HomeMy WebLinkAbout03-19-10 (3)Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA SS
COUNTY OF CUMBERLAND
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 affirmed ands bscribed
before me the __ ~ /y~ day of
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For the Register
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Signature of Personal Representative
Signature of Personal Representative
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Signature of Personal Representative ,~;
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File Number: ~ ~ f ~u ' , ~ ~t~
Estate of SHIRLEY L. PROVOST
Deceased
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Date of Death: MARCH 4 2010
Social Security Number: 166-46-4294
f` /~ N'Q , in consideration of the foregoing Petition, satisfactory proof
AND NOW>
having been presented before m , I IS DECREED that Letters OF ADMINISTRATION
are hereby granted to PAUL R. WHISTLER in the above estate
and that the instrument(s) dated
described in the Petition be admitted to probate and filed of
FEES
............... $ 135.00
Letters
Short Certificate(s) ........ $
Renunciation(s) .......... $
JCP .. , $ 23.50
AUTOMATION $ 5.00
... $
... $
... $
... $
... $
... $
... $
163.50
TOTAL .............. $
as the last Will;(and Codicil(s))
Attorney Signature:
Attorney Name: ROGER B.,~RW ,ESQUIRE
Supreme Court I.D. No.: 6?82
Address: 60 WEST POMFRET STREET
CARLISLE, PA 17013
Telephone: (717) 249-2353
Page 2 of 2
Fnrm RW-02 rev. 10.13.06
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNlN[,; It is illegal to daaplicate this copy by photostat or photograph.
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~~' This is to cerkify (l~ai the inform 1lIt1Sl here given is
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;,1'y~~s d,4 -\ con~ectly co~~ied fro n an 1~ri~~inal (rrltifics.)t~ of Death
`~,'~'~ ~`~~-=~ dj.)1} 'tiled ~~iti r,)e .IS Local Registrar. The orininal
~' ~~I rertificaTe will he frrr~~arded to the State ~''ital
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4103.1M REV 11f1006
TYPE 1 PRINT IN
PERMANENT
&ACK INK 1132-218
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CORONER'S CERTIFICATE OF DEATH
(See instructions and examples on reverse) STATE Fn F NIIMRFR
1. Nam, d Demmnl IFad. middle, last, suHxl 2. Sex 3. Sodel Semrny Numrr 1. Date of DaeM (MmM, day, year)
Shirley L Provost Female 166 - 46 - 4 March 4, 2010
5. Aga Itmt &rtlMey) Under 1 Untlu 1 day 8. Dale d BIM Monty, day, r) 7. andpbm um slate or br epi eau ) 9a. Plan of Deets (Dheck one)
58
Ym. Mwww ~"' ~• ~~" September 4, 1951 Cumberland Co. y PA
^ Irpalbnl ^ ER / Ou~edent ^ DOA ceder
^ Nurdrg Hans Residenm ^OMer ~ Spudry:
eb. Cmnry d Deetll ec. Ciry, Bon, esp. I Drlh Bd. Fualny Name (n nd instltlNon, give dwd and mmeer) 9. Was Demdenl d Hispanic OmUln7 [~ No ^ Yee 10. Race: Amariran In9en, Black, Wtab, dc.
Cumberland Penn 22 Lebo Road (n yes, epedry Cohen, (speaily)
MexKwn, Puerto Rken, ero.)
11. DeWM's Usml Kintl d woe d ale mod d Yb. Do inl stab 12. Wee Decedent ever ro IM 13. DueMas Etlumtion (Spedly ody highest pule axnp lded) 14. Memel Slade: Marred, Naves Marred, 15. Surviving Spo use pt wile, give maiden name)
Kbtl d Wom KFN d Bmhwv / Indeby U.S. Amwtl Fame? Elememary / SemMery (0-12) Cdbge (1~ w 5+) yYldowetl. DNOmed (Speaazllyy
Fuel Cashier Truck Sto ^Yr C~Na 12 Widowed
- iB. Demtluil's Addier I5brl. dtY / bwn, sbb, zip axle) ~Demderd9 Did Decedent
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22 L Road e
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a ,?a, g) vas, uemdrl laved ro peer) Twp.
Carlisle, PA 17015 17h.Canry Cumberland Tovrtwhp? nd.^HO. Demmmlivetl whhin
Actual lirnls d Cny / Bao
18. FeMer's Norm (Flan, middle, last, euMxl 19. Mmwr's Nam, IFxd, middle, maiden surname)
Paul Whistler Catherine Brown
20a. Inlamwnl'e Ham, (Type / Pnm) ZOb. Inlormanye Maning AtlGrs (SbaeL mY /lawn, stab, dP mda)
Paul Whistler 58 Lebo Road, Carlisle, PA 17015
21 a. Metlnd d Dlaposnlon I [~Cnmdron ^ ppMgm
- 216. Dale d Dhlpoaitim (March. day. Year) 21 c. Race d Ohpmitlan (NUm d mmdery, aemetay a onwr pbm) 210. Lannon (Cny / bvm, slate, zip mtle)
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2010 Hoffman-Roth F~.ineral Home & Carlisle, PA 17013
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not ave7eble d tlme d dxtll b
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- Ibnw 2428 rmW m omiplged M pawn ~• Th^e d Death 25. Dab Pmwaicea Deatl (Mash, day, yrrt 26. Was Car Referted b Medkal Examiner / Caawr br a Reason Omar men Crematbn a Dawrn7
,' wta pmrwuimedrM. pLX. 3:00 P. M, March 4, 2010 Yea ^No
CAUSE OP DEATH (See instruotlons and examples) , Appmximeb irrrvd: Pad II: Ewer other ' 29. D'd Tobum Ike Domrwde ro Death7
new 27. Part I: Ewer the ~ d evaas- dbemr, Wun••, a oorlpnmtlane - tliu AreNy named Ida am1n. DO NOT aibr lamina) avenb such r mreac anew, r Onsu ro OrN but nd raiAWg b Me undedyiryy muse 9N•n n Pan I. ^ vas ^ Pmhady
feapwlory arwq, a vuwkdar flhMatlon w'hlldn nMM'dlg the elrorogy. Est M1J am Ceur m each hne. ~
^ No ^ Uromwn
Probable Pulmonary Embolism l
E~ld ~a Hypertension 29.rcFemele:
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Dm b la r a cansequerxe op: ' ^ Nd Regnant wBtln past year
h~et mrlmiarw,Nury, h.
npeoaltly
b~i~une
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FrIYr 91e UNDERLYHI
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Avenls reu4kMigfi~dmMi ~~ c. l a death
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Oue to (a r e axwequence oQ: e ^ Nd pwgnar4, bd pregnant 43 aye w 1 year
d l blow daub
^ llraoxwn A pnpbnl wilhn the pad yrr
3r. Wes r Aibpey 30b. Wee Adopsy Flndnge 31. Manna d OrN 32a. Data d 4yury (M"M, my, Year) 32b. I3esmlw How ~Y Ocmrretl 32c. l'bm d hqury: Ibnw, Fein. 91weL Fsaay,
Pedanied! AveXWb Prbr b Canpletlon
d Luse d DeeM7
~ Netaal ^ Homidda Olnm BuR6q, eR. ($wa'y)
^ Vas ~ No ^ Yes ^ No ^ Apdtlent ^ PerHng Inveeagaeon 37d. Tins d Injury 32e. Injury at Wom? 321. rc Tranaponatlon Injury (SPed/Yl 32g. Lomtlm d Injury (Select, mY / torn, elate)
^ Sukide ^ CouM Nd ba Delenrkned ^ YB5 ^ No ^ Omer / ~BfBta ^ Paerngu ^Padedden
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• Pranoaicdl9 arW mrBrylrq Phylcbn (PhYakian Iptll pralwwilg death and aadNn19 ro mlue d deaN)
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