HomeMy WebLinkAbout03-24-11IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
REGISTER OF WILLS
PETITION FOR PROBATE AND GRANT OF LETTERS
Estate of `~~t~ y<' U ~ ~, ,,~. L ~ ~;
- ~ ~ S ~~ ~.. ~ ~ ,Deceased ESTATE NO: 21- - ( ~- U <~ ~~
a/k/a:
a/k/a:
a/k/a: SS NO:
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 ^ 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 and codicil(s) dated
(State relevant circumstances, e.g. renunciation, death of executor, etc.)
Except as follows, Decedent did not many, 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 defined in
23 Pa. C.S.A. § 3323(g):
C'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),~cept as fo1lQ:ws:
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Name ~ "'- ~`~
Address Re "' i to Dece~pnt -~'- '~'
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USE ADDITIONAL SHEETS IF NECESSARY `"~ '~ ;rte
A ,,, ^.
THIS SECTION MUST BE COMPLETED: -.- -r7
Decedent w dom'ciled at death in Cumberland C unty, Pen Sylvania, with his~er last family or principal residence
(Street address with Post Office and Zip Cod ,Municipality: Township, Borough, City)
Decedent, then ~ years of age, died _1 ~ --- - / (~ at ~~I~~g ~~
(Month, Day, Year of death) ( ty and State where death occurred)
Estimated value of decedent'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 $ ""~ ~(~ . (,~1~
Location of Real Estate in Pennsylvania: (Provide full address if possible.)
Signature(s)
Name(s) & Mailing Address(es)
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Intenm Form RW-02 revised 12.26.10 by Cumberland County pending action by the Court
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Page 1 of 2 ,
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Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF
SS
The Petitioners} above-named swear(s) or affirm(s) that the statements in the foregoing Petition are tine 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 antk"truly ~-~
administer the estate according to law. ~ ~.r ._,~,_,
S~~; o: n t~; or affirmed and subscribed ~~ ~ , , ~-
1, '~ 1' ~"
r rn t~~ ~ _
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before me the `_ : ~ day of Signature ojPersonal Representative
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Sig~tature ojPersonal Representative ~-- w a
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For the Register Signatz»•e ojPersonal Representative
File Number:__ ~. ~'~'' ~ - ~ j _ ~ `~L (~,
Estate of __ r1~1, ~• U ~ d L ~ ~ } 5 ,i ~ ;~ ~ ,Deceased
Social Security Number: 1 ~.'~ _ AGE-( ~ (~ Date of Death:_
AND NOW, ~ (~ ~ ~'; ~.. s ? , '~%v ! ~r , in consideration of the foregoing Petition, satisfactory proof
having been presented before me, IT IS DECREED that Letters _~~ l l~( (O /j t~"rat ~ ~,~
are hereby granted to ~,' ~ ~`' ~~ ,~ (,, ^~Gf ~, , ~;
in fhe 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 ~7~~f ~~ i ' ~(.i ~~'l,~ '~ ~~~ ~~Ill .~ ~f~(,~,/~'1
Letters ............... $ ,;~ ~ GCS RegisterojWil!$ ;} ,r~~r1 ` "`~
f 6~ ~~ ,_ Cry
Short Certificate(s) ........ $_ l ~ U~ ~'
Renunciation(s) .......... $
.-,
... $
... ~
... $
... $
... $
... $
... $
TOTAL .............. $ rf -,~~ `.~~ ~1
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Furor RW-U' rev. 1U.13.U6
Attorney Signature:
Attorney Name:
Supreme Court I.D. No.:
Address:
Telephone:
Page 2 of 2
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This is to certify that this is a true copy of the record which is on file in the Pennsylvania Department of Health, in accordance with
the Vital Statistics Law ~t~ 1953, as amended.
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WARNING: It is illegal to duplicate this copy by photostat or photograph.
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t_~ ,,, ~,~. by =_
Y~"~ `~p~`~p~ `ri=_ Marina ~)'h:eilly Matthew
L.l,.l ~-~-- .Z ~L
~~ ~.i-- ~ = Acting Srate Registrar
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No.
Date
H105.144 REV 1112006
TYPE / PRINT IN
PERMANENT
BLACK INK
432-3.99
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COMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF HEALTH • VITAL RECORDS
CORONER'S CERTIFICATE OF DEATH 116191
(See instructions and examples on reverse) CTCTF FII F NI Ir,A[7CO
1. Name of Decedent (Frst, middle, last, suffix) 2. Sex 3. Soda) Security Number 4. Date of Death (Month, day, year)
Harold L Criswell Male 192 - 30 - 4711 December 3, 2010
5. Age (Last Birthday) Under 1 year Under 1 day 6. Date of Birth (Month, day, year) 7. Birthplace (City and state or foreign country) 6a. Place of Death (Check only one)
Monats Days Hours Minutes Hospital: Other
7 3 Yrs. Ma 5
' 19 3 7 Carlisle PA ^ Inpatient ^ ER ! Otdpatient ^ DOA ^ Nursing Home Residence ^ Other • Spedfy.
6b. County of Death 8c. City, Boro, wp. f Death
~ 6d. Facility Name (If not kutrtulion, give street and number) 9. Was Decedent of Hispanic Origin? No ^Yes 10. Race: American Indian, 81ack, Whffe, etc.
Cumberland South Middlton
' (If yes, specify Cuban, ISP~1
439 Alexander S rin Road Mexican, Puerto Rican, etc.) White
11. Decedent
s Usual Olxu Pion Kind of work done Burin most of woridn Itle. Do not state retire 12. Was Decedent ever in the 13. Decedent's Education (Speuity only highest grade completed) 14. MariMl Status: Married, Never Married, 15. Surviving Spouse (If wife
give maiden name)
Kind of Work Kind of Business I Industry ,
U.S. Armed Forces? Elementary /Secondary (0-12) College (1.4 or 5+) Widowed, Divorced (Specil)~
Hand an Self Em to ed ^Yes I$No 12 Iv'ever Married
16. Decedent's Mailing Address (Street, city /town, state, zip code)
439 Alexander Spring Road Decedent's Did Decedent
Actual Residence 17a.State Pennsylvania Liveina 17c.~ Yes
DecedentLivedin South Middleton
Carlisle PA 17015 ,
Twp
Township?
17b.County Cumberland 17d.^No,DecedentLivedwdhin
Actual Limits of City I Boro
18. Father's Name (First, middle, last, suffix) 19. Mothers Name (First, middle, maiden surname)
Louis C Criswell Lucretia M Fidler
20a. Informant's Name (Type ! Prinq 20b. Informant's Mailing Address (Street, city /town, state, zip code)
Doris J Guise 495 Plainview Road, Gettysburg, PA 17325
21 a. Method of Disposition
^ Burial ^ Removal from State Cremation ^ Donation 21 b. Date of Disposflion (Month, day, year) 21 c. Place of Disposition (Name of cemetery, crematory or other place) 21 d. Location (City /town, slate, zip code)
^ Other • Specify: ;Was Cremation or Donation Authorized
j by Medical Exeminer /Coroner? Yes ^ No DeC . 14 ~ 2010 Hof fman-Roth Funeral Home &
" Carl isle, PA 17013
Crema o
22a. Sig of funeral Service Licen ( person ailing as such)
" 22b. License Number
013144E 22c. Name and Address of Facility
Hoffman-Roth Funeral Home & Crematory
219 North Ha nover Street, Carlisl e, PA 17013
Compl kerns 23a~ only when certifying
physi is not available at time of death to 23a. To the best of my knowledge, death occurred at the time, date and place stated. (Signature and title) 23b. License Number 23c. Date Signed (Month, day, year)
cerf pose of death.
Items 24-26 must be completed by person 24. Time of Death 25. Date Pronounced Dead (Month, day, year)
who pronounces death. Unknown M• December 7 2010
CAUSE OF DEATH (See instructions and examples)
Item 27. Pad I: Enter the chain of events -diseases, injuries, orcomplications -that directly caused the death. DO NOT enter terminal events such as ardiac arrest,
respiratory arrest, or ventricular fibrillabon without showing the etiology. List onty one cause on each line.
IMMEDIATE CAUSE (Final disease or
condffionresultingin each) ~ a. _ Occlusive Coronary Artery Disease
Due to (or as a consequence oQ:
Sequentially list condffions, if arty, b.
leadin to the cause listed on line a.
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26. Was Case Referred to Medical Examiner /Coroner for a Reason Other than Cremation or Donation?
Yes ^No
Approximate interval: Part II: Enter other;ctgnificenl conddions crontdbulir to death, 28. Did Tobacco Use Contdbule to Death?
Onset to Death but not resuking in the underiying cause given in Part I. ^Yes ^ Probably
^ No ^ Unknown
29. If Female:
^ Nat pregnant within past year
^ Pregnant at time of death
Enter the UNDERLYING CAUSE Due to (or as a consequence oq: i ^ Not pregnant, but pregnant within 42 days
(disease or injury that initiated the c r of death
events resuking m death) LAST I
Due to (or as a consequence of): r ^ Not pregnant, but pregnant 43 days to 1 year
d I before death
r
^ Unknown ff pregnant wffhin the past year
30a. Was an Autopsy 30b. Were Autopsy Findings 31. Manner of Death 32a. Date of Injury (Month, day, year) 32b. Describe How Injury Occurred 32c. Place of Injury: Home, Farm, Street, Factory,
Perforated? Availade Prior to Completion
of Cause of Death? ~ Natural ^ Homicide Office Building, etc. (SperafyJ
^Yes ~No ^Yes ^ No ^ Accident ^ Pending Investigation 32d. Time of Injury 32e. Injury at Work? 32f. II Transpodation Injury (Specify/ 32g. Location of Injury (Street, city /town, state)
^ Suictide ^ Could Not be Determined ^Yes ^ No ^ Driver /Operator ^ Passenger ^Pedestrian
M. ^Other • Specify.
33a. Certifier (check onty one) 33b. Signature and Tdlepj~edrfier
Certifying physician (Physiraan cedi(ying pose of death when another physician has prorauntad death and completed Item 23)
To the best of my knowledge, death occurred due to the cause(s) and manner as stated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ - I ~. one r
Pronouncing and certllying physician (Physician both pronoundng death and certitying to cause of death) 33c. License Number
To fire best of my Inowledge, death occurred at the time, date, and place, and due to the cause(s) and manner as stated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ 33d. Date Signed (Month. day, year)
Medical Examiner 1 Coroner December 13 , 2 010
On the basis of examination and I or investigation, in my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner as stated_
34. Name and r s of Person W Completed Ca se of De h (Item 27) Type 1 Print
35. Registrar's ore and District Nymber~ TO~d~ C . Ec~kenro~e, ~oroner
~ 36. Date Fled (Month, day, year) 6375 Basehore Rd., Suite ~~l
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Disposition Permit No. ~~ S I ~ ~ I S~