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HomeMy WebLinkAbout11-12-10PETITION FOR PROBATE AND GR~A.~,TT OF LETTERS REGISTER OF WILLS OF ~`.~c~~~~ ` ~~-~'`~~.:.~ COLTiTY, PENNSYLVANIA Estate of ~~~_. r•\y ~ `~ SCC. t ~t ~.C`~ --~~~1'{~-;r'' File Number ~ ~ ~ t ~' - ~,~~ 't~~ - also known as 1 ~` ,Deceased Social Security Number ~~ L ~ ~ ~~ w ~`~ `~ - Petitioners}, who islare 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 ~~~:_-x? - C~7amed~ui_t]to, .r !ast Will of the ~~ and codicil(s) dated _ ._ ~ ~"' ,,,_ -- - --- (State relevant circumstances, e.g., renunciation, death of executor, etc.J ~ ;~ '"C7 - ~ .. - Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the~nstiument fs~ offered ~~ ~~~~ for probate, was not the victim of a killing and was never adjudicated an incapacitated person: -~=' ~ Q'~ ~B. Grant of Letters of Administration (Ifapplicable, enter: c.t.a.; d. b. n. c. t. a.; pendente life; durante absentia; durante rninoritate) (COMPLETE CN ALL CASES:) Attach additia:al sheets if itecessar}~. Decedent was domiciled atCdeath in ~'~~ _ ~ Y~ t:ounty, Pennsylvania with his !her last principal residence at l \(~'~r~ ~r`~-tom : ~ 1 ~ f~ \~ n . ~~~~~ 1~ ~~\ 1f' C.~ ~v -~. St 1/ _ \ C) r „-, ~ r' ~ ~,• (List street address, totiw,lcity, township, counh~, state, zip code) V Decedent, then ~~ years of age, died on ~ '~L ~~t 4 '}~`\ l` 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 :~~'..uated as follows: i1t l~ $~~, t~OC74 Oct )~ ~(lC"~ ~ttherefore, Petitioner(s) respectfully request(s) the probate of the last W i!I and Codicil(s) presented with this Petition and the grant of Letters in the appropriate form to the undersigned: Si~~nature Typed or printed name and residence 1 !'/~ . Fora, RNV-~? retie. 10.13.06 l~ Page 1 of 2 ~r`?~ 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: (,f Adnzirtistration, c. t. a. ord. b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.) Oath of Personal Representative COM~IONtiVEALTH OF PENi~'SYLVANIA COUNTY OF SS The Petitioner(s) above-named swear(s) or affirn~(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 ~`I ~t .~ X ~ ~ l ~~ l../~' l `` - - -. Signah:re oJPersonal Representative r-.~ before me the ~ _-'1. day of C~7 ` -` t ~ Q ~ , r ~ ~1 ~ \'V~ ~~ ~ ~ ~ ~ ~' \ ,' ,~ ~ ~~ Signature of Persona! Representative ~" ~ --~-~ ' ~ ~~ For the Register Signature of Persara! Representative ~ ; ~. ,, f ,_~ ~ t ^ - .'~ r . ' ~ ' 1 ~ -- _.r._.~ --1 --- ~ ~ ~ ~ tl ~ ~ ~.~~1 ~ File Number: ~ Estate of ~ ~.(~ ~~ ~_ ~1 ~~~!~-~4'~~" ~~ ~'``L~~Y ~ ~'i ~'~~ ,Deceased Social Security Number:~;~~ ~ ~.G - ~(~ - ! ~' ~~t ~ Date of Death: ~~ ~ °~ ~ % °= ~ "~~ AND NOW, `~;(~,L~ ~ ~ l{~~' ~ ~ ~ ~'~~' ~L~ , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters '~ (,~~- ~ (~ ~ f ~~~ t ~~> "~ _,t. ~ ~~- ~7 (. ~'~~ are hereby granted to l'1;~,(; % ~~ ~"~ ~2~~ t`- ~-~~ ~¢~%~ ~ ~ ; Y ~'~`~- ~ -- 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. FEES ( ~ '~-`, ;' -~.,~~- `~ ~,L C,,! l ,, ~ Register of Wi!!s ; , , i 4 Letters ............... $ ~ ~~'? ~ ~ i. l ,1~'~~_ ~-'- L. ~~~~ ~ ~)~ G'r- ~ t ~, Short Certificate(s) ........ $ J L Renunciation(s) .......... $ ~`~? ~;; C~ ~-~C~~ ~C 1 L'i C~ I d ... $ ... $ ... $ ... $ ... $ ... $ ... $ TOTAL .............. $ ~ i ~~( Attorney Signature: Attorney Name: Supreme Court I.D. No.: Address: Telephone: ~ n Page 2 of 2 Furui RbV-U? rev. lUJ3.UG 1l)~.K(1~ RF.V ii)I/1,'-71 ~4~AL REGISTRAR'S CERTIF{CAT14N 4~' D~AtTH V~l'ARNING: It is illegal to dupiical:e this copy ay photostat or pf~otogr~pr~. ~E'~ 1(yl' t}llti CE'I-tltlt;rat~. ~fi.(~f> ~ ~rr~r„`~"„~`;, jhiti 1`, t(t ra'rrii~~ 4°,l<11 11)t' 1)ltOrI1T.itlOi] ~tc're gl~t~ll l~ tort ZH Cif ~; ~,P~ ~- --~'Eiy~~ .~r~trt~~al~ c~L~~rie+,i ~Ii.li~, an (~r'i~~rrnal C~itik~ic~t~: of [~)r~~-th ,~~`~ot,, ~...r; _~, duly fil~~l +~ ith a)i ° ~(~, L(rcal Registrar. Tire <)ri<Yinal ~~~~ `' \`;Z>~~ ~ ,i~rt5wt~<tt~ r~ ,! '~~' t,(-~.~ardfid t(~ tl `~;tate '~!ital .. ~ ~ ' _ ~'~~ ,;~ - ~a,.`~ l~tc't,t'd~ x)'11 ltlr ~~r~~it t j1 g. r ~, .. ,~ ~,, -_ - __ ,- a P 167755~~ ~`'° _ ~~`'r ~, qqr~- ~ti~,f~ „~ ~__~.___ ~_._..---._._.._.. __ ._._______.._..-._ --~~ _ p I .__. _.___..__.___ _..__. ..-_._--- ~ .r ~.,.__„ ENS ~ ~ - -- ..-.-~, t ,t~C: K~'~'.l ~tra!~ N ~~ate f sSUe:tl ~~~rtl~ll'ahC)il ~i111T)r1t'r ~`~~>~••'~"r'rr'~~ , ' n Q ~ ~, _ ~~~i'~ ~ - - _, J ~--ti. ~-~ t.. ~:.~ ~~ -~ H105.144 REV 11f2006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS . -~ ~ ..~ ~- r~ TYPE !PRINT IN s ---( ~ ~ "- PERMANENT CORONER S CERTiFfCATE OF DEATH ~, . ~ ~, ~ BLACK INK (spa instructions and examales on reverse) STGTF FII F NI IMR~F" s.. ~- __... w w 0 LL 0 w z 9f 3L-3~b Sex 2 3. Sopal Secumy Number 4. Date of Death (Month, day, 1. Name of Decedent (First, middle, last, suffix) Dennis J Bonner . Male 216 -72 - 6297 October 2 5. Age (Last Birthday) Under 1 year lhxler 1 day 6. Date of Binh (Month, day, year) 7. Birthplace (City acrd stale or foreign country) 8a. Place of Death (CFreck only one) kbnms Deys Hours Mmuies Hospital: Other. Yrs. Jul 10 19 5 5 },,,,..,, FrostburP r ~ • ^ Inpatient ^ ER /Outpatient ^ DOA ^ Nursing Home Residence ^Other -Specify. 8b. Courtly of Death 8c. City, Boro w of Death 6d. Facility Name (it not inslBUtbn, give street end number) 9. Was Decedent of Hispanic Origin? ©No ^Yes 10. Race American Indian, Black, White, etc. (Specil • ~~ (If yes, specify Cuban, Cum erland hi en bur 1 8 T Mexican,PuenoRican,etc.) 11. Decedent's Usual Occ tan Kind of work do ne dudn moll of world life. Do neA scale retired 12. Was Decedent ever in the 13. Decedent's Education (Specify only highest grade completed) 14. Marital Status: Married, Never Mamed. 15. Surviving Spouse (II wife, give maiden name) Widowed, Divorced {Specify) Kind o1 Work Kind WBusiness / Industry V.S. Amred Forces? Elemantary f Secondary (0-12) 2 College (1-4 or 5+) d d laborer tlle3t piaclcag~rrg ^Yes ®No 1 .1VOrce 16. Decedent's Maili Address Street, cd !town, state. zi code n9 ( Y P ) Decedent's Did Decedent P}, Live in a 17c. ®Yes, Decedent Lived in,,Q~].nT]PncMlrg T'NP l,oo ,~ ~^~ T ^~^ .X~ 1~11ux1 ttuic Actual Residence 17a. State Township? ,ived within cedent r1~ 17d. ^ Ne, Di Shippf~sburg, Pa. 17257 y o L cit / Boro 17b. County 16. Father's Name (First, middle, last, suttiz) 18. Mother's Name {First, middle, maiden surname) James A. Bauer IAis Teeter 20a. Informant's Neme (Type /Print) 20b. Informant's Mailing Address (Street, city !town, slate, zip code) f 17257 sbur Pa l Shi 138 'l`i b Heather Bonner ~i . pp g, ane m er 21a. Method of Daposdan ®Cremation ^ Donation 21 b. Date of Disposition (Month, day, year) 21c. Place of Disposition (Name of cemetery, crematory or other place) 21d. Location (Coy !town, stale, zip code) ~ ^ Burial ^ Removal from State i Was Cremation a Donation Authorized 1~/7/ZO10 c'ill Funeral Have & Cranatory l)Ll P Shi.ppens , Pd. 17257 ^ Other . g~/y; ~ by Medical Examiner /Coroner? ~ Yes ^ No , y ~ 22a. Signature of Funeral Service Licensee (or person acting as such) 22b. License Number 22c. Name and Address of Fadt'ny _ ~ .~ FD-Q1288G.-i, A.~in Funeral Hare and Cramtory, Inc. 51 Asper Dr. ShiPPensburg, Pa. 17257 Complete Items 23ec only when certifying . To the best of my knowledge, death occurred a1 the Ume, data and place stated. (Signature end title) 23b. License Number 23c. Date Signed (Month, day, year) ptrysictian a not available et time o1 death to cerdfy cause of tleath. Time of Death 25. Date Pronounced Dead {tAonlh, day, year) 26. Was Case Referred to Medical Examiner I Coroner 24 for a Reason Other than Cremation or Donation? . Items 24-26 must be completetl by person Yes ^ No who pronounces death. A rX ~. M. O e t o b e r 5 2 010 CAUSE OF DEATH (See Msrtuctlons and examples) r Approximate interval. Part II' Enter other grynifiranl condaions contributing to death, in Pan I i i i h l d 28. Did Tobacco Use Contribute to Death? ^Yes ^ Probably . ven ng cause g n t e un er y Item 27. Pan I: Enter the of events -diseases, injuries, acomplications - that directly caused the death. DO NOT enter terminal events such as cardiac arrest, r Onset W Death but not resulting k N U respiratory arrest or ventricular fibrillation whtwut stwwing the etipbgy. List only one cause on each line. ~ nown n o ^ ^ r IMMEDfATE CAUSE Rnal disease a r condition resulting in r~th) P r ob a b 1 e Pulmonary Embo 1 i sm ~ 29. If Female: nant within past year ^ Not re _~ a Oue to (a as a consequence of): ~ p g ^ Pregnant at time of death if an uentiall Gsl conddions Se , y, b, ~ q y leadmgg to the cause laced on Gne a. Enter fhe UNDERLYING CAUSE Due to (or as a consequence of). r r (disease or injury that initialed the ^ Not pregnant, but pregnant within 42 days oI death c events resultrng m death) LAST. ~ [] Not pregnant, but pregnant 43 days 101 year Due to (or as a consequence of 1: r r helae death ^ Unkrwwn it pregnant within the past year ~ d 30a, Was an Autopsy 30b. Were Autopsy Findings 31. Manner of Death 32a. Date of Injury (Month, day, year) 326. Describe How Injury Occurred 32c. Place of Injury: Home, Fartn, Street, Factory, Office Building, etc. (SpecityJ Penormed? Available Prior to Completion f D th? f C ~t YSLNalural ^ Honicide ea o ause o ^ Accident ^ Pending Investigation 32d. Time of Injury 32e. Injury at Work? 321.11 Transponalion Injury rSpecity) 32g. Location of Injury (Street, sty !town, slate) Yes No ^ Yes No ^ ^ ^Yes ^ No ^ Driver /Operator ^ Passenger ^Pedestrian ^ Suicide ^ Could Not be Detertnined M Aber -Specify: 33a. Cenitier (check only one) 33b. Signature and Ti I e i • Certifying physician (Physician cenitying cause of death when another physician has pronounced death and completed Item 23) _ _ _ _ _ _ _ _ _ _ - ^ _ ed due to the cause(s) and manner as ctated th c ur de k l d T h h 1 ' ~ , j ~- ~, cone r ~ C` _ _ _ _ _ _ _ _ _ _ _ _ _ _ .. - _ _ - _ _ a o c r e eal 0 my now e ge, o t f d th License Number 33d, Date Signed (Month, day, year) 33c ) ^ ea • Pronouncing end anHying physician (Physician both pronouncing death end cenAying to cause o d . _ - - .. _ _ ~ _ - - _ - - - - - - - To the best of my knowledge, death occurred al the lime, date, and place, and due to the cause(s) end manner se state O c t o b e • Medical Examiner !Coroner and due b the cause(s) and manner as stated_ ~ and lace t the tim date i li tl d th d d I i m i i ( of Death (llem 27) type 1 Print s l d C Wh C l P p , , nves ga on, n y op n on, ea occurre a e, a On the beefs of exam nailon an anp e au e e 34 Name and Address of erson o Todd C. Eckenrode, Coroner .~ Regislrar'sSignalureandD r -ilea( ln,aav ad 36 6375 Basehore Rd. , Suite ~I1 ~ ~ I ~ i ZI ` -a.7 ~ O D G / Disposition Permit No. Lj 5 '? a - . {, r-..a c~ __ _, C ~] ~ ~ ~ `,- _ ' - ~~ -t~ -~~~ ~ ~ _. ,~ , _ _ ~ ~ ~ ; < < - ' RENUNCIATION A~ r _ ~;, _ ~,~ _ ,, , ;_ _.~ -- .~, . ~= `~~ ~ ;~ ~ :: - REGISTI~R OF WILLS _ - ~` -~-} ~~' .. ~" - k ~ .._~.~ ~~~ _~ ~ __ 13~.'~ Je~~v~~~ COUNTY, PENNSYLVANIA ~''' rr, Estate of r~~ ~~'1~~~ ~x~~5 r~C~C1~~~' ,Deceased I, ~,a, ~..r ~`_'~ ~ l(~,~,C?~`~ ~ t ~ n nt' ~E` , 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 r'e'- r~~-ro (Date) Executed in Register's Office Sworn to or affirmed and subscribed before me this day of ~, a ~-~'h ~..~y~2 1',~~~ (Signature) (Street Address) (City, State, Zip) 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 `~~~ ~~.,. day Deputy for Register of Wills Notary Public My Commission Expires: t c'~ -- t:?~ ~-~.,~ t `~-- (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission.) Form RW-06 rev. 10.13.116