HomeMy WebLinkAbout10-25-10PETITION FOR P OBATE AND GRANT OF LETTERS
REGISTER OF V~'ILLS OF COUNTY, PENNSYLVAI~iIA
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Estate of i " {~ i1 ~ ~'`•~ ~ ~ ~ `~~ ~ ~~ File Numbe; ~ t~
also known as
,Deceased Social Security Number / ~~' ~ ' ~~ ~ ~ ~~7 ~ ~
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE 'A' or 'B' BELOW:)
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^ ~. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is /are the ~~,~...,z t4~ted in the
last Will of the Decedent dated and codicil(s) dated r~ ~ ~~ - ~
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(State relevant circumstances, e.g., renunciation, death of executor, etc.) __ ! ._.
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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 a~~he:~nsttument~ offered -
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for probate, was not the victim of a killing and was never adjudicated an incapacitated person: ~~ -•~ ~ ~ : - --,
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B. Grant of Letters of Administration
(If applicable, enter: c. t. a.; d. b. n. c. t. a.; pendente lire; durante absentia; da,ra,tte ntinoritate)
Petitioner(s) after a proper search has !have ascertained that Decedent left no Will and was survived by the following spouse (if a.ny) and heirs: (If
Adtniaistration, c.t.a. or d.b.n.c.t.a., enter date of Wil! in Section A above and complete list of heirs.)
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(CONIPLE'TE IN ALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in ~ ~~ ~"°i C~ ~ County, Pennsylvania with his /her last principal residence at
(List scree[ address, town/cit)~, township, county, state, zip code) ,
Decedent, then ~ `~' years of age, died on ~ ~=~ ~ :~ at C~,2t~eb X" Jr- ° c~ P ' ~~ -
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Decedent at death owned property with estimated values as follows: _
(If domiciled in PA) All personal property $ j 5' ~ O
(lf 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:
Where fibre, 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:
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Signature ~`~' Ty ed or Tinted name and residence
Forst RVV-0? rev. ID.l3.06
Name Relationshi Residence
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Page 1 of 2
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Oath of Personal Representative
COI/1;VtONtiVEALTH OF PENNSYLVANIA
SS
COUNTY OF ~ - l~Z~
The Petitioner(s) above-named swear(s) or affirnZ(s) that the statementsJin 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 • ~ ~ C- ~----~--~-~s -
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before me the ~ da
of Signature oJPersona! Representative
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Signature of Personal Representative
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Signature oJPersona! Representative ,_~ ~
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File Number:
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Estate of ~ ~ C /' ,Deceased
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Social ecurity Number: IlU (~ - ~ ~ '' ~~~~ Date of Death: ~~::7U ~~ ~ i,~*~ ti.J) V
AND NOW, ~ ~L~ ~ , in consideration of the foregoin g Petition, satisfactory proof
having been presented b. j~ e me, IT IS DEC REED that Letters _ C3-Y' ~~~ r'Yl ;ni S ~ G~ ~'~
are hereby granted to ~~'~~ its i C ~,
. i.n the above estate
and that the instrument(s) dated
described in the Petition be admitted to probate and filed of reco
FEES
Letters ...............
Short Certificate(s) ....... .
Renunciation(s) ..........
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$ ~, c~
$ Y 4'~
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Supreme Court I.D. No.:
... $
$ Address:
... $
... $
... $
' ' ' $ Telephone:
... $
TOTAL .............. $ ~ ~ ~
Form RW-0' rev. ~o.r3.or Page 2 of 2
Attorney Name:
Ot~~AL REGISTRAR'S ~ERTIFIAT'I~N a~F DEA~~'•I-~
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1105.144 REV 11/2006
TYPE /PRINT IN
PERMANENT
BLACK INK
~~32-3~~
COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CORONER'S CERTIFICATE OF DEATH
(See Instructions and examples on reverse) STATE FILE NUMBER
1. Name of Decedent (RrsL midde, Iasi, suffix) 2. Sex 3. Social Security Number 4. Date of Death (Monet, day, year)
Kevin T McE~oy Male 166 - 66 - 4731 October 18, 2010
5. Age (Last Binfday) Under 1 ear Under 1 day 6. Date of Birth (Month, da , r) 7. Birtltplaoe (City and state a for eign country) Sa. Place of Death (Check anry one)
Mpwq Days Hours Moores Hospital: Other.
25 Yrs n
May 21 , 1 785 Carlisle, PA ^ Inpatient ^ ER /Outpatient ^ DOA ^ Nureing Hone •Residence ^Other • Speciry:
6b. Counry of Death &. C Boro, wp, of Death 6d. Facfiry Name (It rat Insftulion, give street and number) 9. Was Decedent of Hispanic Odgin? ®No ^ Yes 10. Race: American Indian, Black, White, etc.
•
Cumberland
Carlisle
43 West Willow Street (It yes, speary Cuban,
Mezican,PuenoRican,et°.) (Specify)
White
11. Decedents Usual tan Kind of wok done B urin most of work' kfe. Do rat state refired 12. Was Decedent ever in iM 13. Decedent's Education (Speary only highest grade comp leted) 14. Marital Status: Married, Never Marred, 15. Surviving Spo use (If wife, give maitlen name)
Kind of Work Kind of Business / Industry U.S. Amid Forces? Elementary /Secondary (0-12) College (1-4 or 5+) Widowed, Divorced (Specify)
Writer/Producer Music ^Yea ~fNa 2 Never Married -
- 16. Decedent's Mailing Address (Street, sty /town, state, zip coda) Decedent's pA Did Decedent
43 W . Wll lav St . , Apt . 12 17c. ^ Yes, Decedent Lived in Twp.
Actual Residence 17a. State T w
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Carlisle
PA 17013 p
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17d.~No,Decederttuvedwilhin Carlisle
17b.Counry CtIInberland
, Actual Limits of Ciry I Born
18. Fa1Mr's Name (FxsL middle, last, suffix) 19. Mother's Name (First, middle, maiden surname)
Jose h E. Mc~oy Patricia L. F1r~iiTLlllg
20a. Informant's Name (Type I Print) 20b. Informant's Mailing Address (Street, city /town, state, zip code)
Patricia L. Mc~o 309 Stonehed e Drive, Carlisle, PA 17015
21 a. Metftod of Dispositk>n 1 ®Crematlon ^ Daro fat ~ 21 b. Date of Dispositan (Month, day, year) 21 c. Place of Disposfan (Name of rximelery, crematory or shat place) 21 d. Loratbn (Ciry /town, slate, zip code)
^ Burr ^ Removal from State i W~ Crernatlon ar Donation Aufhorized
^ other - sv~h: l by rrl lexentlrter / Corortx7 ®Yes ^ rro C L PA
~ 22a. Signature of Fu I Licensee (or pe
~ 22b. License Number 22c. Name and Address of Faafry
- - ~
~ FDO12633 L Dwing Brothers Funeral HcxT1e, Inc., Carlisle, PA 17013
Complete Hems 23ac only when certllyktg 23a. To the best of my ath occurred at fire rate, date and place slated. (Signature and title) 23b. License Number 23c. Date Signed (Month, day, year)
phyeaian is not available et Mme of death to
cerliry cause of dsM.
- Items 24-28 must be completed by person 24. Time of Death 25. Date Pronamced Deed (Month, day, year) 26. Wa~Case Referred to Medical Examiner /Coroner fa a Reason Other than Cremation or Donation?
wlapraaurtceadeam. Aprx. 1:00 A M, October 18, 2010 Yea ^No
CAUSE OF DEATH (See Instructions and examples) t Approximate iMenal: Pan II: Enter other sianifx:ant axtditions conMbutinq to death, 26. Did Tobacco Use Contribute to Death?
fleet 27. Pan I: Enter the thiID91.flYB[IIS - dfaeasea, injuries, a canpfketfats - that drectly eased the death. W NOT enter terminal events such as cardiac arrest, r Onset ro Death but not resuNing in tM undertying cause given in Pan L [] Yes ^ Probably
respiratory arrest, a veMriculer flxilabon wifaut stewing tM efalogy. Ust arty ate cause on each line.
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^ No ^ Unkrawn
IMMEDIATE CAUSE (Real disease or
catdtanreawtingadeafh) ~ a. Cardiac Arrhythmia ~ .Myocardial Bridging of 29.'iFemale:
[]
Due to (or as a consequence of): ~
SequenfafyGSicortdibns,fany, b. Hypertensive Cardiovascular Disease ;
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the Left Anterior Not pregnant within pest year
^ Pregnantaltimeofdearo
o cause
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ne e. Due to a as a cons uence o r
Enter UNDERLYING CAUSE ( ~ Q~ [] Not pregnant, but pregnant within 42 days
(dseaseorinjurythatinitiatedthe °. ~
events resulting m death) LAST. r Descending Coronary ofdeatn
Due to (or as a consequence of): r [] Na pregnaM, but pregnant 43 days to 1 year
• d. ; Artery berore death
^ Unkrtorm if pregnant within lM past year
30a. Wes an Autopsy 30b. Were Autopsy Findings 37. Manner of Death 32a. Date of Injury (Month, day, year) 32b. Describe How Injury Oceurted 32c. Place d Injury: Frame, Farm, Street, Factory,
Perfomted? Available Prior to Completion
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N Office Building, etc. (Speciy)
of Cause of Death? a
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Wes ^ No ~•Yes ^ No ^ Accident ^ Pending Investigation 32d. Time d Injury 32e. Injury at Wak? 32f. If Trertsponation Inlury (SpedtyJ 32g. Location of Inryry (Street, city /town, state)
^ Suaide ^ CouM Not M Determined ^ No
^ Yes ^ Driver /Operator ^ Paesenga ^Pedestrian
M Other - Specrty: ..-_.. .._. -
338. Certifier (check Doty ate) 33b. Signature and T
• Cartllying physicisn (Physician cenirying cause of death when aratlter physiden has prorauncetl death and canpleted fleet 23) ~r
toner
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TolMbestotmyknowbdge,tlsthoccurrodduetothecauae(s)andtnennerasstatetL-------------------------------- ^ ~
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• Pronouneing end eertlfying physlcisn (Physielan both pratouraing death and afrtfyirtg ro cause d death)
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^ 33c. License Number 33d. Date Signed (Mond, day, year)
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et iM time, date. and place. and due to the caus(e) end manner a sated_ _ _ _ -' _ _ - _ - _ _ _ _ - - -
• Medical Examiner I Coroner October 21, 2 010
On 1M baste o1 exeminstron end I or Invastigatbn, in my opinion, death oceurrW et tM tlme, data, end place, and due to fM cause(s) and manner u sated_ 34 N a r s of P ho Canplet Cause o eM (Item 27) Type /Print
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35. Registrar's t,re and Diehict~N,mtx•t--
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36. Dale Filed (Month, day, year) .
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63 7 5 Bas ehor a Rd . , Suite ~~ 1
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