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HomeMy WebLinkAbout09-27-10PETITION FOR PROBATE AND GRANT OF LETTERS REGISTER OF WILLS OF ~~~-~~) d-~ ~ COUNTY, PENNSYL~/ANIA Estate of 5 ~. t r' ~ P u iEk/~~ ~ ~~ A~Zt rt•-~' also known as Deceased File Number ~ I ~- I ~~ ~-- l~ t'~~~ Social Security Number .2~t ~ ~ t7Z" ~ ~ ~ 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 named in the r"' `~ - <.... ~,.. _ ,, -~ ~~. (State relevant circwnstnnces, e.g., renunciation, death of executor, etc.) : T1 ~ f-rj ?,~ ~ ,: ~ '~ -(~ ~---' Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of-f~t~tisttument~offeie~d; __ ~...1 for probate, was not the victim of a killing and was never adjudicated an incapacitated person: ' " " r ~. :. : tom, ,. ~ , B. Grant of Letters of Administration ~ - ~ ''~ -^` . .J fir (Ifnpplicnble, eater: c. t.n.,- d. b. n. c. t. n.; pe„dente life,, durnnte absentia; durnnCg.~iinoritate) _ ~•..: Petitioner(s) after a prope-- search has /have ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs: (If Adrr,iitistration, c. t. a. ord.b.n.c.t.a., enter date of Will In Section A above and complete list of heirs.) ~~ `~ ,~ ~ 3'? (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. Decedent Si domiciled at death in f ~ q ~ (List street tiddres•s, town/city, totivns tip, counl}J, st e, zip code) County, PennsyJ,vania with his /her last principal residence at Decedent, then C.P ~ years of age, died on ! ~ / at t ~ V t' ~o'r ~`~a 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 $ ~ ~o,-,,, Rw-0~ re,~. 10.13.06 Page 1 of 2 a situated as follows: _ 0~~,~e~ ~- ~f';~~,r- t (~"~`~ CCx:~' > ~~' ~ V -~ ~oOJ~,s Wherefore, Petitioner(s) respectfully request(s) the probate of the last Wiil and Codicil(s) presented with this Petition and the Grant of Letters in the appropriate form to dle undersigned: Oath of Personal Representative COMMONtiVEALTH OF PEN~iS~'LVANIA ~~` ~~ SS COUNTY OF uM : '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 or affirmed and subscribed before me tl~e .-f ~ ( day of ~-. ~a Signature of Persona( Representative ~~ ~,..~ -° - - { ~ . ~ ~ .:~ ~-a to r - Fo; the Regi ter Signature of Persona! Rzpresentatwe 7 ~:A ~ .. ~ _~ f!3 " , ~ , : 7 ...~~,. ~. - File Number: ~` ~ ~ - ~~` l ~ ~ -~ ~ ~~ ~ `~ .., v ' Estate of ~~'~~ ~ ~ i l.f' ~ 1 ~ 1) I ~ ~ ~'tZ ~ 1 ti1~ r _ _, Deceased Social Security Number: (~ ~ ~-- L~ ~' l~ C`l ~--~ 1 Date of Death: ~~ ~ / ~~ ~.1 b AND NOW, ~~ -~-t' ~ > ~ ~~_~~, ,~,~ ~] , --~ ! ! , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters ~' ~ ~~ rlf d f -Y(~~.~~ are hereby granted to ~,t (' ~~~ r ~ ~, ~~~Z-~ 1`~~.,~ 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. p. ,, -' - f-, . c FEES ~, r 'V ~ - ~ ~. `_ _ Reyrsr~,~ of wars ~"' ~'~` (,~,~ ~;1:(, Letters ............... $ ''=~O C ; Z~ ~. Short Certificate(s) ........ $ l r~~ ~ ~` ~-' Renunciation(s) .......... $ ... $ ... $ ... $ ... $ ... $ ... $ ... $ _ ~ ~ ~l TOTAL .............. $ t )~ Attorney Signature: ~M" ~ J ._ Attorney Name: ~~ t , ~ ~~, ~ 4 Supreme Court LD. No.: ,~ ~ l 0 5~0 ~ ._.._ ___ _ _ Address: ~ J`~ 3 N~-~ ~'' ry o t~ . (ycx.~rr+ i S ~O V t'1' P-d ('~ j I~ Telephone: "~ ~ ~ ~~y_ ~ ~~ z Page 2 of 2 I-'urur RVV-O' rcv. lU.lj.O( OCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograpl-i., ('~~ Sf~r~ thl~~ <crtlt)cate. ~(~.OO P 16. ~ 7 4 5.2__3__.. __- Certit-ication NumhL~r -';rrr„~.,.~~;~~ ~(f~lltCt(}'(.(>f?1l'1~~11.1)~T~ii;;(~t~('Il~~l(la~ ~~c~Ctl(l~C, thOf Un i5 ~~tt~,,~~t~,~.~H OF-p~~; ~..~ , . _ ~ ~ , - „ Bath Jp, ~',~~:~ (l~(fy filed with nrE~ <j~ I ~T~•al hc,istr~ -. Z'}7~ (~ri~~ina9 ~' `' '~~`' zt'rTif~i~aie d~~'i t 1/ )~wa(-d~d the. 5tate~ Vital ~ % ~ ' Z ~fl o ~ ,~ ~f ~,~ 1~( Rr~:~cc>rds -_ fi~~ (71 ;,~rr~ el~t ~ ling. i ,, . ,, ~9rMENT 0~~~% -- -- - - ---- - _ ~-- - _a, ~ ~ car -_ r ~ ^ i ~~ -dip ~ r'--~ - ___. rn tV -_ , .- -,_-_ ,y- ~! ~, ~`i- _ ~ ~.., ...1 ~ ~ ~ -.~) j ,^~ -ti-7 '[7 ~ N ~ :~_ ~'j H105-143 REV 11!2006 TYPE /PRINT IN PERMANENT BLACK INK ri 0 w w 0 0 w z COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS - © "r> C_-,_,.'s CERTIFICATE OF DEATH ~ (See instructions and examples on reverse) STATE FILE NUMBER 1. Name of Decedent (First, middle, last, suffix) 2. Sez 3. Soda! Security Number 4. Date o each (Month, day, year) ' Shirley Ann KazimPx fs~le ZOl _ 42 _6941 (~ ~~ ~ 5. Age (Last Birthday) Under 1 ar Under 1 da 6. Date of Birth Month, de , r 7. Birth lace C and state or lor ei n count Ba. Place of Death Check on one ~ Months Days Hours Minuses 1950 April 25 (+ ~71I1gt~1 D•C• Hospital' ,~, ~ Other: Yrs. , n tient ^ ER /Out alient ^ DOA '~I pe p ^ Nursin Home g ^ Residence ^ Other - SpecNy: 8b. County of Death 8c. City, Boro, Twp. of Death 8d. Fadlity Name (If not institution, give street and number) 9. Was Decedent o1 Hispanic Odgin? ~ No ^Yes 10. Race: American Indian, Black, White, etc. I~uphuu I~c1rrl~Shl1T'~; ~m GL _~_ 7T__l~ 1 Ul1L ' I-iKA7 (11 yes, spedfy Cuban, (Specily~ ' b } Mexican, Puerto Rican, etc.) j~ 11~ 11. Decedent's Usual Occ lion Kind of work done d udn most of woddn life. Do not state retired 12. Was Decedent ever in the 13. Decedent's Educatbn (Specify only highest grade comp leted) 14. Marital Status: Married, Never Married, 15. Surviving Spo use (d rode, give maiden name) Kind or Work Kind of Business/Industry U.S. Armed Forces? Elementary !Secondary (0-12) College (1-4 or Si) Widowed, Divorced (Specify) ~~ 1 E I~ 1 n11rSe healthf:are ^Yes ~ No 3 IiSIT1ed c . aZ I0er 16. Decedent's Mailing Address (Street, city /town, state, zip code) Decedent's Did Decedent 519 Shippl~sburg Rd . ? 17c. Yes, Decedent Lived in ~H -1;~WP~ ~ Trop. Actual Residence 17a. State PA T hi owns p 17d. ^ No, Decedent Lived within ~IIlberj alld Shippensburg, Pa. 17257 . 17b. County AdualLimitsof City/Boro 18. Fatfrer's Name Fir middl , I st, s ~ ~ 19. Mother's Neme (First, middle, maiden sumeme) er Jose ~. S c~ R. E]-izabeth Breeden 20a. Informant's Name (Type /Print) 20b. Infonnent's Mailing Address (Street, ci /town, state, zip code) Richard E. Kazimer 519 Shippensburg I~d. Shippt~sburg, Pa. 17257 21 a. Method of Disposition r ~ Cremation ^ Donatron 21b. Date of Disposition (Month, day, year) 21 c. Place of Disposition (Name of cemetery, crematory or other place) 21d. Location (City/town, state, zip code) r ^ Burial ^ Removal from state ~ Wac Cremation or Donation Authorized 12 2010 Aug Inc. Dllgail Funeral Harle & G4>?.nntory Shippf~sburg, Pa. 17257 ^ Other - S by Medical Examiner/Coroner. ®Yes^ No , • , . 22a. Signature of Funeral Service Licensee (or person acting as such) 22b. License Number 22c. Name end Address of Facility ~ ~ FD-012884-L ~~ ~ ~ (~~to ,Inc. 51 Asper Dr. ShiPpensburg, Pa. 17257 Complete Hems 23a-c Doty when certifying 23a. To the best of my knwwledge, death occurred at the time, date end place stated. (Signature and tide) 23b. License Number 23c. Date Signed (Momh, day, year) physician is nos available at time of deelh to certify cause of death. Items 24.26 must be completed by person 24. Time of Death A r 25. Date Pr rxd Dead (Month, y, year) ,{ a 26. Was Case Reterted t edicel Examiner i Coroner for a Reason Other than Cremation or Donation? who pronounces death. ~ ~/, M !/ ! /~ / / / ^Yes No CAUSE OF DEATH (See Inatructlona and ex plea) r Approximate interval: Pad II: Enter otfter sionifirant conditions contributirte to death. 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 enter terminal events such as cardiac arrest, ~ Onset to Death but not resuding in the undedying cause given in Parl I. ^Yes ^ Probably respiratory arrest, or ventricular fibrillation without sh/owing the etiobgy. List only one cause on each line. r No ^ Unknown IMMEDIATE CA 9SE (Final diseas~ a at~ /~ .1 ~~ i condAion resuttin in elh , J J V r /~ a~t ~./ ~ ~~~~ G / / `^'~! 29. II Femal Due to (or as a J~ryse ce of): , of pregnant within past year t ti f d th ^ P t SeqGuentially list conditions, it any, b .J ~ ~~ t, ~~~L ~ NAM 1~/~,r /~Q ~~ J , V regnan me o ea e ^ feeding to the cause listed on line a r r Enter the UNDERLYING CAUSE Due to (or as ~puence o /• ~ { Nor pregnant, but pregnant within 42 days of death ~ ~ ~IY i (disease or injury that initiated the c. ~R /I~ fM.~ ~ 'C~ ~ r~ ath) LAST t di d --JJ~ _ ~ ~;/~ ~Cf j J r ^ even s resu ng m e . r Due to (or as a cronsequence oQ: r ~e ~ L ~' My ~~ ~ Nol pregnant, bus pregnan143 days ro 1 year before death d. r r ~ ~ .{ "''/ ^ Unknown it pregnant wthin the past year 30a. Was an Autopsy 30b. Were Autopsy Findings 31. Manner of Death 32a. Date of Injury (Month, day, year) 32b. Describe How Injury Occurred 32c. Place of Injury: Home, Farm, Streer, Factory, Pedomted? Available Prior to Completion ~~-~!/ ^ Office Building, etc. (Spr!ciyJ of Cayse of Death? L~7Nalural Homicide ^ Y ^ Y ^ N ^ Accident ^ Pending Investigation 32d. Time o1 Injury 32e. Injury at Work? 32f. 11 Trensportation Injury (Sped .Location o1 injury (Street, city /town, state) es o es o ^ Suicide ^ Could Not be Determined ^Yes ^ No ^ Ddver/Operator ^ Pas nger Pedestrian M' ^ Other - Specity: 33a. Cenifier (check only one) 33b. Signature and Thle difler Y /~ ~ _ • Certltying phyelolan (Physician certifying rouse of death when another physican has pronounced death and completed Item 23) To the best of my knowledge, death occurred due to the cause(s) end manner as stated _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ \ ' - ~ W w • Pronouncing end certitying physician (Physician bosh prorauncing death and certitying to cause of death) To the best o1 my knowledge, death oaurrcd at the time, date, and place, and due to the cause(s) end manner es stated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ 33c. License Number ~y~~ ~ {1/ 33d. Date goad (Month, day, r) ~ ~~ • Medical Examiner/Coroner ( / - Onthe basis of ezeminatfon end / or investigetlon, in my n, deal ccurred at the time, date, end place, and due to the cause(s) and manner as stated_ ^ 34/./y' e a d ss of eef~n o C eJd~C u/§e.~,7y=n~'ath ( 7J Type / P °..~ V ! ~ 35, Registrar's Signature and D' xM N r 36 a Filed (Month day, year) / V / . / / / / , ~ ~ ~ _ `~~' ~~~c~~ s~ Disposition Permit No.