HomeMy WebLinkAbout08-12-10PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF,~ ~ ~;,~~,~i--~; .~;-r--l'J,~) COUNTY, PENNSYLVANIA
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Estate of ~ ~. ', L. ` ~..-= ~ Jt= ' ~ ~' ~ 1 (~ File Number ~ ~ ° I ~.' ~" ~~~
also known as ,~ ', '?
'l G~~~. ~:,~'_ =~ l ,~~ ~~ ~ ,Deceased Social Security Number ~ '-" ~ ~J 'y G'
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 ,; ;,~ c~ ~~~ . ~''. ~~iC.f~l t-~'GU named in the
last Will of the Decedent dated ~ '~ nd codicil(s) dated ; {
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(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 thf; instrument(s) offered
for probate, was not the victim of a killing and was never adjudicated an incapacitated person: ~[~
^ B. Grant of Letters of Administration
(Ifapplicable, enter.• c. t.a.,- d. b. n. c. t. a.; pendente lite, durante absentia; dc~rni~7~iniccoritate) ~'
C ~ c- - _.,
Petitioner(s) after a proper search has /have ascertained that Decedent left no Will and was survived by the following sp~.ts~if any) alletrs ';~If `~'
Administration, c. t. a. or d.b.n.c.t.a., enter date o Will in Section A above and com lete list o heirs. `- ~ G
Name Relationshi Resi~ettce ~ ' `~ ~ -
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(COMPLETE IN ALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in ~ /,L(~ >r~3 jt~ ~-~ ~ unty, Pennsylvania with his /her last princi al residence
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(List street address, totivnicity, townslcip, count), state, zip code) _~~y~~r~N1 r
Decedent, then years of age, died on ~~ ~ • ~~hat ~~};;~:~,J~:t,~,`~ ~f--r~~ ~ c?~T~- ,rZ ~- (=1/'~ ~ ~`•' ~;~,,
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Decedent at death owned property with estimated values as follows:
(If domiciled in PA) All personal property $~~ G'~L~Z7
(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:
Signature Ty ed or Tinted name and residence -~
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Fa•m RW-0? rev. 10.13.06
Pabe 1 of 2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF ..aL( ] ~~~ G" ~ 5..- 1.~
The Petitioner(s) above-named swear(s) or affirnz(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.
Swori! to or affirmed and subscribed ~ ~~` ' ~~'"
r ..., • ~gnature of Perso~tc~l Xe~jresentative
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before ~Y~e the ~~_ day of _, !-_~
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~'J l.;! ` ' ~~`, ~~~' ! Signature ofPersatal Representative ~-~ ~` " t
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For the Register Signature of Personal Representative ~'' -~'~
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File Number: `~
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Estate of -'~ ' ~' ~ !' ~ ~'~ ~ /U` ~' 1•--'Y~ ,Deceased
Social Security Number: y/ - j ~ ~ :~~lGl ( Date of Death: G' ~_~~~
AND NOW, ~^ ~... ~'~ ' ~ ~- ~~C~ ~~~ , in consideration of the foregoing Petition, satisfactory proof
having been presented bef re me, IT IS DECREED that Letters -~ ,J ~ ct ~ 1.~-'- ~--
are hereby granted to <- -~-E.-~,`,1 ~'> I`.1~.\ 1 l ~ li ~
}} _ _ in the above estate
and that the instrument(s) dated ~ _ •'~ I ~ Z C~C> ~ `~' .~j ~-- l -- ~' L` C.? ~ _ _ -
described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(sl) of Decedent.
FEES ~,,`' !// C.-(,~,~~JC,(.~,~ \f
Register of Wills +
Letters ............... $ s`~L~ C~ ~~:',~ ~' ~::(~~'(~~ y~ ' ~ '~
Short Certificate(s) ........ $ ~ GNU Attorney Signature: _
Renunciation(s) ......
~;
~c~
.... $
$ I `:~ ~~~ Attorney Name:
• • • $ ~ ~ ~ ~` Supreme Court LD. No.:
... $ .~-=5 ~~c,
-- Address:
... $ ~ L~~
... $
... $
... $
• • • $ Telephone:
... $
TOTAL .............. $ GZ . ~_`-?_~-
Form RW-D' rev. 10.13.06 Page 2 of 2
~OCAL REGISTRAR'S CERTIFICATION OF DEA'T'H
VV~~r~tNIIN~; It is illegal to duplicate this copy by photostat or photograph...
I'l'l' It)i~ Ohl" =.'Ci-(91);_'~jtC". `+,(:~, ~k%
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H105-143 REV 11/2008
TYPE I PRINT IN
PERMANENT
BLACK INK
1. Name of Decedent (Flret, middle, Wst, suffix)
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5. Age (Last Birthday) Under 1 year Under 1 day
Months Days Haan Mnutes
8 7 Yrs.
:r; r,,, "%;T - ~. 1_'his i~ t~~ ~~rtif~~ that the in1-~~r-nation hers ~,~ven is
~~p~.l~ Of p~~,~ .~ cf~r--rect(v c~lpie.d fr~lillall (>rig>tnal (certificate of Death
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,~,`o`'',~ t1~~.~ lulu lile~l «~ith n-e a~~ l.c~cal Registrar. The original
', - ~~ s' I ~l rtit~i~ ~)tr: ~'v~il1 1)e irtrGVarded to the titate Vital
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:~; - '~~~' ~~~.~;i I~e~itrcls Uf-flee IO-- (-lerrna-len~,t t-ilitlg.
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-~-- -- I .~ rc~li IZc T-ai~=1) Date Issrled
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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. Social Securtty Number 4. Date of Death (Month, day, year)
fen R nerd Female 191 - 18 - 3401 08/08/2010
6. Date of Birth (Monts, day, year) 7. Birthplace (Ci and shale or fore' country) 8a. Place of Death (Check only one)
Hospital: Other:
09/26/1922 not available ^Inpatient ^ER/Outpatient ^DOA ursingHome ^Residerlce ^Othe
Bb. County of DeaM 8c. City, Boro, Two. of Death 8d. Facility Name (H rtot instituhon, give street and number)
Cumberland S.Middletown Manor. Care
11. Decedent's Usual Uon Klnd of work done d rtlost of world Hie. Do not state retired 12. Was Decedent ever in the 13. Decedenrs Edtrcetion (Speciy
Kind of Work Kind of Business / Industry U.S. Armed Forces? Elementary /Secondary (0.12)
Masland ^Yya Wrro 12
16. Decedent's Mailing Address (Street, pN /town, state, zip code) Decedent's P A
Actual Residence 17e. Sate
250 Walnut Bottom Rd. , Carlisl 17b.County Cumberland
PA
18. Father's Name (First, middle, last, suHiz)
20e. Informant's Name (Type /Print)
Betty B.Mullen
21a. Method o1 Disposition ~ (~ Cremation ^ Donation
^ Burial ^ Removal from Sate
^ Other -Specify: ~ Wae Cremetlon or Donation Authorized
~ by Medical Examiner / Corerter?
22~}.Si u of Funerel Mce t r person acting es {uch)
- is Aa A na 'YA'
9. Was Decedent of Hispanic Origin? ~ No ^ Yes 10. Race: American Indian, Bladr, White, etc.
(If yes, specify Cuban, (Specify)
Mexican, Puerto Rican, etc.)
completed) 14. Marital Status: Monied, Never Married, 15. Surviving Spouse (If wife, give maiden name)
-4 or 5+) Widowed, Divorced (Specify)
Did Decedent S, rti d d l e t o
Live in a 17c. Yes, Decedent Lived in _ w A~
.~ Twp.
Township?
17d. ^ No, Decedent Lived within
Adual Limits of City / Boro
19. Mother's Name (First, middle, makkn sumama)
Helen M. not availa
206. Informant's Mailing Address (Brest, city /town, state, zip code)
55 E.Park St Carlisle Pa 17013
21 b. Dale of Disposition (Month, day, year) 21 c. Place of Disposition (Name of cemetery, crematory or other place) 21 d. Location (City /town, state, zip code)
Yea^No 08/11/2010 Evans Cremation Service Leola, PA
b. Ucense Number 22c. Name and Address of Fadlity
Fllfll '~Ql.S - F.wi no Rrntharc Fnnr~ral Hnma Fi"3(1 4 . Hanover ,fit _ _ (',art i .41 A _ PA 1 7n1 _~
Complete hams 23et Dory when certiying
physician is not available at time cl death to 2 To the f my know) ath at the time, date and ce slat (Signet and tiNe)
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~ 236. Lice Number
~~ 23c. Date Signed (Mo th, da ,year)
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cerHty cause of death.
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Items 24-26 must be completed by person 24. Time of Depat~h
~ 25. Da Pron Dead ( nth, day, year)
(
y ~ 26. Was Case Referred to Medical Examiner /Coroner for a Reason Other than Cremation or Donation?
who pronounces death. ~
1 1
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8 Yes ^ No
CAUSE OF DEATH (See instructions and a plea) r Approzimate interval: Part II: Enter other significant cenditons contri6utirw to deel;g, 28. Did Tobacco Use Contribute to Death?
Item 27. Pan I: Enter the chain of events -diseases, injuries, or complications -that directly caused Hie death. DO Tenter terminal events such as cardiac arrest, r Onset to Death but not resuhing in the underlying cause given in Pert I. ^ Yes ^ Probably
respiratory arrest, or ventricular fibrillation without showing the etk>togy. List only one cause on each line. ~
r ^ No ^ IJnknown
IMMEDIATE CAUSE (Final disease or
condition resulting in death) ~ a _' r,~,~ ~ ~~~ ~/~C~ ~-~ ~~. ~ r ~~~ ~ 29. If Female:
^
Due to (or as a consequence op: ~ - Not pregnant within past year
SequenHelry list conditions, it any, b i
feedin
to the ceuce listed on line a ^ Pregnant at Time of death
g
.
Enter the UNDERLYING CAUSE Due to (or as a consequence of): ~
-
^ Not pregnant, but pregnant within 42 days
- (disease or injury Cher initiated the r
events resulting m death) LAST. c of death
Due to or as a cons uence o ~
( eq f): - Not nanl, but r nant 43 da s to 1 ear
^ Pre9 P e9 Y Y
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- before death
^ Unknown H pregnant within the pest year
30a. Was an Autopsy 30b. Were Autopsy Findkgs 31. Manner ath 32a. Date of Injury (Month, day, year) 32b. Descdbe How Injury Occurred 32c. Place of Injury: Home, Farm, Street, Factory,
Perforated? Available Prior to Canplelfon
Natural ^ homicide Office Building, etc. (Specity)
of Cause of Death?
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^ Yes ~~Flo ^ Yes ^ No ^ Arxident ^ Pending Imastigation 32d. Tme of Iryury 32e. Injury at Work? 32f. If Trensportatlon Injury (SpecilyJ 32g. Location of Injury (Sreel, chy /town, state)
^ Suicide ^ Could Nol be DeterminuW ^ Yes ^ No ^ Ddver /Operator ^ Passenger ^ PedesMan
M ^ Other - Specfy:
33a. Certifier (check only one) 33b. Signature T Certlfer
• Certilying physician (Physician certitying cause of death when arwther physician has praaurtced death and completed Item 23) I J ~ c~
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=:~ To the best of my knowbdge, death occurred due to the cause(c) and manner as statetL _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - I-
• Pronouncing end terlHying phyaician (Physician both pronouncing deaN end certityirtg to cause of death)
To the bast of m
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^ 33c. Lice a 33d. Date Signed (Monts, day, year)
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ue to the cause(s) end manner es ateted_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Madkal Ezaminx /Coroner r ~ ~ ~ r - ~ Q
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On the beefs of examination and / a investigation, in my oplnbn, death occurred at the time, date, end place, and due to the cease(s) and manner ae atated_ ^ .
34. Name ar~rJ ss~~
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Type /Print
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LLD 35. Registry i lure and t' umber
' 36. Dale Flied (Month, day, year) ~
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