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HomeMy WebLinkAbout08-20-10PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF WILLS OF C,t.w~b•eri.~na~ COUNTY, PENNSYLVANIA Estate of ~ ~ ~~~ rl t ° ~ l (, ~ File Number ~/~/DSO 0 !O S also known as Deceased Social Security Number ~ ~ I y I 1 ~` ~ b U~3 Petitioner(s), who is/are I8 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 A ~ i named in, e last Will of the Decedent dated and codicil(s) dated C e ~ -:.._, State relevant circumstances, e. _ ( g., renunciation, death of executor, etc.) ~- `~ " '' iV n- ~=i'1 ~'' Exce t as follows, Decedent did not ma p ~. ~ p rry, was not divorced, and did not have a child bom or ado red after executi~ G °::.~ t:; 7 ~ ( ) nstrup~tt s d.t3> for probate, was not the victim of a killing and was never adjudicated an incapacitated person: '~ ~ C7 ~ '~ - ~ .Trt Cam? .. TI ~/. ' .+" ~B ..+" • • '- . Grant of Letters of Administration - ; rn .__ (Ijapplicable, enter: c.t.a.; d.b.n.c.t.a.; pendente lire; durance absentia; durante minoritate) Petitioner(s) aRer 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 date of Will in Section A above and complete list of heirs.) P~~, P.~IT~ De~cede~nt was domicile at death in (List street address, town/city, towns/tip, county, state, zip code) with his /her last principal residence at ~~5~ ,~, Decedent, then -t -L years of age, died on ~Q 1(~ at _ _I p~ •` yd ~M ~l ~~'-t S ~~ r loS~ ~~ Decedent at death owned property with estimated values as follows: (If domiciled in PA) All personal property $ ~w d D w (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 Letter9 in the appropriate form to the undersigned: Si nature T d or rioted name and residence Bri fi{- -'~ ~ ~PP'~r t- l 01 3 b a s f- tr-t ~~ S i7're~- P tZ Form RW-01 rep-. to.t3.o6 Page 1 of 2 ~V (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA / SS COUNTY OF Gti/IX-~'1 u~~10` , The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true ankl carrect to the best of the knowledge and belief of Petitioner(s) and that,. as personal representative(s) of the Decedent, Petitioner(s) wjill well and truly administer the estate according to law. Sworn to or affarmed acid subscribed bef a me the ~Q~ day of For the Register Signature ojPersonal Representative Signature of Personal Representative File Number: ~/ ~Q' ~1~ ~.~ Estate of ~Il~c 5e~, ~n /vt/~ Deceased Social Security Number: f °~ ~ "- y ~ ~ ~U73 Date of Death: ~~ lh~_ C7 ~ c~ AND NOW, 0~ , ~1 ~ . in consideration f the foregoing P~i satisfacfi~?y pro~r having been presented before me, IT CRE D that Letters - ~ `-~? ~ 5~ are hereby granted to ~ -f^~ ~ ~ _- ~ ~-,' 'n the a ove estate`_ and that the instrument(s) dated -- described in the Petition be admitted to probate and filed of FEES Letters ............... $ ~ a Short Certificates} ........ $ t~ R nunciation(s) .......... $ ~ d~ ... $ 9_3_ Sb ... $ Gov ... $ ... $ ... $ ... $ ... $ ... $ ... $ TOTAL .............. $ o as the last Will (and Codicil(s)) Attorney Signature: Attorney Name: Supreme Court I.D. No.: Address: Telephone: RegisterAf"Wi11s ;~-, ,~~~~ Fa•,n RW-02 rev. ro.ts.oe Page 2 of 2 o ~+ "~~ ~ "Y7 ~~~ r~~~ ,~ °,' tV c , RENUNCIATI N ; ~ ~ 7~ ~~~. , ~ r,..T ~ REGISTER OF WILLS -> --- n [ .~v~l;~r.~'1~inr~~ COUNTY, PENNSYLVANIA m Estate of Deceased I _ ~(~, ~~ 111- Vf }~~ , in my capacity/relationship as ~~ (Print Name) ~~' of the above Decedent, hereby denounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to na/20/x° (Signature) -'-l ~'o ~ Nil ~~ ~ ~v~ -- (Strett Address) ~IJ7,~~ ~l~-,~~ P_,~ !~L~7a_~~- (City, State, ZipJ Executed in Reguter's Office Sworn to or affume subscribed before a this _ day of , eputy or Register of Wills Executed out of Register's Q~ce Before the undersigned persgnally appeared the party executing this renunciation end certified that he or she executed the rdni~nciation for the purposes stated within on this day of Notary Public My Commission Expires: (Signature and Seal of Notary or other officliall qualified to administer oaths. Show date of expiration of Notary's Commission.) Form RW-06 rev. 10.13.06 _ . r - I H705-805 REV 1/OS This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. WARNING: It is illegal to duplicate this copy by photostat or photogra/ph. pp~~ ~, ~~ ~ dlo Fee for this certificate, $6.00 ' ' al Registrar P 11343154 No, 3- ~- aS Dafte n r.a ° ° ~.y ~i 1~J':7 -'Z~ i ~~~ aa• C N r, - -, c~ I ~., vy -T', 7YPE/MBNT IN PERMANENT euac TNK 0 a a F- Z w U O w g z H705.143 Rev. 7187 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF l3EATN aTATE FaE NDMRER NAME OF DECEDENT (Fin6 MiOtlle,. Lssry SEX SOCIAL SECURITY NUMBER OF DEAT (Month. D y,.Vear~ L ~ S. ]. _ _ AGE (Last Bxthday) Y DATE OF IRTH BIRTHPLACE (City atM Mon9,s Oeya 11awa Mmuea (ManN, Day, Year) Slate or Foreign County) AL . , oT R~ Yrs. e ,a•m ERIOUp•Eenl ^ DOA ^ ~ M'a ^ Ra•iance ^ ' ^ S. 9.. 7.. 9a. Spea N1 ' COUIJTYOF DEATH CITY BORO, TYyPOF DEATH FACILITY NM4ETIIra1 MaBlutim, gwe sank end number) W CEDENT OF HISPANI O IGIN7 RACE - Ahu:ritan Irvuan. Black.'Mfne, e, NoYea~ II yas, epeafy tle~n, '. (SPe rY) hi • D Har isbur Harrisbu Hos ital Nexa:an,P Daicanelc. White aup n. eb. g.. r x- ed; p 10, DECEOEN75 USUAL OCCUPATION KIND OF BUSINESSIINDUSTRY AS DECEDENT EVE DECEDENT'S EDUCATION ~ MARITAL STATUS-Married; SURVIVING SPOUSE r a l .urea of •crk Nau e4uvmrnoo k a ~ 1 r Y ~ U.S. ARMED FORCES? u I •° °°N c a r 1 rs ar+ae comWudl os e Never Martletl, YNOOwed, Divorcetl (SpeenYl e ero m•r en nnme wN. e l .40Aa were Ng 1A° Broker Insurance Yea^ No.~. e • Y •rRem•rY °n l0-,:1 •a n-.«s•) 11a. /1e: 12. 17. 14. us. DECEDENT'S MAILING ADDRESS (Sireel, Cityliown, Stela, Zip Coca) DECEDENT'S 17a. Slate pans a Did 17e tlecedenl livetl in nvp ^ Yes ACT ~' 1153 Brockon C1rC lie , . UAL da=ypant . RESIDENCE 1e New Cumberland, Pa. 17070 (See aulructiona Uva in a. No. decedent Nved on otllx aide) rib. cautay Cumberland lo`s'nsh~P? 170.^ wnNn edual lirrats of W a ntylboro fRTHER$NAME (FUsf, Mitltlle, Lasl) MOTHERS NAME (Firs( Mitldle. Maiden Surname) ;tA 19. I MgNT' NAME (Type/Pnm) INFORMANT'S MAILING ADDRESS (SlreeL Qly/town, Stale, Zip Code)', 20a. 200. METHOD Of DISPOSI/Tlpjpl 1''~ ^ 1MTE OF DISPOSITION M n 0 Y PLACE OF DISPOSITION- Narrle of Cemetery, Crematory Of OIhM Place LOCATIO - Cny own, Stale, Zip Code Bu1tei L]Lremeacn ~JtemOVal from Slate ~^ nar) ax , 1 •v. ' «~i oular(sp~N) ^ 2,b- 3/12/05 s Cemeter 21t:.St. Mar :,d.Mi dl~etown Pa. 1.7057 $IONATURE F FUNERAL SE VICE LICENSEE OR PERSON ACTING AS SUCH LICENSE NUMBER NNAE AND ADDRESS OF FACILITY ~a ~, x2b. 0-10098-L 2x-Matinchek & Dau hter F. ltm., Middletown, Pa. OWllplall NM11a 23et Only wtNylcenirying To 818 bes~ofmy Kilo tiledge; daaN OCCUred et V,etime; daleantl piece staled. LICENSE NUMBER DATE SIGNED Veal) etomh Da phraxaen (s rgtevadaDk el Ume of death to (Sigrwtcae arM Tub) ~ i , y, cerblY cause of tlsaM. 27s. - 27R 27c. 'items 24-26 mull ce completed by TIME OF EATH DATE P EO A (MOnI , Day, V ar WAS CASE REFERRED TO AMEDIC, LEXAMINER /CORONER'+ v ~ person vdw pronounces deam. (/ G/ 28. Ves ^ No 24:. / Q M 29. 27. PART L Emer rM a:••••u, bjun•a or <ompuc.lions vx.ica cw••4 me N.•m: o• r,« enr« me m•4• of Ny:q, w<n •• c•rM•c or rup" ovy arn•e, •n«n or n.,n ONUr•. ~ gpproxanale PgRT 11: CUtt r signd{cant conditions convibuaflg to deam. but Usr onlyom Fww on •ua lire.. • inlltYal between pOt t Sultim,~ in tree uridenyinq cause green nt PART I ~ onset and death IMMEDIATE CAUSE tFinal disease or coraiaon . ~ ~- ' ~ ~ ~ a t - a. resWlnlq in tlealh)-- OUE TOIDRA ACONSEOUENCEOI Sequentially ssl conditions o_ c«__. ~ - Hany, leadalglo nnnlBtllBle OUE T01 ASA ONSEOIVE OFI~ ' ' rauae. Ertler UNDERLYING c. CAUSE (Asease ay iryury Mal initialed eY¢mS DU ro IOR AS AGON9EDllENO£ OFI. yesufmq on seals t usT a -WAS AN AUTOPSY VYERE AUTOPSY FINDINGS MANNER OF DEATH DATE OF INJURY TIME OF INJURY INJURY A7 YJDNK? D SCRIBE HC W INJURY OCCURRED PERFORMED? AVAILABLE PRIOR TO COMPLETION OF CAUSE ral '~ Homicide © Nat (Ma,m, Day, Yeu) '~ OF DEATH? u ^ Pentlitg lnvesbgatwn AWdenl ^ Yes ^ No ^ , . 70s... 7qD. M 30c. JO . Ves No'{,/ ^ 7~,je Yes NO~ ^ SuCide ^ Could rwt Da detennirted ^ PLACE OF INJURY - A( home, larm, sneer, last aY, odice (SI et, CitylTown, State) LOCATION 2N. 2M. 29. a,.l4ra.•t° 15n•elNl 70e. 70f. CE leled item 231 deals an0 can 0 1 ~ r n R NATURE AN~ TLE ERTIFIE I J p a ....-- _. .,. _•. ^ ~~4 f i{iP tI a Di t o my nowNidga Wa~ occwigd Ause W the CiUSea(a)' tl mallmr » TO ~ ` ^L , r 7t L . (!~/' LICENSE NUMBER SIGNED (MOnm, bay. Year) Dj4T E 'PRONOUNCING AND CERTIFYING PHYSICIAN (Phy;tcian DOIh ptonour~ng death aNcettilyirlq to cause d deam) y, ,. \ L, Z ( ~ +? . -; _ 7 . ~T ~ ~, To the best oy my knowledge, tleath accurretl at the Ilene, dale, and place, antltlue to the Cauaes(t).antl manner as staled... .. ....... I ~ 71c. _ ` f ] d .MEDICAL E%AMINERK:ORONER yQ.p{ {F~J7~/~~'./~,t1/(e~/}~ q/j/}~/~ (Item 27) TOype or Prmss '~ On Ne Dasis W examination arWlor Invesligatlon, In my opinion, deaM occurred al the time date, and place, antl due to the causea(s) and ^ ......, . ...... .... : m ne ss stated ~, ~ J'f H6 - F D~ . .............. ................... .. ...... ......... ..... ............. an r 71a. 0 i. I ~oN T - > REGISTRAR'S SIONANRE AND NUMBER DAT ILED (Ma, ,Day. Year) 1 q r C ~ ~ ',- ~~ 17. ~ :. LSLIr3:LJVL1--{1 ]4. .) /