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Home My WebLink About06-07-10PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF WILLS OF CUMBERLAND Estate of Leonard F CZARNECKI also known as COUNTY, PENNSYLVANIA File Number 21-10- ~ ~~~ ,Deceased Social Security Number 204-12-4780 Leonard F Czarnecki Petitioner(s), who is/are 18 years of age or older, apply(ies) for: (COMPLETE A' or `8' BELOW.) ^ A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the named in the fast Will of the Decedent, dated and codicil(s) dated State relevant circumstances, e.g., renunciation, death of executor, etc. Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the instrument(s) offered for probate, was not the victim of a killing and was never adjudicated an incapacitated person: ^X B. Grant of Letters of Administration app ica e, en er: c..a.; .n.c..a.; pe en a de; uran e a sen ia; uran a moron a e 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 Administration, c. t. a. or d. b. n. c. t. a., enter dafe of Will in Section A above and complete list of heirs.) Name Relationship Residence Susan Colteryahn Daughter PA Ronald Czarnecki Son .,.~.. PA ~ r ; ~'~' ~ +__:., , (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. "~~'~ w C:;' :~~,'",> Decedent was domiciled at death in Cumberland County, Pennsylvania with his /her last principa eat Z" `_` _~ t 411 Norman Road Cam Hill Lower Allen Cumberland PA 17011 ~- T-~ ~ '~' (List street address, town/city, township, county, state, zip code) '~ ~"' -~''1 G''1 .. Decedent, then ~_ years of age, died on 12/17/2009 at 411 Norman Road, Camp Hill, Cumberland County, PA Decedent at death owned property with estimated values as follows (If domiciled in PA) All personal property $ (If not domiciled in PA) Personal property in Pennsylvania $ (If not domiciled in PA) Personal property in County $ Value of real estate in Pennsylvania $ 139,900.00 situated as follows: 411 Norman Road, Camp Hitl, Cumberland County, Pennsylvania 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: Signature Typed or printed name and residence ~ t~=-,U~zarnecki ~ 121 East Countryside Drive ~ ~~ ,~! ~J Boiling Springs, PA 17007 Form RW-02 Rev. ~o-~s-loos Copyright (c) 2006 form software only The Lackner Group, Inc. Page 1 of 2 ~~ .% 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 and subscribed b e me this day of the Register ~~~~ Signature of Personal Represent; ~~~~ G'f arnecki ~i/~!.~~ cam/ Signature of Personal Representative Signature of Personal Representative File Number: 21-10 ~- U ~ ~/ Y .. ~_ c~ , _ ~_ ~, y°-?. ,. ... J ~ ~ ~ ~'' J' S / { { ) v ' am . ~ R~ ~ ~ ~ ~ .n~ y .. ~..` ` E/ j " F ~ ~~ .~,,,~ ~ r ~ i'"ar"i C.11 * . ~ ~ G''1 ~ Deceased Social Security Number: 204-12-4780 Date of Death: 12/17/2009 AND NOW, ~.~- 1 , (~ ~ ~~ , in consideration of the foregoing Petition, satisfactory proof having been presented,k~efore me, IT IS DECREED that Letters of Administration are hereby granted to (,~t~- p ~~~-F CZ rneCkl 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 .......................................... $ e ter of Wills ~ .. , ~~ ~ _ ~ Short Certificate(s) ....................... $ ~ ~ ~ ~ ,~;~ Attorney Signature: Renunciation(s) ............................ $ ~ , C ~- ' $ ~ `5 ~ Attorney Name: EIIZabet Snover $ > ~ Supreme Court I.D. No.: 20099 $ JOHNSON DUFFIE $ Address: JOHNSON DUFFIE $ P.O. Box 109 $ Lemoyne, PA $ Telephone: 717-761-4540 $ $ TOTAL ................................... $ f Form RW-OZ Rev. 10-13-2006 Copyright (c) 2006 form software only The Lackner Group, Inc. Page 2 of 2 Estate of Leonard F CZARNECKI li)S,,,ns KGY il)i/I L.. L~AL REGISTRAR'S C~R~'I~I~ATICJN OF DEA-'Thl `,~J/~RNiNG. ft is illegal to duplicate this c~p~,r by photostat ar photograph. (C~'~~1~ }~=ee fur this t~t~rtifit:atL~. "~(~~,~)(~ ,, ,.,,.;,~ 'rr ' -r ~i~l")i, ~ ;,°~ ~c.~t~til~~t ti,a~~~ th>` i)lt~n~mation l~h~re t7iven is ~ b r ,ttr'rss~~~Q~-t~ ~h ~'~~~,"-"-~, ' ,?i'r~~'~ X~~' `e_f,i,I~ti ~1-~?113 .317 t111'_'`lila~ ~eltljlC~:ite ~Jf Death _ - ,~'~"'~: ` ~;. )(ti~~, 4t~tit ~ ~,~)ti~l E~+: ~1~, Lt~;:al ke~~tstl-~tr. ~'he i)rt~~)nal , ~,~'~~ ~"~ ~~' ~ _ - ~)-(~i~i,~t(.' ~.~~ii"~ it4 ~trtw,u-t.Eec1 t{1 the Stale Vital , . sj ~ ~~ ? ~.~~ ; ;'; ~ 'i ~ i~;~L~tn-~!~ E ))1~i~c~ i~t~t~ ~~t;~,rma,)etti filil~g. ~ ~~ ~~ * : -., , ,,r>; .. ~ ,_ . ~V-`~~ ~ 1~ ,~'-~ DEC 1 8 2009 LGrvrt ~~~ ~a~~t r P 1593416 ----- ---___ _.. ,~ , . ,, ~~ .~r~~~1~~ 114 #" r~ +} ' ,, ~ _ ___._._ ._------- -~_. _~-._ -_~ - - -- - C~ertttic~tliun '~1)1)I~~tr ,., r _ - i.lr,~;t~ 1~..~~1~;;°,11 ~ Gate ls~ued _... ~ q . ~~ ` ~ ~' ~? ~ ' ~~'°~*t lam j .' 1 , ...~,I ~ =~,,,1-.. ~.1 ~ ~...~T.. 4_ ~1 ~: .. 3 .~ ~~~ ~) C'~";` i"'t7 %•'3 ~) ~ ~~ tai REV 11/2006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS 'E /PRINT IN ERMANENT CERTIFICATE OF DEATN BLACK INK (See instructions and examples on reverse) STATE FILE NUMBER 1. Name of Decedent (First, middle, last, suffix) 2. Sex 3. Social Security Number 4. Date of Death (Month, day, year) Leonard F. Czarnecki Male 204 - 12 - 47x0 December 17, 2009 5. Age (Last Birthday) Under 1 ear Under 1 da 6. Date of Birth Month, da , ar 7. Bi lace C' and stale or tor si count Ba. Place of Death Check onl one Months Days Hours Minuses Hospital'. Other 8 4 Yrs. 0 c t o b e r 7 , 19 2 5 Dickson City , PA ^ Inpatient ^ ER (Outpatient ^ DOA ^ Nursing Home ®Residence ^ Other -Specify: Bb. County of Death 8c. City, Boro, Twp. of Death 8d. Facility Name (If not institution, give street and number) 9. Was Decedent of Hispanic Origin? ®No ^ `!es t0. Race: American Indian, Black, White, etc. ~ (I1 yes, specify Cuban, (Specify) Cumberland Lower Allen Twp. 411 Norman Road Mexican, Puerto Rican, etc.) white 11. Decedent's Usual Occu afion Kind of work d one d udn most of workin life. Do not state retired 12. Was Decedent ever in the 13. Decedent's Educatlon (Specity onty highest grade compl eted) 14. Madtal Status: Married, Never Married, "5 Surviving Spo use (It wife, give maiden name) Kind of Work Kind of Businessllndusiry U.S. Armed Forces? Elementary /Secondary (0-12) College (1-4 or 5+) Widowed, Divorced (Specify) Accountant Local Government ®Yes ^No 12 2 Widowed 16. Drcedent's Mailing Address (Street, city I town, state, zip code) Decedent's Did Decedent Lower Al-1eri T Pennsylvania Liveina 17 nce 17 tual Resid di A St t ®Y D d lLi 411 Norman Road c e a. a e c. es, ece en ve n^_ wp Township? Cumberland 17d.^No,DecedentLivedwithin t7b C Cam Hi11, PA 17011 . ounty Actual Limits of Ci /Boro N 18. Father's Name (First, middle, Iasi, suNtx) 19. Mother's Name (First, middle, maiden surname) Joseph Czarnecki Mary Kozlowski 20a. Informant's Name (Type !Print) 20b. Informant's Mailing Address (Street, city /town, state, zip code) Richard Czarnecki 121 E. Countryside Drive, Boiling Springs, PA 17007 21 a. Method of Disposition s ^ Cremation ^ Donation 21b. Date of Disposition (Monts, day, year) 21c. Place of Disposition (Name of cemetery, crematory a other place) 21 d. Locetion (City /town, state, zip code) • s ® Burial ^ RenwvalfromState ~ WasCremationorlMnationAutfwrtzed December 22 2009 Indiantown Gap National Cemetery Hanover Twp PA 17003 ^ ^ Other - S by Medical ExamirrerlCoroner4 ^Yes No , . , • 22a. Signature o rat S ' e Licensee or person acting as such) 22b. License Number 22c. Name and Address of Facility . ~ IFSO L Parthemore FH & CS, Inc. , P.O. Box 431, New Cumberland, PA 17070 Complete items 23ac my en certifying 23a. To the best of m nowledge, death oxuned at the time, date and place stated. (Signature and title) 23b. License Number 23c. Date Signed (Month, day, year) physician is not availab at ime of death to certRy cause of death. ~ 4' ~ T 2 Items 24-26 must be completed by person 24. Time o1 Death 25. Date Pronoun Dead (Month, day, y r) 26. Was Case Referred Medical Examiner I Coroner for a Reason Other than Cremation or nation? ~ who pronounces death. ~ M. r - _ C ^Yes o CAUSE OF DEATH (See Instructions and examples) r Approximate interval: Pan II: Enter other 'f' i i n i h 28. Did Tobacco Use Contribute to Death? Item 27. Part I: Enter the chain of events -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, i Onset to Death but not resulting in the undedying cause given in Part ^Yes ^ Probably respiratory arrest, or ventricular fibrillal'ron without showing the etiology. List only one cause on each line. , r ^ No ^ Unknown IMMEDIATE CAUSE (Final disease or i diti lti i death) ~ ~ ' 29. If Female. on resu ng n ~ con _~ a a 2 1 11+.~ i nthi ^ N t t t Due to (or as a nce off: r ~ - pregnan v o n pas year ^ Pregnant at time of death Sequentially list conditions, if any, b (~ (,~ ^ leading to the cause listed on line a. s Ente the UNDERLYING CAUSE Due to (or as a c sequen of) r - Not pregnant, bui pregnant within 42 days f de th - (disease or injury mat Initiated the ~' ,~(~ /S r c ~~ ' o a ^ ~ events resulting in death) LAST. --~ i Due to (or as a consequence of) - Not pregnant, trut pregnant 43 days to 1 year • r d. s before death Unknown if pre nant within the ast ear - g p y 30a. Was an Autopsy 30b. Ware Autopsy Findings 31 Manner of Death 32a. Date of Injury (Month, day, year) 32b. Describe How Injury Occurred 32c Place of Injury: Horne, Farm, Street, Factory, Performed? Available Prior to Completion of Cause of Death? ^ Natural ^ Homicide Office Building, etc (Speciy) ^ ^ ^ N ^ ^ Accident ^ Pending Investigation 32d. Time of Injury 32e. Injury at Work? 32f. If Transportation Injury (Specify) 32g. Location o1 injury (Street, city /town. state) Yes No Yes o ^ S i id ld N t b D t i ^ C d ^Yes ^ No ^ Driver /Operator ^ Passenger ^ Pedestrian u e ou o e e erm ne c M. ^ Other - Spacity: 33a. Certifier (check only one) 33b. Signature and Title of Certifier ^ Certifying physlClan (Physician certifying cause o1 death when another physician has pronounced death and completed Item 23) death occurred due to the cause{s) and manner as stated To the beat of my knowledge _ _ _ ^ _ - ~ , _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ • Pronouncing and certMytng physician (Physician both pronouncing death and cert'~fying to cause of death) To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) end manner as stated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ 33c. Liven Number 33d. Date Signed (Month day, yeah /~ / _ `~ -~ /0 _„~ ! C. ~ • Medical Examiner/Coroner On the basis of examination and I or Inveatlgatlon, in my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner as stated_ ^ I (,~ (f[ ~j V l 34, Name and Address of Person Who Completed Cause of Death (Item 27) Type r Print 35. Registrar/s~ atur e and Dis~~t'~i~n / T . _)I ~I ~ ` I ~ I '' / ~C7~ / 36. Date File (Month day, year Kimberlee P. Youngr MD ~ ~ - (.lJ7df~ ~~,.Z /~ ~D~' ~ Famil Practice Disposition Permit No. ~~ ~ /~ ~-~/~ i~ ._~~~ r. _. w ~~ ~ 0 ~K "' ~ A~ 8y 5 J RENUNCIATION REGISTER OF WILLS CUMBERLAND COUNTY, PENNSYLVANIA ~~ RT 4RP~~ ~ ~~ ~ !~ ~1~~~ Ct~ Estate of Leonard F. Czarnecki I, Susan M. Pellman (Print Name) Deceased in my capacity/relationship as daughter of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to Richard Czarnecki V ~ ~ r ~ ~ ~il D te) Executed in Register's Office Sworn to or affirmed ~ r subscribed before e this ~ day of ~ ~` 1(~ 1 I E i n, _ ,i~ n Ir ~, ~ ~~ _ eputy~Fo~teg~ter of Wills _~ 1 9 ~ , ~„~~~ gnature) 405 Hemlock Drive (Street Address) New Cumberland, PA 17070 (City, State, Zip) 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.) Form RW-06 rev. 10.13.06 `! ~ / i"') / f C_? - ~- ~ ~ ~, ~4~~ JUN ~7 AM 8~ 5`~ RENUNCIATION REGISTER OF WILLS CUMBERLAND COUNTY, PENNSYLVANIA ~ ~~ T ~~~~N ~ C ~ ~u~~~~...a ca. Estate of Leonard F. Czarnecki I, Ronald Czarnecki (Print Name) son Deceased in my capacity/relationship as of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to Richard Czarnecki ~' / ~/ (Date) (Signature) 411 Norman Road Executed in Register's Office Sworn to or affirmed~,a~. d subscribed before e this "1'" ~ day of ? ' % ' ~~~r A / ~ v eputy fo st of Wills (Street Address) Camp Hill, PA 17011 (City, State, Zip) Executed out of Register's Office Before the undersigned personally appeared the party executing this renunciation acid 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.) Form RW-06 rev. 10.13.Ob