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? R Gi STER 0~ ~`-ILLS
L,c!/y,~r,~~~~/J~ COL~TY, PE:ti~SYLV:~,~~_-~
Na;ae of~ Decedent: ~~ ~ ~ f ~ ~'~ ~ f~~~~ c~~~ ~ _ _
Date of Ueath:_ r~ ~ V~~~ ;~~f~ r (~~ ~-J 'c ~ File Num'~er: ~-~~~~~~..~ - V ~~~ ~~ ~~?
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To the Register:
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i certiry u:at Notice of Estate Administration required by Pa. O.C. Rule 5.6(a) of the Orphans' Court
:Rules was served on or mailed to the following beneficiaries of the above-captioned estate on
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,vamp: Address:
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r ~ ~ I C. ~ - ~,,, ~~_ V.[: ~ ~"V ~ ~^~c~ Cam.. ~ ~ i ~ ~...~ .~ i ~ r- f'_ f ~ ~ ~.... I ~`~~ ~ `~~~ ~~~.v ~I t.~, ! ' l~
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('If mote space is needed, :attach separate sheet.)
Notice has now been given to all persons entitled thereto under Pa. O.C. Rule 5.6(a) except:
Date ~ ~~ ~~ ~;. ~ ~~ ~~~ ~~
P~orm R ~-=L ~ reti. D.l s. G6
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Signa^,~re oJPerson ~i r,.g hi orm _
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Capacity: ~ Personal Representative ^ C:ounsel
Name of Person Fili this Form
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Address _
Teleph;;ne
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