HomeMy WebLinkAbout04-21-10PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF ~c,~.m~xxlar~d COUNTY, PENNSYLVANIA
Estate of ~ ~ct.~ ~'1G.~ 1PX File Number oC.'~'~' y `~~(3
also known as
Deceased Social Security Number a0~1- v~b - ~r ~ l0'1
Petitioner(s), who is/are 18 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
(State relevant circumstances, e.g., rentmciation, death of executor, etc.)
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after
for probate was not th t~ f
in the
.., :.,
~ ~, ~ . _
N ~' _, -
,:: i' . ! J
,it(s) of~cr•~dw::-~
> e vtc tm o a ktlltng and was never adjudicated an Incapacitated person: ~~ ~":` ~ . '
_~
~/ Z,.
l~ B. Grant of Letters of Administration ~J ~ c-::_,~
(Ifapplicable, enter: c. t. a.; d.b.n.c.t.a.; pendentelite; durante absentia; durante n:inoritnte)
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
Administratioi:, c. t. a. ord.b.n.c.t.a., enter date of Will in Section A above and complete list ofheirs.)
PA
Decedent was domiciled at death in ~ C~ V1 County, Penns lvania with his /her last rincipal residence at
(List street address, town/city, townsliip, county, state, zip code)
Decedent, then ~ years of age, died on _ 7'0~~- Oq at L ~~,r ~ oi- ~od, ~p'Mt, CO~r ~A~,,,, P.4
Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property $ ~} 3~ 3,'] p
(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:
Si nature T ed or rioted name and residence
-~-e~r,n~ q L~,r.~
1._ a rd ~ners .A t "~..
J'R~'t~'S ~ - KEc..c..~-~.
So ~ ~~ , i U
Fa•u, RYV-03 rev. 10.13.06 ~:
Pagelof~.,~~~~
;~t
~,
(COMPLETE IN ALL CASES:) Attach additional sfTeets if necessary.
Oath of Personal Representative
COMiV10NWEALTH 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 affirmed and subscribed
before me the ~ ~
day of
~O~u
For the Register
x
Si a re of Persona! Representative ~ A~ r-~~
~ `.}r
" ~
...~ ~ R" s.1 ...
-~
Signature ojPer a! Repr entative ~~'~;~ "'~--
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Signature of Personal Representative -}
-rj W -- ~''"'
~~~
G?
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File Number: ~ -~ ~(~ - ~~~~
Estate of ~ ,Deceased
Social Security Number: ~ n q - ~~- la j (~ ~ Date of Death: ~ -~9 -~
AND NOW, ~ d/(~ , in consideration of the foregoing Petition, satisfactory proof
having been presented before me, IT IS DECREED that Letters YY1 `
are hereby granted to ~, ~Q Q~ (~ ~,,,~ ~D„ ~ . _ n ~ nn ., ~
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 ............... $~•oC~
Short Certificate(s) ........ $ lp . (`~
Renunciation(s) .......... $
... $~3
... $
... $
... $
... $
... $
... $
... $
TOTAL .............. $
in the above estate
Register of Wills
Attorney Signature:
Attorney Name:
Supreme Court I.D. No.:
Address:
Telephone:
Form RW-U' rev. IU.l3.U( Page 2 of 2
OCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00 Ilttflft,,,,rr~~~~-------, This is to certify that the information here given is
,,ytt~~~p~TH OF p f~~~` _ correctly copied from an original Certificate of Death
~~~~ o _ l~ duly filed with me as Local Registrar. The original
;,,- _ ' : Z certificate will be forwarded to the State Vital
~ s -~°~~ a Records Office for permanent filing.
P 15657602 =-0~~9~-
Certification Number ~~"9l!HENT
;~!43 RE'J 11:2006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
+PE : PgINT iN
'SLICK NKT CERTIFICATE OF DEATH
FiSBB IflSt~laCtlAfl3 9flfl AYAmnlna nn .a.•a.en1
g~sfrar /r"~ Date issued l
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t. Nartw d Decedent tFast, made, last, suMixl 2. Sex J Socw1 Secunry Number 1 d Death )Month, tla , ye!`rr f •- Y +t
~ Age Mast dnntlayt U year Under 1 yy 6 Dale of &M iMontn, day, year) 7. Brrtttplace tCiry arw state w for countiyl 9a Face of Death tCnecK Dory onel
8 xrOrieta Days r•ours M+turas • HC;:.iwl: Other: ,
Z Yrs !Q " / ~ t~ AN V K ~h l D ^ Inpatient ^ ER r Outpatient ^ DOA Nursing Hane ^ Resdence ^Ortrer
' 80. County cl Death 3c. Gry. 3oro, wp f Death 8d. Facllily Name )If not ~nsbtutton, ryve sUeM and 9. Was Decedern of Hispanic Ongtn? ~.yo ^ Yes 10. Race: Arnercan IrttlN7t; Bladk. WIWe. etc.
~ w ~ lu Yes. speciry Cuban. (SCeuht~
V M ~"' IfA."V~ ( V r O Mexican, Pueno Rican. etc.)
t t. Decedent ; Usuar Oce erart IK.nd dl work dent Jun nest of wwkm Ida. Oo riot ;late rewetll 12. Was Decedem ever m the t ~. DBCedenl'S Educatron (Specify orny hugnest grace complatedl 11. Marna) Status: Horned. Never Marr;eJ, 15. Survrvmg Spouse !If wda, give maWert name)
Keno d Work KuW of Busatess ~ Indus U.S. Nmed Forces? Widowed. D>vwcW (Spea/y)
uY ~ Elementary /Secondary (0• t 2) Codega , t ~4 or 5.) ~
~- ^Yea W e~ __
t6 Decedents Maaxtq Aowess ISueeL city: town, swt~~ Decedent's Drd Decedent
/ 8~ ~ ~m0 f•- e rictwl Residence f 7a. Stale Live u1 a 17c. Yes. Dxetlent Lntd in I Tw
n C 'V Townstup~ P~
~- ~ G JfJ ~_ 170. County () ~ ~, 17tl. No. Deeedern UveO wtmet
Actuar Lunils d Gry; Boro
tB Famer s mt tF rsz rbae. !ast, su ~ i ~ ~~ 19. Maher's Name Ifust. m~ao'e Hoiden surname)
l` ~ U~ .~• (~3~G~Ie
20a. Informant s Name ype - Prxu) 200. kdwmants fAarletg Adore Street, cry i 1own, Swte~Otle)
r-~ QrP,cc~ ~ ~~o~e A--,~Ne('s aL_. l73zy
~ 2t a Method d Di ^ Crematan ^ Donatlat 2tb Oate of Dtsposrtan tMonth, day, year) 2tc. Place of Oisposiuon )Narw •JI cemetery, crematory .X otMr place) ltd. Location tC~ry :own. state code)
8una1 ^ Rerttorar from State :Was Cramatbn « OOnofibfl AutA«ized Q' •~ L 1 /,.,,, •,~ , {/~^)~ / y~
^ Omer ~ Sbealy : Oy lkdical Eaarnirter / C«oner? ^ves ^ No V '~ ~' O ~ ~11(~I Q V1 r(~W ~/ ~A NG~ i I' ~•+ >~' l N ,'v (~~ Q f 71.C/
•
'2a. Sgnawre ,r al nx a .xensae tw rson ac;n as h) 22b Ucense Numtar 22c. Name and Adlres5 d Faahry __11 _
t or ~- ~ ~I/ ~ ereo_( ~5c1 S Art/s~ , ~~,. /7 ~ r
Items ~ „Ny when cerbfytrtg 23a, To :re Jest of , Deam occurred at tfte tune, dale ono pWCe stated. j$1gr1a1urs arw,'ttk) , 23b. License Nirrtber 23C. Date Si
pny ,riot avalabw al time d deem :o n 1 ,~ •y, ~ ~ ~ w 1 goad i MOntn, day. year)Q C~
wrory cause d seam. Cy J'~ a-" W I"~-l- ~ r N ~ r` 1v 2 7~ t{ ~. ~ ~' ~ ~'~ Z 1 Z, ~~ ~ 1
trams 2326 must W conydeted oy parson 24. Tame of Deam 25. Data Proratwtcetl Dead iMOnth, day, year) 26. Was Case Referred to Meacalcxammer ~ Coroner tw a Reason Cmer man Cremation w Datatany
weed pronounces seam. ~ •• ~„ •r M Z ~ r 1 C.A Ct 9 ^ Yes t,~No
CAUSE OF DEATH (SN instruction and aaamplts) , Approximate r:errar Pan II: Enter diner ~anificarn wlat .Horn vmg',o=earn, 28. Dd Topacco Use ConmbWt to peaN?
item 27 Part I Enter me ~Ytain of events - Olseases, .ryunes w comWtcattons -that duecey uuaed tM deem. DO VOT enter terminal events strtlt as carttwc arrest. r Onset to Deam out not re n the undo
respvitory arrest. or vwWtcular hondatgn wilhdul sftowrrtg the audogy. List ordy Arts C7uae on aeon Iwte s ~mg' rlYin9 cause given in Pan I. ^ves ^ Ptotudy
t ~NO ^ Urtltrgwn
WIAEDUITE CAUSE .Fowl asease w r r
canatron resuaing n oeaml -~, a. P4 ~k . >^ L C to x ~' s •e,a .!
~' r ~ ~ r. 29. If Female:
Oue to Icr as a consequence ol): t
Sequenitarry lest cw,attons. 4 any. b. r (,5~1~ot pregrtarN wimp past Year
o me cause .itietl on woe a. t
^ Pregrtant at tarn. d tkath
enter t UNOERIYtiIG CAUSE Due ;o .or as a consequence d): t
~asease a ayury that Hoot me r ^ Not pregrwnt. oW pregnant wNwt 42 nays
events rasudmg ,n ,learnt LA~i. c, r d rkath
• Due .o ;ter as a cbnsequence oq:
• s ^ Nw wegnarn, out pregnant 43 days to t yeti
d r
, oerwe seam
^ Unxnown d pregnant wiflan tM peal yw
30a Was an A,aocsy 3(A bYere Autopsy F~nangs 31. Manner of Death 32a Date of I u ~MOnm. Ja
Performed' Avartaoie pow to C r h ry y. year) 720. Descnoe How Intury Occurac
dntplencrt ~ 32c race dl Inwry. Home. Farrn, Street, Factory.
of Cause d Deam Ly Natural ^ Hom~cx7e GMKe Budang etc. jSpeary)
^'+es :ad ~ ^ res ^ No ^ AccWenl ^ Pendng Invesugatidrl 32d. ,ime cal Iryury 32a. In)ury at'NCrx ~ 32t It'ranspura cn ~rlury tSp~rh' 72g. ',;,cation of Injury Street. ary :own ;oriel
^ Swede ^ CouW Na oe Determrted H ^ Yes ^ tvo ^ Dover G9'etw ^ Passenger ^Peaestnan
Gtner ~ cec^r
!3a i;ane:er ~crecx :niy ,:nti
• Certifying phyaiuan ; W ysKran cert~h;mg .apse ,r ;earn when another pnystaan Has pronounce0 daatn and ~;mpiettd Item 237 )~ ~ ,
To tiN best d my ttnowNtlgt. death occurred due to the cause(s) and manner as sated_ _ _ _ _ _ _ , iL - (~
• Pronounnng antl uMlytng physKtan ~ P! ys~c an Dorn prortcuncmg Jeath and ceNhying to ruse of deals, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
-;. ...F
To the best d my knowNtlge, death occurred at tM carne. data. amt --• --~. _ .: >. i~mcer _ 3~J Da;e igr9~ !ACr:n :;~ ,ea:.
place, Mtl due 10 lfw cause(s) and manner as stated_ _ _ _ _ _ _ _ _ ~f ,.
• Medical EaamuNr / C«oner ' - - - -' - - - M ~~ /` •~ 1 •7 LI D ~ /+j7 - S ~. ._ C L~L ~~
On ;he Wsn d eaam and! or :nvesugation, in my p ~ n, death occurred al ifN time, dale, and plsce, and due to IM causes) and manner as sbled_ ^ l•, 1.
~`r ;4 -- 4,k7re5 ~ ':;r: T/nG'~: :ie'ad r- use '.I :~9o'n ~n.7 7y~t ?...
36 C 12 ~ :7 'r 'nln Jay di!
- a 9 _ - ~ ~~'S Crt.i,;~e lr+-~(, G°,-a~~Cur„~ `~ t7~2~
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