ham, Inc., Carlisle, PA 17013
Complete iMrro 23ac ony when rerlgyirp 23e. To the bee d my occurred at tits time, dab place sated. (Sigrtebre and tilt) 23b. License Number 23c. Date Slpted (Madlt, der, Year) I1
phyaNdut fs ncl available a time d death b 'Dr9~ I~ ` . ~ ~ ~ N -~ ~Q ~- y~ a ~ t/
aroy cause d dash. ~ a 9~,/
name 2428 mwt be completed by perean 24. Tkne d Deem 25. Date Prrarorsred Dead (Monet, day, Year) 2& wee Case Refers b Medics Esantkter / Caawr br a Reasm Omer Cremetlon a Donetiort7
who pranatna dean. .S ~ ~ M. ~Y ~" ~Cv ~ 6 l ~ ^ Yea .. "0. .
edervd: Pad II: Enter otlter ' 28. Did Tobacco ilea CatUibub to Dedh7
CAUSE OF DEATH (See Instructions artd examples) t APPb ^ Yes ^~
Itsrn 27. Pan 1: Enter tiw disin d events -diseases, iryraies. a aanplintiaw • mat dirscgy caused the dam. DO NOT enter lerrnind events such ae cardiac erred, ~ Orteet b Datlt but rot rasWtirg in the urwbryktg cease given Mt Part I. .!F'
respirefay arrest, a vearlaYar IlbriMation wdhad atbwing tlr etidogy. Lief sty ate cause on each Mne. r ^ No Unknown
c• i 29. If Female:
~Ep111TE CA~g~ F ~ disease a ~~ //~ / _ •~Q. r
condtion rosuWnl In ~) } a • ~~F'~WW r ~*/~ ~ ^ Not pregnant wkhin peat Year
r 6~ °~ ^ Pregnant at time d dash
Dw as a r
Ma caWtlaa, N arty, b, ~•• 1t ^ Not pregnant. hW pregnant wigtin 42 days
k~iN a cause Magid m 9na a. n 7y d dea9t
w ,
Ertbr tWWERLYNKi CAUSE on: d
(disease a ma irdMabd tits c. ~~- Vr/Q CCM- r ^ Na pregnant, but pregnant a3 says b 1 year
events r.aulYng`'~' In deem) usT. o a (a m ~~ ~~-~ ~ baare d.agt
~~ r ^ unknown it pregtent wimp tit Feat year
d. ~ ~
30a. Was an Autopsy 3~. Were Autopsy Findings 31. Merrta d Deem 32a. Date d ~Y (Monet, day, year) 32b. Describe Hav Injury Ocaxrad 32c. Piece of IrtJtrry: Florae, Farm, Street, Feday,
Penarrwd7 Availade Prbr to Completion ~( Ogice BuikMng, etc. (Speclly)
d caws d Deam7 ~811~ ^ ~"ic~
1-,/ ^ AaideM ^ Pending Investlgatbn ~' TMne a ~Y 32e. Injay at Work? 321. N Trensportatlon Injury (Spadly) 32g. Location d inpay (Street, city I town, stab)
^ Yss~No ^ Yes ~ ^ Yes ^ No ^ Drtvet/OpefalOr ^ Pessertper ^ Pedestrian
//////~~~~^^ f ~s ^ Swdda ^ CoWd Na be Deremined M. abet -specify:
33e. Ceniger (dwJdc oNy one) //+ ~ ,.
• CertNying physkbn (Physician cenNying cause of deem vdten Brother physician has pratotatced deem end txvnpbted Item 23) ~ ~. S e ~~ VAS /~ ~/
To the bsN a my knowbdge, death occurred dw to Ute cause(s) and manner a etatsd - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - N 33d. Dab Sign (Monet, des er)
• Prorauneing and arrtltying phyaklen (Physkien both prorwundng deem and cenifying b cause of deem) S OD ~ / ~ D!
To ttre bee a my Nnowladge, datllt orxurnd a the tlnw, dMe, and plw, and dw to the pus(s) artd manner a aWsd_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ i7
• Medical EsamMer/Coroner
On the bash a eaamMabn and / or InveaUgatlon, m mY opptlort, dam occurnd at tM tine, data, and place, and dw to tM nua(a) and manner as staled.. ^ 3~4.'Na~me`and Address d Person NRa Canpk+ted Cause Deem (Nam 27) T !Print ~ 0 f O
3s.Regia ~ `wr and r- / /~ 3s. FMed(Monm,day yar) V ~~1~I ~+ ~-~a ~ D D .
~ bZ.l / I~--I ! I v I ~ 1~ /~-0l oZ/rT /~ u~ ~' /G
Dlspodtion Permit No. O ~~~~'" T / • • /~~ ~/~ ~ ?~ ~'
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RENUNCIATION ({(~,~ ~:;~~~ ~~~
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REG TER OF WILLS
~~ ~ ~r ~ h COUNTY, PENNSYLVANIA
02... /-- /U - ~~.XO ~
Estate of
I,
.~
La u v~~ ~
Deceased
in my capacity/relationship as
(Print Name)
of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
~^en~ L~
~ ~ fl
(Date)
,, ,t ~ -__
(ignat e) ~ --
~` ! ~ ~ ~~C
(Street Address)
(City, State. Zip)
Executed in Register's Office
Sworn to or affirmed and ubscribed
befo e this ~ day
of ~
,.~~'
,~
r_ eputy for e i ills
u/
Executed out of Register's Office
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 day
of ,
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.)
S
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Form RW-06 rev. 10.13.06