HomeMy WebLinkAbout02-24-11PETITION FOR PROBATE AND GRANT OF LETTERS
REGISTER OF WILLS OF ' ' 1 ~~' ~ COUNTY, PENNSYLVAI~ IA
Estate of ~ \. ~ ~ 1.s-%"~ ~ V ~ L- (~ File Number -~ ~ - ~ ~ •-V C...:~ >~t~~ t--~
also known as - ~ ` t ~ ~-
- ,Deceased Social Security Number ~ ~,~ 6
Petitioner(s), who is/are 18 years of age or older, apply(ies) for:
(COMPLETE 'A' or 'B' BELOW.)
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^ A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is /are the C' ~ ruined inure ~~
last Will of the Decedent dated and codicil(s) dated ~`~ ~'~-' ~~
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(State relevant circumstances, e.g., renunciation, death ojexecutor, 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 of~the;mstrument(s~offered 1
for probate, was not the victim of a killing and was never adjudicated an incapacitated person: --~-~ ~~ ~-'a' - -~• '~'
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B. Grant of Letters of Administration
(Ijapplicable, enter: c. t. n.; d. b. n. c. t. a.; pendente life; durante absentia; durante niinoritcue)
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
Adtnirtistratiori, c. t. a, or d.b.n.c.t.a., enter date of Will in Section A above and complete list of heirs.)
~~ ~~
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Decedent was icil d at death i ~ ~ __ '~ Q, b'\ C~ County, Pennsylvania ith his /her last principal residence at
(List street address, totivn/city, township, count), state, zip code)
~~
Decedent, then -~'~ Years of age, died on ~ ~~ ~~ . G~` , ~~/,~
Decedent at death owned propec~ty 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 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:
or arinted name and residence
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Forst RW-0? re,,. Jo. J3.o6 Page 1 of 2 `~.
(COMPLETE IN ALL CASES:) Attach additional s{ieets if necessary.
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF
SS
The Petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing Petition are true and correct 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 io or affirmed and subscribed
before me the r .- ~-ti day of
Signature of Personal Representative
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~, ~~ < <-~ l.`i. ~~~ ~'- ~ ~ 1 Signature o Persaial Re resentative ~ '~ -~
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For the Register Signature of Personal Representative
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File Number: ~-:-r~ ~ `_ ~ ~ ' ~..' ~-}~ <-.7 ~ ~ ~r~
Estate of t '~~ ~' ~' :,~~~ t,~'~~. ~'~ ~,~ i t~. ILA . ~...~ ,Deceased
Social Security Number:
Date of Death: ~ (,~ - t:~~-) -~~~ '~~~~` ~ ~~
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AND NOW, . ' ~~~ ~>~ L ` ~'~ t ~~:` .:> ~- ~ , ' ,-~1 , in consideration of the foregoing Petition, satisfactory proof
having been presented before me, IT DECREED that Letters ~~~`~~'p,ti ~ 1 1 ~:~ ~~ `C ~' C'1~ `~
~,
are hereby granted to (! (, ~ (~~=' ~ ~ ~, ~~~^ ~ ,~" ~ }
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
Letters ...............
Short Certificate(s) ....... .
Renunciation(s) ..........
$ ~ G:.t ~
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$ ~~ .LET
$ ~; i`:~;
... $
... $
... $
... $
... $
... $
... $
TOTAL .............. $ ~_
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Register of Wills x, ~
Attorney Signature:
Attorney Name:
Supreme Court I.D. No.:
Address:
~~
Telephone:
r-~,-„~ Rw-o~ ,-ev l0.l3.or Page 2 of 2
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CORONER'S CERTIFICATE OF DEATH
(See Instructions and examples on reverse) STATE FII F NI IEARFR
1. Name of Decedent (Flrst, middle, last, suffix) 2. Sex 3. Sodal Security Number 4. Dale of Death (Month, day, year)
T ter B Nicks Male 170 - 68 - 1970 October 20, 2010
5. Age (Last Birthday) Under 1 year Under 1 day 6. Date rn Birth (Month, day, ar) 7. Birthplace (City end state a country) Ba. Place of Death (Check only one)
M0^s's ~vs Molxe Minutes Hospital: Other:
33 Yrs. June 1, 197 7 Car 1 i s le , Pa ^ Inpagent ER / 0 gent
utpe ^ DOA ng ^ Residence
^ Nurei Home ^Other • Spedty:
• fib. County rn Deem Bc. City, Boro, wp of Death Ed. Farilhy Name (If not ltsHlution, glue street and number) 9. Was Decedent of Hispanic Ongin? ~ No ^ Yes 10. Race: American Indian, Blade, White, etc.
• (II yes, specity Cuban, (SpecVly)
Cumberland South Middleton Carlisle Re ional Medical Center Mexican,PuenoRican,eta.) White
11. Decedent's Usual Lion Kind of work d one du' rtasl rn IHe. Do rat atere retl 12 Wee Decedent ever In the 13. Decedent's Education (Spadty only highest grade comp leted) 14. Marital Status: Married, Never Married, 15. Surviving Spo use (If wife, give maiden name)
D1SC .~°~~ Kind d Buswess / IMustrtryy
EntertalnmenL U.S. Armed Forces? Elements / Seconds 0 12
ry ry(' ) Colle
ge(1-4or5+) Widowed, Divorced (Speci/y)
^vea ~ ----------12 ------------- Never Married
18. Decedents Meiling Address (Street, dry /town, srere, zip code) Decedent's ern S y van 1 a Did Decedent
1 160 Redwood Drive Aduel Residence 17e. slate Live in a 17c. ^ Yes, Decedent lived in Twp.
Carlisle , P a 17 013 Cumber 1 and Township? 17d. ^ No, Decedent lived whhin
17b. County
Carlisle
City / ~
Actual Limits of
18. Father's Name (First, mkldre, last, so(fa)
William J. Mickey 19. Mother's Name (First, middle, maiden ems)
Karel Ann Sheffer
20a. IMOrtnent's Name (Type I Print) 20b. Infortnanfs Mailing Address (Street, dty /town, state, zip code)
Caret Nickey 61 E. Pomfret St. Carlisle, Pa 17013
21 a. Method rn Disposition ~ ®Cremetbn ^ Donation
• 21 b. Date of Disposition (Month, day, year) 21 c. Place of Disposition (Name d cemetery, crematory a Deter place) 21 d. Location (City / tcrvm, state, zip code)
^ Burial ^ Rertaval from State !Was Crerrletlon er Def1ai10r1 Authorized
• ^ Other • Speciry: ~ by Mealcal ExerMner /Coroner? ®Yea ^ Na
Oct 24 , 2 010
Dugan Funeral Home & Crematory Inc .
Shippensburg, Pa 17257
22a. Signalu Funeral Serv' person acgrg as such) 22b. License Number 22c. Name and Address of Fachity
- FD-012909-L Ronan FLmeral Home 255 York Road Carlisle, Pa 17013
Complete 23ec Doty when cergtyirg 23e. To the best of rtry kitowAedge, death occurred et the time, dale and place staled. (Signature and title) 23b. License Number 23c. Dale Signed (Month
day
year)
physician is rat available at grtie of deem to ,
,
cergly cause rn deem.
Items 24-26 must be completed try person 24. Time of Death 25. Date Pratounced Dead (Monet, day, year) 26. Was Case Referred to Medical Examiner /Coroner for a Reason Other than Cremation or Donation?
who pronounces death. 12 ~ 01 P . M. October 2 0 2 010 Yee ^ Na
CAUSE OF DEATH (See instructions end examples) 1 Approximate interval:
hem 27. Pan 1: Ester die diem rnevents -diseases, injuries, a colrgtlicatdons - mat directy caused me deem. DO NOT enter terminal events such as cardiac arrest, r Onset to Deam Pad II: Enter other filgntlaent cortditiais contributkg to death,
but not resulting in the undedying cause given in Pan I. 26. Did Tobacco Use Contribute to Death?
^ 'Yes ^ Probably
respiratory artest, a ventricular fbdllation wglard sftowltg me etldogy. List Doty are cause on each gne. r
1
IMMEDIATE CAUSE (Final rxsease a 1
[] No ^ Unknown
aadhionresultfngmdeem)
Mixed Dru
To
i
it
~ 2s.hFemare:
_~ a.
g
x
c
y Endocarditis - Etiolo ^
Due to (or as a cortsequertce oft: ~
Un nown Not pregnant within past year
sequengaUY list condigons, h any, b ~
leafing to the cause rued on gne e. ^ Pregnant at gets of death
Eller me UNDERLYING CAUSE Due to (or as a consequence d~: ~ ^IVa pregnant, but
pregnant within 42 days
(disease a injury mat klifiated me c. r
events resulting m deem) LAST. r of deem
Due to (o as a consequence of): r ^IVa pregnant, but pregnant 43 days to 1 year
• d, r
1 before deem
Jnknam Y pregnant within the past year
30a. Was an ANapsy
Pedamed? 30b. Were Autopsy Flndngs
Avagade Prior to Completion 31. Manner of Death 32a. Date rn InJury (Month, day, year) 32b. Describe How InNrY ~ur~ 32c. Place rn Injury: Home, Fenn, Street, Factory,
afCauseafD
e
a
h?
t
^Nalurel ^liomidde
Oct. 20 2010
Consum tion of Mixed Medications Office Building. etc. (Spedly)
Home
Yes ^ No ~
,.
~
r
^ Yes y~ I No
`-[ ~'°'ccident ^ Perzkrg Invesigagon 32d. Time of Injury 32e. Injury at Work? 321. If Transponatlon InJury (Spea'IyJ 32g, Locagon of Injury (Street, city /town, state)
^ Suic9de ^ Cab Not be Determined ^ Yes ~No ^ Driver /Operator ^ Passenger ^ Pedestrian
Unknown AM~ Ogren-span/ : Doti Drive, 'C rlisle, PA
33a. Certifier (deck only ate) 33b. ignature and Tdle of Ceni
' C~Mn9 f~YU~m In c:erMyutg cause rn deem when another physician has pratounced deem and carpkted ham 23)
To thebastrnmylmowbega,deedtoccurredduetothecsuse(s)endmannarnsMed--------------------------------- ^
• P
d - (~' Coroner
ronoun
ng and eertfyMg physidan (Physidan tam pratwrtdrg deem anti cerglyirg to cause d deem)
To the bast of my knowledge, death occurred n the gets, date, ell place, and due to the ceusa(a) and mamter as sletad_ _ _ _ _ _ _ _ _ _ _ ^ 33c. Lxrertse Number 33d. Date Signed (Monet. day, Year)
• kkdkal Examiner I Coroner
On the beak of exeminetlon sod / a Inveaggatlon, In my opinion, death occurred M the time, dale, end piece
and due to the esuse(a) and manner as staled
~ December 17 2 010
,
_ ~. Name and Address of Person Who ed Cause of m (Ite
~
~
~e m 27) Typo /Print
35. Registrar' i tureandol;~~
~DateFUea(Manm,aaY.Y~rt Todd C. E
Lcenrot
c
, Coroner
6375 Basehore Rd. , Suite 4~1
-
Dispositon Permit No. (/ 1 ~~ I r~-C`
RENUl~CIATION
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. RE ISTER OF WILLS
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COUNTY, PENNSYLVANIA 1 ~> z:;
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Vic,
Estate of L~ ~ ~- C'
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,Deceased
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
x '~ k ~- I 1 C -'C
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(Date)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this day
of ,
Deputy for Register of Wills
Form RW-06 rev. 10.13.06
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(Signature)
e
(Street Address)
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(City, State, ZiF)
Executed out of Register's Offce
Before the undersigned personally appeared the
party executing this renunciation and certified
that he or she executed the renunciatio for the
purpos stated within on this ~ day
of - , .~
u i
My Commission Expires: f ~~ ~ ~~~~.,,~
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's Commission.)
NOTARIAL SEAL
DARCIE A. NEIL, Notary Public
~ ior~ ~Expir~s IVY. 24,