HomeMy WebLinkAbout03-11-11IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
REGISTER OF WILLS
\ ,~ + PETITION FOR PROBATE AND GRANT OF LETTERS
Estate of VV~L.`.1'~'~n CT ~ w~T ,Deceased ESTATE NO: 21-
a/k/a:
a/k/a:
a/k/a:
SS NO: ~~~ 7_~1~- ~C~J
Petitioner(s) who is/are 18 yrs of age or older, apply(ies) for: COMPLETE SECTION `A' or `B' AND "C" as
applicable:
O A. Probate and Grant of Letters Testamentary or 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 under
the last Will of the above-named Decedent, dated _~_-_ j ~I~ G~ ~ l __ and codicil(s) dated
(State relevant circumstances, e.g. renunciation, death of executor, etc.)
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the
instruments offered for probate; was not the victim of a killing, was never adjudicated an incapacitated person, and was not a
party to a pending divorce proceeding at the time of death wherein grounds for divorce had been established as def' ed in
23 Pa. C.S.A. § 3323(g):~ t~ E -5 C.~,f'('Ec~C~~ n(lG-cr,~(~ h~-~' ~'~(~5 ~'~fC~ ~~[~c°rQ~ ~ ~
^ B. Grant of Letters of Administration
(If applicable, enter d.b.n., pendent life, darante absentia, dnrante 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(8), except asfollows:-
Name Address xewnoosnt w ueceaenc
USE ADDITIONAL SHEETS IF NECESSARY
THIS SECTION MUST BE COMPLETED:
Decedent was domiciled at death in Cumberland County Pennsylvania, with his/her last family or principal residence
At TeS F1 Cx.:~ <ZO A~ NE~v l ~trE ~A ~~~y ~
(Street address with Post ice and Zip Code, Municipality: Township, Boroughs, C'i`ty)
Decedent, then ~5 years of age, died ~ C ~y'~ ~o~~ 1 ~ at W~r~~~~E , ~~~1 n~yi vat i ~l.
(Month, Day, Year of death) (City and State where death occurred)
Estimated value of decedent's property at death:
If domiciled in PA
If not domiciled in PA
If not domiciled in PA
Value of Real Estate in Pennsylvania
Total Estimated Value
s ~G~000 ,OCR
S
S
S
$ 0.00
Location of Real Estate in Pennsylvania: (Provide full address if possible.) tq~ ~ ~ ~~ ~DA~. ~~-1~~~) 1-~-~- rQ
~-~ Signature(s~ ~ Name(s) & Mailing Address(es)
\ ~~ t) L
C ~ i P ~~~~3
All personal property
Personal property in Pennsylvania
Personal property in County
Interim Form RW-02 revised 12.26.10 by Cumberland County pending action by the Court rage i of ~
OATH OF PERSONAL REPRESENTATIVE
Commonwealth of Pennsylvania
County of Cumberland ~ SS
v~ A
The Petitioner(s) herein named swear or affirm that the statements in the foregoing Petition are true and v ~, x
correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representatives of tr:~ ~ ~ W
Decedent, Petitioner(s) will well and truly administer the estate according to law. O ~ ~" ~ " ~"
v v `/ v v
~ ^
~x -~~.zz
Sworn to or affirmed and subscribed ~ ~ -~ -: --
_ ~ f ~...~ ~ ...
~ ~ eel ~'
bef me this ~th d y f '~ G ~ ;; N z
"~ - ~x v
the Register
DECREE OF PROBATE AND GRANT OF LETTERS
Estate of I V + ~ ~ (Q,,y~ ~ i~P~.~ Deceased File Number: 21- ~ U ~ ~ _ ~ ~~~p
AND NOW, this ° day of _ ~/ ~ ~ ~ ~
the re erne side hereon, satisfactory proof having been presented before me, IT IS DECREED that Letters n
testamentary - of Administration
are hereby granted to:
`~ (If applicable, enter cta, d.b.a, d.b.ac.ta., etc.)
ct~la V • c~rn~'~
the above estate and that instruments(s) dated ~ in
admitted to probate and filed of record as the last Will and odici s) of Decedent ribed in the petition be
FEES:
C 6~
:J
Letters ....................$
will ........................ i ~ .
Codicil(s) .................
( )Short Certificates
( )Renunciations.......
Bond ............................
Other ............................
.................................
...............................
Automation FEE.........
5.00
JCS FEE ................... 23.50
T~
lenda Farner Strasbau h,y
Register of Wills
~~~~
Signature of Counsel a it nt
i
Atty's Si ((ature
PRINT'ED`Name:
Supreme Curt I No.: SZ
Address
Phone:
TOTAL ................$ .~~~~ Fi ax.
Interim Form RW-02 revised 12.26.10 by C 'berla d County pending action by the ~Co-urt--
Appearance
V~
Cc~~~~s~c P~ ~~c~~~
C7r~~ q1~0 - 0075
l~~ O - n07
Page 2 of 2
OCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate. $6.00
P 17263338 _
-- -- Cee~i#ie~aEic~-Alui~her -
H1[
°w
r
d
0
0
This is to certify that the information here given is
a>rrectly copied from an original Certificate of Death
duly filed with )T~c as Local Registrar. The original
' certificate will be forwarded toi the. State Vital
Reco ~ ~ ~icc for p ~ an ~ 1t filing.
~~
_o • Re+~istra Date Its(-led
5-743 REV 11ft006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
YPE /PRINT IN
PERMANENT CERTIFICATE OF DEATH
BUCK INK
(See inetruCtlons end examples on reverse) STATE FILE NUMBER
1. Name d Decedent (First, midde, IaH, wlFa) 2. Sex 3. Social Sewdly Number 4. role d Death (MOMh, day, year)
William G. Wert male 207 - 34 - 7099 March 3 2011
5. Age ILeal Bimdey) Under 1 year lMda 1 tleY 6. Date d Bill (MOdh, day, r) 7. BiMplace (Chy erd NMe a lor e' n camryl 6a. Place d weth (Clwck ony one)
Mwea • wn Hours kl+vnsr HoapiWl: Other:
65 vrs. Nov. 15, 1945 Carlisle, PA ^klpetlam ^ER/Oulpatlenl ^DOA ~NUrsmg Horne ^ReslOBnce ^Olher-Spedly:
Bb. County d Death Bc. City, Boro, Twp. d Death Bd. FadBy Noma Ig not imtgdion, gHa street ertl number) 9. Was Decedent d Hispenk:Origin? ®No ^ Yes 70. Race: American Indian, BWd, Whge, ale.
. (K yes, WagY Cuban, (Speciy)1
Cumberland Carlisle Forrest Park Health Center Abxwbn,PUen°wean,etp.j White
11. Decedenl'a Usual lion em d wok d one d mod d wxxkin Me. w rrot slate reload 12. Was DecetleM ever in the 13. Decedanl'e Educelion (Specgy oMy tkphest grade comp leted) 14. Medtel SeWS: Herded, Never Merced, 16. Surviving Spo use IB w6e, gNe maiden comae
Kind d Wok Kmd d Busnass / IMus1ry U.S. Armed Faces? Elementary /Secondary (012) Cdlege 11./ a 5+) Witlowed. DNorcetl ISpdM
Driver Trucking ^Y.B ®No 12 Married Jackie Wert
16. Decedem's Maikng Address ISlreet, cgY /+~, state, zip code) Decedem's Did Deoedent
Sale Pennsylvania LNema n°
d~ Penn T
AauM Reeitlence l7a
®ves
D
c
tlem ti
75 Fickes Rd. .
,
,
ve
e
e
wp.
Townshq?
N
ill
17241 17tl. ^ No, Decetlem Lived wghir
nn. couMyCumberland
ewv
e, PA A~um~d ~/~
16. Fatlrers Name (Fast midde, Msl, sugix) 1B. MdMr'a Name (First, middle, maitlen romaine)
Paul Wert Viola Thumma
2w. mlament's Name (Type / PdnQ ~ 2F4. Marmanl'e MaiNng Address (Street, dry / town, stale, zIp cotle)
Sheila Miller 40 Mont Diner Ave. Shi ensbur A 1725
21 a. Methotl d Dlsposilion ^ Crernalian ^ Donaton 21b. Dale of Dspaidon (Momh, my, year) 2/c. Place of Dispagbn (Name d oaMary, aenrdory a dha plate) 21tl. Localien (Cgy I town, s161e, iq cotle)
® Burial ^ Removal from Seale I Was Crametlen a Dautbn AsdhaWd
^ Dina-Spa+N: MMeaICME:emineryCaoner7 ^Ye6^NO March 8, 2011 Westminster Cemeter Carlisle PA 17013
22a. SlpWUre Service Lice person BCgrlg 86 elldl) 22b. Liceme NIellber 22c. Name end Address d Fadgy
014831-L -ffiicker F.H. inc. 112 W. St. PO Hox 336 PA 17257
23ao Doty when cerBlyi°9
e nd aveilsble al ame d death m 23e. To the Deal d my
Mr~, deem accred at the dine, dale pYCe skied. (SgnaWre antl tNe) 230. L.iceme NurMer
' 23c. Date Signetl (MOMh, day, year)
~ddeam. ^
wvu.c~~ ~ a~Si~- ~
~Q,J- ~ hl~rck 3, ~a r ~
gems 24-26 must 0e carpleled by person 24. Time d (Math 26. role Pronatxetl Dead (Mahn, Oey, year) 26. Was Case Rde
rr
e
d
to Medical Examiner 1 wroner Ia a Reason Other then Cremation or Donation?
who prawunce6 dadh. /
O l I ~ A M. fti /' G h 3 ~ d t 1 r-
-
~
. ~
^Ves L7 n~
CAUSE OF DEATH (See InsWglons end examples) r Approximate IMervel: Pad II: Erna dher BioNlkam r rrdrions mnlrAUlino le death, 26. Dtl Tobacco Use CaMribde b welh?
Item 27. Pan L Eller the chain d evems - drseases, uqurias, a cemPkcaBOns - met drectly caused the tleedl. DO NDT enter lermind eems aah as canFac artesl. r Omet to Death bd not resdlkrg in the undedying cease given n Pan I. [.~+FES ^ Probably
resplremry anesl, a ventricdar fibrBatbn wi0wd Bhovmg me etiology Llsi only one cause on eem Foe. r
//
~
^ No ^ Unknown
WMEDUITE CAU6E (Final tlisease w -/
. V
mrdlbn resul0ng in death)
L
l
~
~
/'
~~n 29. g Farele:
r
-
wif.r. w.
~~ ~~,.
~
'
_~ a.
/
-
_
-
^ ^
quence oQ: ~
Due
lo (
a
as a
cons Nd gegnaM within pass year
Sequent~aW gal cerltlilllens, g any, b. ~
lead ro ti
IiM
tl
Y ^ Pregnant al Ilene of tlealh
ro cause
e
m
ne e. Due to (a as a co uence d ~
Enter me UNDERLYING CAUBE °8fq I~ I Nd pregnant, 0d Pr nom within 42 days
^ ~
~~ r~~~ I~nmd)id~ , c. 1 d tlealh
Due to (or as a consequence oq: r ^ Nd pregnant, 0ul pregnan143 days to 1 year
d tx:lae tlealh
^ Unknown it pregnant wghin me past year
3w. Was en Autopsy 300. Were Adopsy fin0ings 31. Manner Death 32e. wee d Inprry (Monm, tlay, year) 3ffi. Descdbe How Injury Occuned 32c. Place d Injury: Home, Ferm, Slreol, Facbry,
Pedonnod? Avagade Prior to Complmian local ^ Harwdtle Ogwe Buildng, etc. (SpedtyJ
d rouse d wash?
^ Ves No ^ yes to ^ ~itlenl ^ Pentling Invesligedon 32d Time d Iryury 32e. Inlury al Work? 321. II Traneponation Injury (Spealy) 32g. Location d Injury j5lreet, dly 1 town, slate)
^ Suidde ^ Cadd Not he Ddemlkted ^Ves ^ No ^ Driver I Operator ^ Passenger ^Petledrian
M anm ~ srany:
33a. CeMller (check Doty ale) 330. Sgnalure Cengler
• Cedflyfng phyaklen (Physiden cedsyirg cause d tleelh when andher phy,;ician has pronouncetl death end mmplded Item 23)
~/'v
~
Te Ute beeldery lorosdedge, tleMh aucarM dsebllre eauege)antl arrlrer as alelerl_--------------------'-'-----'--- ^ vti~
• Pronourrdng end cenNying physkAan (Physician tsdh prmounrig tleam and cengytrp b cause d death)
To th
b
e d
k
led
tl
N
tl
t th
t
d
l
t
M
d
M d
m
^ 33c. License N r 33tl. role Signed (MOMh, aay, year)
e
as
my
now
ge,
ee
occune
p
ace, er
ue
a
e t
re,
a
e, en
o
e uuae(s) and manner an staled_ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _
• Medkel ExemirralCoroner O O ~ ~ //
w the basis a examlrradon entl / or Invesligedon, In my op n d•tl urretl el me time, dale, antl plsre, antl due to tM ceuea(e) end manner u sMtetl_ ^ ~ Name ~~dd Address Person
ed Cause d wath (gem 27j Type f Print
~OA
~
j
~}1°
!
35. Registrar's Si~alae an ' trio N Filed ( Ih, day, year) /
'
"
_
,
~ ~ • ~
D ~-J ( (~ t! f
- ~ ~r ~ ~ ~ ~ r~ ~ z
d" -~. . ,~ .
Disposgron Permit No. _ ~Z,p 7[~ 77
LAST WILL AND TESTAI-~NT
OF
WILLIAM G. WERT
I, WILLIAM G. WERT, of Newville, Cumberland County, Pennsylvania, being of
sound and disposing mind, memory and understanding, do hereby make, publish and declaze
this as and for my Last Will and Testament, hereby revoking and making void any and all
former Wills, Codicils, or writings in the nature thereof, by me at any time heretofore made.
FIRST: I hereby direct my Personal Representative to pay all my just debts, funeral and
administrative expenses out of my estate, as soon as practicable after my death.
SECOND: I direct that all taxes which may be assessed in consequence of my death, of
whatever nature and by whatever jurisdiction imposed, shall be paid out of my estate as a part
of the administration of my estate.
THIRD: I give devise and bequeath my entire estate, be it real, personal or mixed to my
children, DENISE ELLEN MORRISON (daughter) and DONALD GEORGE WERT (son) or
their heirs with the exception of the following personal and real property:
1. My ownership interest in my retirement plan that I have with United Parcel
Services is bequeathed to my deaz friend Sheila Ann Miller;
2. My 1972 D-35 Martin Guitar and my country and rock and roll music is bequeathed
to my deaz friend Sheila Ann Miller;
3. My 2002 Terry RV Camper is bequeathed to my dear friend Sheila Ann Miller;
4. My tool shed and all of my tools is bequeathed to my son, Donald George Wert;
5. My Rifle 30/30 Bolt Action Clip-Feed Gun and 12-gauge shotgun is bequeathed to
my son, Donald George Wert.
FOURTH: I nominate and appoint my sister, Sheila Ann Miller to serve as the Executrix of
this my Last Will and Testament. In the event my sister is unable to serve as my Executrix, for
whatever reason, I name my deaz friend, Sheila Ann Miller as Executrix of this my Last Will
and Testament. I direct that my personal representative(s) shall not be required to give bond or
security for the performance of their duties in any jurisdiction.
FIFTH: In addition to the powers conferred by case law, by statute and by other provisions of
this Last Will and Testament, my personal representative, and any successors in that capacity
shall have the following discretionary powers applicable to all real estate and personal property
held by them, which powers shall be effective without Qrder of any Court and which shall exist
and continue until the time of actual distribution:
A. To retain any property of any nature received by them for whatever period it shall
be deemed advisable;
B. To invest and reinvest all or any part of the assets of my Estate without regazd to
statutes limiting the property which a fiduciary may purchase;
C. To sell, transfer, exchange or otherwise dispose of, any part of the assets of my
Estate, for cash or on terms, publicly or privately, or to lease, without liability on the
purchasers to see to the application of the proceeds, and to give options for these
purchases without the obligation to repudiate them in favor of a higher offer;
D. To execute and deliver any deeds, leases, assignments or other instruments as may
be necessary to carry out the provisions of this Will;
E. To borrow money, if necessary to facilitate the administration and closing of my
Estate, including the right to borrow money from any bank, and to mortgage or
pledge any asset of the estate as security;
F. To loan to, and to purchase assets from, my Estate, even if also acting as Executor
thereof;
G. To assume continuance of the status of any beneficiary with regard to death,
marriage, divorce, illness, incapacity and similar incidents or matters in the absence
of information deemed reliable without liability for disbursements made on such
assumption;
H. To make any distribution hereunder either in kind or in money, or partially in kind
or partially in money, considering of course the reasonable wishes of the
beneficiary. Distribution in kind shall be made at the appraised value of the
property distributed, as it is set forth in the Inheritance Tax Return filed in my
Estate;
I. To exercise any subscription right in connection with any security held hereunder,
to consent to or participate in any recapitalization, reorganization, consolidation or
merger of any corporation, company or association, the securities of which may be
held hereunder; and to delegate authority with respect thereto, to deposit
investments under agreements, to pay assessments, and generally to exercise all
rights of investors;
J. To continue in any partnership, joint venture, joint ownership or other business
enterprise of which I am a part at the time of my death;
K. To compromise claims;
L. To continue for whatever period of time my personal representative shall deem
necessary any ownership as a tenant in common or as a partner, in real estate or
other property and to act as I would have done had I been living;
M. To do all other acts in their judgment necessary or desirable for the proper
management, investment and distribution of the assets of my Estate;
N. I direct that my personal representative shall be compensated for the services they
render as Trustee and Executor under this my Last Will and Testament;
O. Should any changes occur in the Internal Revenue Code or Pennsylvania statutes
after the date of the execution of this Will which affect the tax liability of my estate,
then to the extent possible and as may be permitted by law, my personal
representative shall have the power and discretion to interpret this Will and to
administer my Estate in a manner which results in the lowest tax liability possible;
P. Should the principal of any Trust herein provided for be or become too small, in the
TRUSTEE'S discretion, so as to make establishment or continuance of the Trust
inadvisable, my TRUSTEE or my Executrix may make immediate distribution of
the then remaining principal and any accumulated or undistributed income outright
to the person or persons and in proportions they are entitled to income. Upon such
termination, the rights of all persons who might otherwise have an interest as
succeeding income beneficiary or in remainder shall cease.
IN WITNESS WHEREOF,1 hereunto set my hand and seal this ~~~'~ day of
~~~~~ 2011.
SIGNED, SEALED, PUBLISHED and
GLARED in the pr a ce of:
0. ~ ~.~'
~ ~~"F.~-'"~ ~ ~ (,P~
V~L G. WERT
ACKNOWLEDGEMENT
I, WILLIAM G. WERT, the TestatOR whose name is signed to the attached or
foregoing instrument, having been duly qualified according to the law, do hereby
acknowledge that I signed and executed the instrument as my Last Will and Testament;
that I signed it willingly, and that I signed it as my free and voluntary act for the purposes
therein expressed.
~~~ . ~ ~
WILLLAM G. V ~ RT
Sworn or affirmed and ac owledged before me by WILLIAM G. WERT the Testator,
this ~`~~ay of , 2011.
otary Public
~pMMONWEAI.TH OF PENNSYLVANIA
Notarial Seal pubiic
Valerie F. Gsell, Notary
CarNsie Boro, ~rnberland Counf.Y
pqy ~nmisslon F.~r~ ~^ 9, 2014
Member. pennsvNania p~odaNon ~ Notaries
AFFIDAVIT
We, WILLAIM G. WERT, ~~/, ~ ~ • ,~~%
~a 1 , ~ the Testator and the witnesses, respectively, whose names aze
i7. Ca~,v~-, ~ -
signed to the attached or foregoing instrument, being first duly sworn, do hereby declare
to the undersigned authority that the Testator signed and executed the instrument as her
Last Will and Testament and that she had signed willingly, and that she executed it as her
free and voluntary act for the purposes therein expressed, and that each of the witnesses,
in the presence and hearing of the Testator signed the Last Will and Testament as witness
and that to the best of their knowledge the Testator was at that time eighteen (18) yeazs of
age or older, of sound mind and under no constraint or undue influence.
~~/, ~ ( nA
sidin I\lC,l~t~t' ~'~ C r ~`~
TESTATOR, g
WITNES5,~~,~„~~q- .9- I~ ~y.Y residing at i DO~j,L~4~.CC(r~
WITNESS, 0.u- ~ l~asiding at ~ r l i 5 ~ Q~_,~ 171=3
t~rn~, c~hc-~ ~, C~r~:~~~
Subscribed, sworn to and acknowledged before me by WILLIAM G. WERT,
Testator, and subscribed and sworn to before me by ~~i /.~ - ~/~i~r ,
and ~ ~~ ,the witnesses, this ~'~'-' ! day of
'~- 2011.
Notary Public -
L
COMMONWEALTH OF PENNSYLVANIA
Notarial Seal
Valerie F. Gsell, Notary Public
Carlisle Boro, Cumberland County
My Cortrmission Expires OQ. 9, 2014
Member. PennsMania Association of Notaries
-~
AFFIDAVIT Of SHERI D. COOVER. ESQUIRE
I, Sheri D. Coover, Esquire hereby certify the following:
1. William G. Wert was a client who had previously retained me to
represent him in a divorce proceeding which was pending in the Cumberland
County Court of Common Pleas.
2. On Friday, February 11, 2011, William G. Wert visited my office and
expressed that he wanted for me to draft a Will, a Power of Attorney and a
Durable Healthcare Power of Attorney for him.
3. At the time that he visited my office, William G. Wert expressed what
terms he wanted included in his will, including the fact that he wanted for his
sister, Paula Heckman to serve as the executrix of his estate.
4. I drafted the Will, Power of Attorney and Durable Power of
Attorney for William G. Wert on February 14, 2011 and took it to the Carlisle
Hospital where he was admitted as a patient at that time so that he could sign the
documents.
5. At the time that I drafted the Will, I typed the fourth clause in the will
to state "I nominate and appoint my sister, Sheila Ann Miller to serve as the
Executrix of this my Last Will and Testament."
6. This clause was typed in error and should have stated, "I nominate
and appoint my sister, Paula V. Heckman, to serve as the Executrix of this my Last
Will and Testament."
. ' . _,.,
7. The clause that was mis-typed was due to my error and was not the
wishes of William G. Wert who expressed that he wanted his sister, Paula V.
Heckman, to serve as the Executor of his Will.
8. Sheila Ann Miller was a friend to William G. Wert and was not his
sister.
9. William G. Wert expressed that he would like for Sheila Ann Miller to
serve as the executor of his estate if his sister was unable to serve as the
Executor. This wish is properly identified in the Will.
10. I did not learn of the error in the Will until after the death of William
G. Wert.
Sheri D. Coover, ESQ.
COMMONWEALTH OF PENNSYLVANIA
SS
COUNTY OF CUMBERLAND
ON THIS, the 1 day of ~/~~ 2011, before me, the undersigned officer,
personally appeared SHERI D. COOVER ,known to me (or satisfactorily proven) to be the persons whose
names are subscribed to the within instrument, and acknowledged that they executed the same for the
purposes therein contained.
IN WETNESS WHEREOF, I hereunto set my hand and officja~ seal.
COMMONWEALTH OF PENNSYLVANIA I
Notarial Seal ~~
Valerie F. Gsell, Notary Public
Carllale Korb, CumtieMnd County
G:xnmbsion rss Oct. 9 2014
MamDer. PannavNania Assodatlon of Notaries Notary Public
RENUNCIATION
REGISTER OF WILLS
ClA~1'~~A{lLO COUNTY, PENNSYLVANIA
w0, a
H
~ a ~
O ~ a~ V O
Q
a
~~N O~
U
Estate of _ ~~~•~-~~~ ~. ~~T ,Deceased
I, Sr-~~~"A ~n~ mt ~-L~ , in my capacity/relationship as
CXEC~~1 (Print Name)
X of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
~QI~.LA V. i~EC.zsY,~,"1Zo~ y02x.SN~~~21vE, cA2.us~F_ Pq l~pl~.
~- ~ .~
(Date)
(StBm+ture) - -
y~ ~ rt/~o/~i~-~Pr y ~i~ ~
(Street Address)
(City, s a ,zip)
Executed in Register's Office
Sworn to or affirmed a s bscribed
befo~re~j this t:~ ay
of % / ~.
. v
uty for Regiser of ills
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 daze ofezpiration of Notary's Commission.)
Form RW-06 rev. 10.13.06