HomeMy WebLinkAbout02-28-11IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
REGISTER OF WILLS
PETITION FOR PROBATE AND GRANT OF LETTERS
Estate of ~ ,Deceased ESTATE NO: 21- ~.U ~, ~- (Jr~~~-1
a/k/a:
a/k/a:
a/k/a:
Petitioner(s) who is/are 18 yrs of age or older, apply(ies) for: COMPLETE SECTION `A' or `B' AND "C" as
applicable:
^ A. Probate and Grant of Letters Testamentary or O Administration c.t.a., or d.b.n.c.t.a. (complete Part C also)
and aver that Petitioner(s) is/are entitled to the aforementioned Letters n y::-tender
the last Will of the above-named Decedent, dated and codicil(s) dated ~~~ -"' ~,
~.
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(State relevant circumstances, e.g. renunciation, death of executor, etc.) - _ ~ ~ ' s :_
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted affet~~ion o~the = =~
instruments offered for probate; was not the victim of a killing, was never adjudicated an incapacitated pPr~~ and was`not a = ~ `~ i
party to a pending divorce proceeding at the time of death wherein grounds for divorce had been e~6C§hed as fl~'ined~`
23 Pa. C.S.A. § 3323(g): ~, +~~ p
L~
~ B. Grant of Letters of Administration
(If applicable, enter d.b.n., pendent lite, durante absentia, durante minoritate)
C. 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 Administration c.t.a. or d.b.n.c.t.a., enter date of Will in Section A and complete list of
heirs); was not the victim of a killing; was never adjudicated an incapacitated person; and was not a party to a pending divorce
proceeding wherein grounds for divorce had been established as provided in 23 Pa. C.S.A. § 3323(g), except as follows:
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UJC. ALU11 wPIAL JtliJr, l J 11' 1VC:(:r;JJAKY
THIS SECTION MUST BE COMPLETED:
Decedent was domiciled at death in Cumberland County, Pennsylvania, with his/her last family or rincipal residence
At ® CJ~ _ o
(Street address with Post Office and Zip Code, Municipality: Township, Borough, City)
Decedent, then ~~ years of age, died ~~~~ ~t~U ~ ~ at n
(Month, Day, Year of death) (City and Stagre death occu ed)
Estimated value ofc;~:.;Pdent's property at death:
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 $
Total Estimated Value $ ~ t a y'1. ~~
Location of Real Estate in Pennsylvania: (Provide full address if possible.)
Signature(s) Name(s) & Mailing Address(es)
uucun~ r~iu~ RW-VL fCVISCQ iL.LO. iu oy ~umoenana ~ouniy penning action ny the c:our[
Relationshi to Decedent
Page 1 of 2
OATH OF PERSONAL REPRESENTATIVE
Commonwealth of Pennsylvania ~ SS
County of Cumberland
The Petitioner(s) herein named swear or affirm that the statements in the foregoing Petiti~ are true mid
correct to the best of the knowledge and belief of Petitioner(s) and that, as personal repre~tive(s}~af thex~ ~'
Decedent, Petitioner(s) will well and truly administer the estate according to law. `~?~ j r~~ ~,~ r a
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Sworn to or affirmed and subscribed -=' U~ ~ `~ ~ ' '
before me this o2~ day of ~ ~ ~ `~~-=
~. f~t~~ ~ a G ! ~ F-.., ~..~ o
~~
For the Register
DECREE OF PROBATE AND GRANT OF LETTERS
Estate of ((~, ~ ~p .f ~ ~ ~, W ti ~(~, ~ P G ~S ,Deceased File Number: 21- ~ -~~~
AND NOW, this ~ day of l~C1Y'e.~ a O l l , in consideration of the Petition on
the reverse side hereon, satisfactory proof having been presented before me, IT IS DECREED that Letters
Testamentary ~ of Administration are hereby granted to:
(If applicable, enter c.t.a., d.b.n., d.b.n.c.t.a., etc.)
rl~i:u~~ L ru,~ ~ 1~ r in
the above estate and that instruments(s) dated described in the petition be
admitted to probate and filed of record as the last Will and Codicil(s) of Decedent.
lenda Farner Strasbaugh, ~ (~ ~~ awl Z ~..~. ~ _
Register of Wills
FEES:
Letters ....................$ ~~ ~ Cf~
Will ....................... -.
Codicil(s) .............. .
(~) Short Certificates U -
( 2) Renunciations.......
Bond ............................
Other .............................
.................................
Automation FEE......... 5.00
JCS FEE ................... 23.50
--~ ~ . r~ ~
TOTAL ................$ ~9
Signature of Counsel Required to Enter Appearance
Atty's Signature
PRINTED Name:
Supreme Court ID No.:
Address:
Phone:
Fax:
Interim Form RW-02 revised 12.26. ] 0 by Cumberland County pending action by the Court Page 2 of 2
OCAL REGISTRAR'S CERTIFICATION OF DEATIi
WARNING: It is illegal to duplicate this copy by photostat or photograph.
~ ~'ee for this certificate, $6.00
P 17047927
Certification Numher
This is to certify that the information here given is
correctly copied from an original Certificate of Death
duly filed with me as Local Registrar. The original
certificate will be forwarded to the State Vital
Records Office for per)r)anent filing.
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Loco] Registrar ~ Date Issued
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I REV 11/2008
/ PRINT IN
MANENT
~CK INK
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
CORONER'S (CERTIFICATE OF DEATH
(St>!a inatrutrtlona and examples on revt>,rae) ~t.r~ ~„ ~ ,,, ,,,e~„
1. Name of Decedent (FkaL middle, lest, wfflx) 2. Sex 3. Sold Security Number 4. Date d Death (Monet, day, year)
Kenneth E S otts Ma - ~ 2 Februar 22 2011
s. Age (Last BMhdey) .Under 1 r Under 1 B. Deb d Birth Monet, da , 7. E>I end elate a ea PWx9 d Math check one
oar class awew q rf ~ 5 U /' ~ ~~: other:
6 6 Yre. S e t emb e r 13 19 4 ry ^ k,p.tlent ER / outpetlerd ^ DOA ^ Nurelrp Hare ^ Reeldence ^omer . spedly:
' 8b. Ca+bY d Death &. Cay, of Death ed. FedMy Name (B not Inadtrrtlort,
give street number) B. Wae Dsoedent d HiepenFc Orlgkt4 No ^ Yea 10. Race:.Aradcen.kxfen, Black, White, etc.
•
Cumberland East Pennsboro (tl Yea, ~h CtAtan, (sPepM
Hol S irit Hos i al "'"'d'""~P'"'t°~'"~ero•> ~j `
11. MaderA's Utuel Kkrd d work done mat d Me. M rqt amts 12. Wee Decederd ever M the 13. MadeM'e Eduadon (Spedty ady hlgtteet grade conpbted) 14. MertlM 3latue: Martled, Never Married, t s. Surviving 3pouas (I1 woe, give maiden name)
Kktd d W KkW of Buakuas /Industry U.S. Amud Forae4 Ebmsnbry /Secondary (012) College (1-4 a 5+) Widowed, Dhiaced (SpecHY)
(~ ~ r.. ~ae ^No ~ ~/ t~ r C 4~ ~-~
~ 18. Deadem'e McAingt Address ( dy /tam, state, zip /~~de)
~ Decedent's
Adtml Reeldence na
b AP n n s u I c.E n i' ~
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j
/ 0 l Y V '~~ o ~ /T p T .
a
? , 7c. ^ Yea, Decederd LNad in
Twp.
Utred wdNn
n ~ 17d. ~
17b. Camly r ~ ,~ b O f`
G
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/ t7 a
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O m !
~Y Boro
18. Femer'e Nertu ( middle, bet, ) 1 B. Motlur'e Name (Fhst, mkde, maklen eumeme)
e ~ ri
20e. Infarturk'e N (Type / Pdrd) 20b. Inlormenye MelBrtg Addreee (Street, dly /town, stab, ap.code)
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~ 21a. Memod d Ofepalam ^ Cremetbn ^ Donatbn 21b. Date of Diapaidon (Month, day, year) 21c. Plea of Dlepatlbn (Ne of cemetery, crematory a other plea) 21d. Loation (Cdy /town, sbte
)
^ Btxlel ertavd State
Otlter • S
ecly: f Mhe Crbrlatlort a Donation AWtorMd
by AIedlGrl ExamNter / Cororrrl ^ Y
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es
No
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22a, d Funeral Servla Llceruee (a person adktg ae each) 22b. Llar>se Number .Name and Addreec of Facory ~, h !
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CompMts deny 23eo aNy when ardryfrq 23e. To the beet of my ,deem ooaxred et the tlrtu, date and place ebbd. (Signature end title) . Llanee
23c
Mte Si
ned (Month
da
ear)
phyefden b not avadeDb at time of death to .
g
,
y, y
artlh cause d deem.
pars 24-28 moat be cortpNted by person 24. Time of Death 25. Date Pronorxrad Dad (Madh, day, year) 28. Was Case Rebrred ro Medk;el Examiner / Caaxir fa a Reason Other than Crematbn or Donation?
wltopronaxtoeedeem. 9:10 A.M• Februar 22 2011 f~vee ^No
CAUSE OF DEATH (See lratrtectione nfd exempbe) r Apprexknete ktbrvel:
hem 27. Part I: Enter ant mrn d event - dtaeaeee, kqudes, a axnpNadone - that directly atxard the death. DO NOT enter temdnal events such as cerdec enact, r cruet ro Death
k
t
d Part II: Enbr other
but not reeultlng In the urxferlytrg auee given h Part I. 28. Dk1 Toberxo l)se ContrBxAe to Deam4
Yea Probe
^ ^ ~
reap
e
ory anent, a ventrlct
er IWrlBetlaf wdlwrA stxxvNg 8u etldogy. Uel ony au ease an each Bra. r
(fk~ r
(FkNd dleeefe a r
~ ^ No ^ Unknown
B h
C0~0"
? ~ a. Occlusive Coronarv Arterv Disease ~
DM, Remote CABG 29. If Female:
Duero (a as a cauequerta of): r ^ NotpregnentwkMnpastyear
~~Bet axtdtlbru, d cry, b, r
b sues lbbd on wre e. r
^ Pregnarrt at seta of death
Eraer yip ~~ Duero (or u a conaequerxe off: r
...
^ Not pregnant, but pregnant wahln 42 days
~ ~ ;
IAdveneb~ c. _ r
_ -"'~" of death
Due to a ae e
( COna• °~~ ^ ~pregnent, but pregnant 43 days to 1 year
;
• d ^ Unknown tl pregnant within the pest year
30a. Woe an Auropey
PeAamed7 30b. Wero Aulopey FktQnpe
AveBabb Prior ro Conpletron 31. Memw of Oseth 32a. Date of I
~Y (, ~'~ ~ ~. ° Fbw Ir~ay Ooourrod 32c. Pl~e of Injuy: Home, Farm, 91reeL Factory.
of Ceues of Deem? ~ t'tetr'rM ^ Frornktirb Oltlce BulkBng, etc. (SP~YI
^ Yea ~ No ^ Yea ^ No ^ Accident ^ Pendhg Inveatlgeaon 32d. Time of Injury 32e. Injury n WoAt7 32f. N Trarupodetlon Injury (Sperd/y) 32g. Laxaon d Ir>Mxy (Skeet, dry /town, state)
^ Suklde ^ Could Na be Delenrrined ^ Yoe ^ No ^ Driver I Opsretor ^ Paeeerger edeetdan
M Omer
33a. CertlBer (dteck ally ens) 33b. 3lgnehse and Tide Cerdtler
Cerdlykq phyeklan (Phyak4en aMtlNmA auee al deem when enotlter phyaittian has pronounced death ertd cortpleted Item 23)
Totlbbeetdmylarowbdge,dwffiaxurnddwtotMduee(e)andtnwuraMaled--------------------------------- ^
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I~Y~rt ~ p~atdng deem end oentlting ro auee d deam)
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To 1M bed d my knowbdge, deetlr aawrnd of the time, dab, end plea, end dw b the
awe(s)andrrwauraabbd__________________ ^ 33c. tJanN Number ~ 33d. Mte signed (Monet, day, year)
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On pre East d sxtHrgnaBon and I a h my oplnron, death occrared h 1M time. deb, and plea, and dw to 1M awe(s) end mwrsr o ebled_ ~ Februar 24 2011
34. end d P Capbbd of (da
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enrote, G
oroner
6375 Basehore Rd., Suite 4~1
Mechanicsbur Pa 1
Dbpaltbn Permit No. _ _Q ~ ~ Z "1' "7' ~_
RENUNCIATION
~ ~~::~~
c ~ ~: -t-~
,~ GISTER OF WILLS ~ ~~~ ~ ~ .;~ ~-. z-,
( ~~ ~, r-
t. '. COUNTY PENNSYLVANIA =E~ `' ~ c ' Y ~ _`:
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Estate of ~ ~ S Deceased
I, - u-~ ~- f 1 e..- in my capacity/relationship as
(Print Name)
e C~, .~~~1-~e~ of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
~r o~C ~ ~~..~u o~~ ,r..~~ 11
(Date)
(Signature)
(Street Address)
(City, State, Zip)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this S' ..day
of CL
Deputy for Register of Wills
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
of ,
Notary Public
My Commission Expires:
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's Commission.)
Form RW-06 rev. 10.13.06
RENUNCIATION ~
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REGISTER OF WILLS ~_~-E ~ ~
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PENNSYLVANIA ~;
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Estate of ~ ~ ~ - ~ Deceased
I~ o in my capacity/relationship as
(Print Name)
~ o1n of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
a-a8-f~
(Date)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this day
of ~2~ t't: a a ()
~~, rr-~•
Deputy for Register of Wills
(Signature)
(Street Address)
K ~ ~-, P ..~4. ~ `71 a ~
(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
of ,
Notary Public
My Commission Expires:
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's Commission.)
Form RW-06 rev. 10.13.06