HomeMy WebLinkAbout09-07-10PETITION FOR PROBATE AND GRANT OF LETT:ERS
REGISTER OF WILLS OF ~ ~ s COUNTY, PENNSYLVANIA
Estate of
also known as
Deceased
- ~ ~.
File Numb ~ _ ~~i~~~ r ~ .1 (_ ~ 1
j ~ ~(J
Social Security Number ~~
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
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Wined in the
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(State relevant circumstances, e.o., renunciation, death of executor, etc.) ;-,~ -~;'- '°-i .-
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Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of"t~ee.i~sfrument(~offered ',
f,1:`:
for probate, was not the victim of a killing and was never adjudicated an incapacitated person: ~?~) "-"
t:~. ~ _
~. Grant of Letters of Administration
(If applicable, enter :• c.t.a.; d. b. n.c.t.a.; pendente lire; durante absentia; durante minoritate)
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
Ad,rtirtistratio,i, c. t. a. ord.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.)
ecedent was domiciled at d~th in ~ C1~~~~ County, Pennsylvania with his /her last principal residence at i'
(List street address, town/city, township, counh~, ~st'ate, zip code) ~,
Decedent, then ;~~ Years of age, died on ® at C. 1
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:
Wherefore, Petitioner(s) respectfully requests} the probate of the last W iif and Codicil(s) presented with this Petition and the grant of Letters in the appropriate form to
the undersigned:
I _ Si~~nah,re _ Tvoed or printed name and residence I
For-nc RW-(J? ,-e v. 10.!3.06
Page 1 of 2
(COtYIPLETE IN ALL CASES:) Attacl: addt'tioiia[ sheets if necessary.
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RENUNCIATION' ' ~ ~ ~-, ` ~ :.
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RE ISTER OF WILLS ~ ~ - ~ ~--.
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~ COUI~ITTY, PENNSYLVANIA ~ `,~ w. . ,
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Estate of ~p ~~ ___ _ ,Deceased
I, ~ ~ ~ ~~~ ~ ~ .~~ , in my capacity/relationship as
(Print Name)
of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
~. A ,/ _ _
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{Date)
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(Signature) ~-
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(Street Address)
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(City, State. Zip)
Executed in Register's Office
Swot-n to or affirmed a subscribed
before e this - day
of ? ~,: , ~r ~~-
Deputy for Register of Wills
Form RlV-06 rev, 10.13.06
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 L' "~~ day
Notary Public ~~
My Commission Expires: ~'~_~ ~~j~~%,~~ ~ ~ ~,.c~ 1,~-~..
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(Signature and Seal of Notary or other official qualified to
administer oaths Show date ofgqexptr~t Notary's Commission.)
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3 REV 11/2006
/ PRINT IN
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ACK INK
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS t
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CERTIFICATE OF DEATH
(See instructions and examples on reverse) CTATF FII F NI IMGFR
1. Name of Decedent (First, middle, last, suffix) 2. Sex 3. S°cial Security Number 4. Dale of Death (Month, day, year)
Tina M.Askins female 184 - 48- 8064 June 17, 2010
5. Age (Last Birthday) Under 1 ear Under t da 6 Date of Birth Month, da , ear 7. Birth lace CI and state or for ei count 6a. Place of Death Check onl one)
52 Months Days Hours Minutes
5-15-58
Harrisburg Hospital:
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^ Other.
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ER /Outpatient
~ Inpatient y:
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ursing Home
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Bb. County of Death fic. City, Boro, Twp of Death 8d. Factlily Name (If not institution, give street and number) 9. Was Decedent of Hispanic Origin? }a No ^ Ye:; 10 Rats: American Indian, Black, White, etc
• Cumberland Camp Hill Holy Spirit Hospital (,f yea,specitycuban, {Specify)
Mexican, Puerto Rican, etc.) whit e
11. Decedent's Usual Occu fion Kind of work d one Burin rtrost of work life. Do not state retired 12. Was Decedent ever in the 13. Decedent's Education (Specify only highest grade completed) 14. Madtal Status: Married, Never Married, t 5 Surviving Spouse pt wife, give maiden name)
Kind a Work Kind of Business/Industry U.S. Armed Forces? Elementary /Secondary (0-12) College (1-4 or 5+) Widowed, Divorced (Specity)
d
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Michael
clerk magistrate ^vea C~No 12 - marr
e
~ 16. Qecedent's Mating Address (Street, city /town, state, zip code) Decedent's Did Decedent
Decedent Lived in East P e n n s b o r o Twp.
P P n n a Live in a 17c
~ Yes
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631 Gates Lane .
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Cumberland rnwnsmp?
17d ^ No, Decedent Lived within
17b
nt
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E n o l a P a 1 7 2 5 .
ou
y
Actual limits of City/ Boro
18. Father's Name (First, middle, Iasi, suffix) 19. Mother's Name (First, middle, maiden surname)
Au ustine Bri idle Emma Rohrbach
20a. Informant's Name (Type /Print)
Michael S.Askins 20b. informant's Mailing Address (Street, city !town, state, zip code)
631 Gates Lane Enola Pa 17025
21a. Method of Disposition r ^ Cremation ^ Donation 216. Date of Disposition (Month, day, year) 21c. Place of Disposition (Name o1 cemetery, crematory or other place) 21 d. Location (City /town, state, zip code)
r
Burial ^ Removal from State r Was Cremation or Donation Authorized
6 - 2 2 -10
Resurrection Cemetery
W .Hanover Twp P a
^ ther - S i I by Medical EzaminerlCororrer? ^ Ves® No
~ 22a. S' urrera ce Li ( son acting as such) 22b. License Number 22c. Name end Address of Facility
. ~ ~ ~ - FD013945L Neumyer Funeral Homelnc 1334 N. 2nd St :Hbg Pa 17102
Complete items 23a c only when certifying 23a. To the best of my kn dge, death occurred ~t the time, date and place stated. (Signature and title) 23b. License Number 23r,. Date Signed (Month, day, year)
physician is not available at time of death to // J~
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certity cause of death. j`_
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Items 24-26 must be completed by person 24. Time of Death 26. Date Pronounced Dead (Month, day, year) 26. Was Case Referred to edical Examiner /Coroner for a Reason Other than Cremation or Donation?
N
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who pronounces death. S U ~ ~~ - M, ,.T L~ y.i ~ ~ ~ ~ t/j t ~ Yes
o
CAUSE OF DEATH (See Instructlona and examples) r Approximate intervaL• Part II: Enter other sj~ficanl condifions contributing to death. 28. Dld Tobacco Use Contribute to Death?
Item 27. Part 1: Enter the chain of events -diseases, injuries, or complications -that directty catued the death. DO NOT enter terminal events such as cardiac arrest, ~ Onset to Death but not resulting in the underlying cause given in Part I. ^ Yes ^ Probably
respiratory arrest, or ventricular fibrillation without showing the etiology. List only one cause on each line. t
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^ No Unknown
IMMEDIATE CAUSE (Final disease or I ~~
condition resulting in death) >, j "j ~,~ f) ( ~ ~ -v t '~ < l // j-~ , . l t- f! la` d ' r + ` 1 ~
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, 29 If F male.
Not
re
nant within past
ear
.
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Due to (or as a consequence of)'.
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Pregnant at time of death
Sequentially list conditions, f any, b I
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leading to the cause listed on line a.
i Not pregnant, but pregnant within 42 days
Due to or as a conse uence o
Enter the UNDEFLYING CAUSE ( q ~ of death
(riisease or injury tlrat in'Itiated the I
c
nt
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t 43 da
s to 1
ear
N
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na
events resulting m death) LAST.
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• Due to or as a conse uence °
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pr
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y
pregna
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n
a
before death
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Unknown if pregnant within the past year
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30a. Was an Autopsy 30b. Were Autopsy Findings r of Death
3 32a. Date of Injury (Month, day, year) 32b. Oascr(be How Injury Occuned 32c. Place of Injury: Home, Farm, Street, Factory,
Pertormed? Available Pnor to Completion
of Cause of Death? .~
Natural ^ Homicide Office Building, etc. (Specify)
^ Accident ^ Pending Investigation 32d. Time of Injury 32e. Injury at Work? 32i. If Transportation Injury (SpecilyJ 32g. Location of injury (Street, city /town, state)
^ Yes ~o ^ Yes ^ No
^ Y
^ N
~ DriverlOperator ^ Passenger ^ Pedestrian
AA ^ Suicide ^ Could Not be Determined M. es
o
^ Other - Specify:
33e. Certifier (check Dory one)
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33b. Signature and Tdie of Certifier -
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Certifying phyalcian (Physician cedllying cause of death when another physician has pronounced death and completed Item 23)
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e cause(s) an
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To the best of my knowledge, death occurre 33c. License Number 33d. Date Signed (Month, day, year) -
• Pronouncing and cerlHying physician (Physician both pronouncing death and certifying to cause of death)
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manner as s
ate
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To the best W my knowledge, death occurred at the time, date, and place, and due to the cause(s) an ,
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• Medical Examiner/Coroner
On the basis of examination and / or Investigation, In my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner as stated_ ^
34. Name and Address of Person Who Completed Cause of Death (Item 27) Type 1 Prin+. G f . } ,` t I (, ; I J
Registrars S' re and Distric r ~f~ ~ ~„t I ,J I ~ I ~ I ` I 36• Dat//G ~
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Disposition Permit No. o