HomeMy WebLinkAbout08-03-10PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF ~ V ~ ~ ~d lbw ~ COUNTY, PENNSYLVANIA
Estate of ~~~J `~ py ~ ~ ~ ~~ ~`' y
also known as
Deceased
File Number r~~ - ~ (~+ - ~ ~~
Social Security Number ! ~ ~ ~ ~b ~~~~~
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(CO/t~IPLETE '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
narned in the
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~~
. - ~~
(State relevant circumstances, e.g., renunciaticn, death of executor, etc.) , ..~~ e, ~' ;
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of ,tk~o~~~t~ment(s1 offered- , •,
for probate, was not the victim of a killing and was never adjudicated an incapacitated person:
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B. Grant of Letters of Administration ~-; --i ~ --" ,.-~
(Ifapplicable, enter: c. t. a.; d. b. n. c. t. a.: pendeiue Cite; durante absentia; durairte ninoritate) t^+~ ` '~~ l
CG '~ ~.
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. ord.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.)
Name Re(ationshi
P ,~ ~
c~ ~~ti
(COMPLETE IN ALL CASES:) Attach addition/al sheets if necessary.
Decedent was domiciled at death in t~GlM V/ ~r ~/~/~~ County, Pen yw nia with his /her
~/~d • ~ / ~
(List sU•ee address, tow~i/city, township, county fate, zip c e) ~ ,
Residence _ _~ ff
~ J ~ . ` 1 el~1. ~''t''<Gf y v~Q
Mme- r,.t cry ~; f~ 1 ~~S G
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s~rincipal r~ iden~e at ~~~~~D~,~' ,
r `~, . , n.- G~' , i, 1
Decedent, then ~ years of age, died on ~ ' at
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
situated as follows:
Form RbV-0? ,•en. lOJ3.06
lit< y,~~'ica:'
$ ~!7
$ C%'
$ C--~
R
Pagf, 1 of 2 ;~~
V
,,
.~ a
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:
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF liG~t ~f,U h !•~-~-~
SS
The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true and con'ect 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 sr affirmed and suhscribed ~.- ~~j~-~'~--~--- `-
:--~ tSignatw~e of Persona! Representative
hefort me the __`,~ day of
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,~` ~ ' (~.' , t `~ _, ~~!~ Signature of Personal Representative
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For the Regi ter Signature of Persona! Representative '_~' .:.t;, ~l ,._
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File Number: c~ ~ ~ L . -~ `~ l.~ ...
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Estate of % ~~; ~'\~,~ ~ ~ U~(~ t~ ~ `C~
,Deceased ~ J ~)
'~
Social Security Number: ~ ~ C~ ~~~-F ~ 1 '"1 ~ Date of Death: 7 - ~ - ~ L
AND NOW, t'~~, ~1'L `~ -Y- ~ :~ C ~ L~ , in consideration of the foregoing Petition, satisfactory proof
having been presented before me, IT IS DECREED that Letters ~-~ ~~`1'1 f i 1 1 ~ ~ "L.r~'~ ~ ?G'i 1
are hereby granted to ~~ Li ~ (''~ (~~ F) ~t UC.i V '~.I
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 Decedeni.
FEES
Letters ............... $ r
~~ - ~~-
Short Certificate(s) ........ $ !~ (,) ' Cs ~~
Renunciation(s) .......... $
t,- ~._ C:
... $
... $_
... $
... $
... $_
... $
- -,
TOTAL .............. $ '~.~ .
Register of Wills _ ~ ~, ~ ~l-_~ ~ j~
~~ r.
Attorney Signature: ? f ~°~"`-'~~~~~-
Attorney Name: ? ,~~-''_
Supreme Court LD. No.: ~~ ~`~q
Address: ~
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~~~ 6 G ~~
Telephone: ~/~~ ,~~~~~- ~J'~~~~ ;,~_
Furut RGV-0? rev. 10.13.0( Page 2 of 2
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H105-143 REV 15/2006
TYPE I PRINT IN
PERMANENT
BLACK tNK
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CERTIFICATE OF DEATH
(See instructions and examples on reverse) CTATF FII F NI IMtiFR
1. Name of Decedent (First, middle, last, suffix) 2. Sez 3. Social Security Number 4. Date of Death (Month, day, yeeu)
Thanes C. V 199 - 36 - 5745 Jul 8 2010
5. Age (Last Birthday) Under t ar Under t da 6. Date of Birth Month, da , ear) 7. Birth Ci and state or fe el n coon 8a. Place of Death Check ni one
kbnms Days Hours Mkwtes Hospital: Other:
55 yrs. Sept. 15, 1954 Fountain Hill, PA ®Inpatient ^ ER /Outpatient ^ DOA ^ Nuraing Horne ^ Residence Comer-specify:
8b. County of Deam tic. City, eoro, Twp. of Death 6d Facility Name (If riot institution, give street and number) 9. Was Decadent of Hispanic Origin? ®No ^ Yes 10. Race: American Indian, Black, White, etc.
(If yes, specify Cuban. (5'peci!)7
Mexican, Puerto Rican, etc) ~h~te
11. Decedent's Usual Occ tion Kind of work done d uri most of world life. Oo rtot state retired 12. Was Decedent ever in me 13. Decedent's Education (Specify only highest grade comp leted) 14. Marital Status: Married, Never Married. t5 Survmng Spo use (R wife, give maiden name)
Kind of Work Kind of Business /Industry U S Armed Forces? Elementary /Secondary (0-12) College (1-4 or 5+) Widowed, Divorced (SpeciyJ
Researcher Medicine ^Yas ~No + Married Kathleen A. O'Neill
16. Decedent's Mailing Address (Street city /town, state, zip code) Decedent's Did Dacedern
Pennsylvania Live in a
d m Hatm~dPn Tw
t 7
Deced
nt Liv
t
l R
id
7
Ye
t
A
S
5902 Ste hens CrOSSln
P g p
p.
ence t
s,
e
e
ua
es
a.
ta
e
c.
c
Decedent Lived within
TO~~ ? t 7d. ^ No
3
Cti
b
l
Mechanicsbur PA 17050 ,
Pr
anr
~m
t7b. County
Actual Limits of City / 8oro
1B. Fathefs Name (Frst, middle, Last, suffix) t9. Mother's Name (First middle, maiden surname)
Geor e Cris in V Clairebette Folk
20a. Informants Name (Type /Print) 20b. informant's Mailing Address (SVeet, oily I town, state, zip code)
Kathleen A. V 5902 Ste hens Crossin Mechanicsbur PA 1705
rrV-
21 a. Memod of Disposition i !.~ Cremation ^ Donahon 21 b. Date of Disposition (Monet, day, year) 21 c Place of Disposdan (Name of cemetery, crematory or oCler place) 21d. Locaton (City /town, state, zip code)
i
~
Budal ^ Removal from State r Yas Cremation or Donation Authorized„-,t
JUl 9 2010
y
Dugan Cremator 1.,'
^
r
^
i b Medical Examiner/Coroner? Yes No y St z1 Sbl]rC~ ~ PA
22a. Sgnature of F Se Licensee ( ' rson acting as such) 22b. License Number 22c. Name and Address of Facility 8 Market Plaza Way 1
- ~
` FD-138630 1 z'
Compote ' 23ac Dory when cer6lyi 23a. To ma best of my knovdedge, deem occurred at me time, date and place stated. (Signature and title) 23b. License Number 23c. Date Signed (Ir10nm, day, year)
phys~ ~ is rid available at time of da to
certiry cause a deem. i
Items 2426 must be completed b1' person 24. Time of Deam Month, day, year)
26. Data Pronounced Dead ( 26. Was Case Referred to Medical Examiner /Cornier Ia a Reason Other than Cremation a Donation?
w4to ~o~~ dam' I = Z V ~ M. G
J U L`{ p Z O / O ^ Yes ^ No
CAUSE OF DEATH (See instructions and examples) r Approximate interval: Part II: Enter other 5i~ifin~rlt conditions contributing to deem. 26. Did Tobacco U:;e Contribute to Oeam?
Rem 27. Part I: Enter me Cftalll of events -diseases, iryuries, or cortpkcations -that direcby caused M+e death. DO P40T enter terminal events such as cardiac arrest, r Onset to Deam but not resulGrg m me underlying cause given in Part I. ^ Yes ^ Probably
respiratory arrest, or ventrk:ular fibnllatbn witMut sfwwing me etiobgy. List Dory one pose on each line. r
r
I
~ No ^ Unknown
IMMEDIATE CAUSE (Final disease or i 29. tt Female.
cordRion resulting in death) t
-~ a. LIVER FAf>;uRE
^ Not
re
nant wahin
a
e
t
Due to (or as a consequence of): I p
g
p
ar
s
y
^ F>regnant at lime of deem
Saquenhally tst conditons d any b ~ ^
the
leading to muse listed on line a. i
Enter 81e UNDERLYING CAUSE Due to (or as a consequence of): ~ Not pregnant, but pregnant witnin 42 days
W death
(disease or injury mat initiated the
c'
t
t
^ N
b
4
d
~
events resulting in deem) LAST.
Due to for as a consequence of): i o
pregnan
,
N pregnant
ays to t year
3
cefore seam
d. ~ ^ Unknown it pregnant wdhin me past year
30a. Was an Autopsy 30b. Were Autopsy Findings 31. Manner of Death 32a. Date of Injury (Monet, day, year) 32b. Describe How Irry'ury Occuned 32c. Place of Injury: Home, Farm, Street, Factory,
Performed
Available Prior to Completion
of Cause of Deam?
~~II ^ Homidde
lLN Natural ofhce Building, eta. Ispeci/y/
^ ^ N
^ ^ Accident ^ Pending Investigation 32d. Time of Inryry 32e. Injury at Work? 32f. If Transportation Injury /Specify) 32g. Location of injury (Street, city I town, state)
Yes No Yes
o
^ Solaria ^ Could Nd be Determined
M
^ Yes ^ No
^ Drnver/Operator ^ Passenger ^ Pedestrian
Other -Specify
33a. Certifier (cheer Dory one) 33b. Signature and Tine of Tier
• CertMylny physkian (Physician cedily+ng cause of death when another physiaan has pronounced deem and completed Item 23)
d~M occurred due to the cause(s) and manna as sated
_
_
_ _
_ _ _ _ _ _ _
To the bast of my knowbdge
^ -
_
_ _ _ _ _ _ _ _
_
_
_ _ _ _ _ _ _ _ _ _ _
,
• PronamtM9 arld c~Yln9 Physican IPhYSician born pronoundng deem and certifying to cause d deem) 33c. License Number 33d. Date Signed (Mont
h, day. )rear)
To the best of my knowbdge, rfeaM occurred at the tlrna, date, and place, and due to the cause(s) and manner as stated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ®
• AtedMalExaminer/Coroner O 7.- O 1 ZO O ~ p
~/ ~ 0 Z 0 / O
~
On the basis of examination and / or investigation, in my opinion, death oal,rred at the brae, date, and pkce, and due to the uuae(s) and manner as statecL ^ 34. Name and Address of Person Who Completed Cause of Deam (Rem 27) Type /Pmt
3s. R ar tlxe Diat mbar ~ l ~
I I i I~ I~ I
~ 36. Date F (Monet, day, rear) S?6v~, K N ov ,~ p 'y Medical Ctr. ~
M.S. Hersht.
~
, ~ ~d ka J
~ »n3~
DisposNOn Parmtt Ng. 0479746 •