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Home My WebLink About04-28-11IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA REGISTER OF WILLS PETITION FOR PROBATE AND GRANT OF LETTERS d ~ ~~ Estate of :_. ~ t:~ /'' ~ ~ c~ ,~, ,Deceased ESTATE NO: 21- ~ ~- ~~~ S 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. (compl'ete Part C also) and aver that Petitioner(s) is/are entitled to the aforementioned Letters p ~ r _ under the last Will of the above-named Decedent, dated j1/~i' ~', ~~ / ?/~ ' and codicil(s) dated ~~ ~ `f ~ (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 e~cecution 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): ~ , ;, ^ B. Grant of Letters of Administration ! _~g~,~ sa -___~ (If applicable, enter d.b.n., pendent I~te, durante absentia, durante mmeb~t~) ~~ ' ' - f`v" , C. Petitioner(s), after a proper search, has/have ascertained that Decedent left no Will and was survived b ~ r~:, '~ ~ ~:., 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 T a~~ohr~plete fist of heirs); was not the victim of a killing; was never adjudicated an incapacitated person; and was not a arty `~-~ `' P Y t~ Pending-divorc+~ , `~ proceeding wherein grounds for divorce had been established as provided in Z3 Pa. C.S.A. § 3323(g~except as follows: ~_`~` `~' :...-> ~' Name `"` ~ Address Relation_shi to Decedent ~ ~ ~ ~~'L ~ N ~,C r ~ ~~ s~~ l~v N ~ X91 ~ G l~ ~v ~ r G' C~ het r w ~:., /'°I A ..~ ~ ~ G / /J.~.:,- ~F--.,,~ USE ADDITIONAL SHEETS IF NECESSARY THIS SECTION MUST BE COMPLETED: Decedent wa do ciled at dLeath in Cumberland County, Pennsylvania, with is/her last family or principal residen e C iGj ,r ~~ ! i~ ~ ~~~ (St et address with Post Office and Zip Code, Municipality: Township, Borough, Cit) ,~ Decedent, then ~ years of age, died ~~. ~ ~ ~ / /' at /i'j~ ~a-,/,~Gs ~,,~,~ ~, ~~~~ ~_ (Month, Day, Year of death) (City and State whe 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 $ - _Ifnot domiciled in PA Personal property in County $ r _Value of Real Estate in Pennsylvania $ - Total Estimated Value $ ~_ Location of Real Estate in Pennsylvania: (Provide full address if possible.) ~ ~ ~ ~ Signature(s) Name(s) & viailing Address(es) _ , c~• s .l~v c/v Interim Form RW-02 revised 12.26.10 by Cumberland County pending action by the Court , ` 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 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 to or aff rm; d and subscribed ,., r~ ~-~ ~ - b or e thl~ ~ da of -'~ ~~ ~~ J -- DECREE OF PROBATE AND GRANT OF LETTERS the ab ve estate and that instruments(s) dated admitted to probate and filed of record as the e Register -- _,~ _ _~ ~ -: .,.~. ,,._. _" 3 4::. :~ c~ Estate of ~~ f~ ~/dx ~~~ ~ ~ ~/a ,Deceased FileNumber: 21- _ ~ ` AND NOW, this ~~,..~'~day of ~t ~~ ~~;,`%' in considera i ton of the Petltlon on the reverse slde hereon, satisfactory proof ha ing 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.) FEES: Letters .................... ;, $ ~'~ ~~' ~~` Will ...................... . '.G~~ Codicil(s) ............... G~~~ - - ( ~ Short Certificates _ ~! C:" ( j)Renunciations..... .._ h, ~"i~~ - Bond ............................ -- ~ Other ........................... .. ................................. Automation FEE......... 5.00 JCS FEE ................... 23.50 %~~~~~~ TOTAL ................ $ -~..5~- In ~~~-s ~ ~ ~ c. .J `- ° ~ C1 ~~ " ;~' ~ ~G'C/ ~d'~~crrbed in the l~ctitior be Wi' 1 an Co~dici (s) of Decedent. ~'" ~~ a ,~ ~ ~ - ,~~ ~ . ,~",~ Glenda Farner Strasbau h ~` "~ f ~ .f t°E:' ~ c.~t~-'e' .~ -'',~ -t,~,~ Register of Wills ~~'` r_. Signature of Counsel Required to Enter Alppearance Atty's Signature PRINTED Name: Supreme Court ID No.: Address: Phone: Fax: -- Interim Form RW-02 revised 12.26.10 by Cumberland County pending action by the Court Page 2 of 2 lni_',ni IZ1-~ ~u~;ir-, LC~AL REGISTRAR'S CERTIFI+~~A'I'I~pN GF L~E,A••I ~'ARNING; It is illegal to duplicate this, (w~py h~ phtat05tat i~31• ;~hr~tcg~~,~;,~~; Fey for this ~~rtificatr° ~;r~-i)(~) -- ) , ; . ... tttlr'. rr, ,u„~~. 1` s i 14 ~ . I t ~ it~t~ ~~ tff-;~~ fl, ~ I S 1C:1 I~ 7 t,l I '11?~(~ ( ~ ".?I(I~.ICI' (rt 1)s'~ii}) ~. ,~ _ s 1 k ) \\`1~`~, dy.; ~ s-1~1, rl:."41 .~i: ~ ,?~..ti \~. :rt ~fl~ll i d~l° b~Yr~.r ll~ct7 ~~~ ~ .~I~tll~r.,l(_ „~,~ ~~_ _ ti I,i)v~~l f.a t"s~~. ~.ytz;~+~° \'~~l~lf o. z p i,; C..3, `2_ i. ~?~~ '~, (~t.'i. 1':.64 I_ ~i rl. L.i' I)ti(i iC. ~1[ ~(Nt°}'t3 ~ 1.. .' ,~, ~; .~ ~ . P 1729641 ~~~~~ :,,~t~~ . ~~ _ _ . C'ertlflLallul) ti(unrlcl~ ~ ~~. _ _ ,,,,,,_x,,~,_ , C7 -... - , ~~ :.~- . . ^~~ ~oy. . mac- 1 ) f . - -~ ~~ .- j:.. ~-..~ r~ ~-1 .. '---r _',~ / ~ J ~ p ~~ ~ .~ :,: ;i - ,r'~ ~./ Y .~ ' 1 H105-143 REV 11/2006 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS TYPE /PRINT IN PERMANENT BLACK INK CERTIFICATE OF DEATH (See instructions and examples on reverse) STATE FILE NUMBER 1. Name of Decedent (First, middle, last, suffix) 2. Sex 3. Social Security Number 4. Date of Death (Month, da , Laura Irene Smith y year) Female 192- 30- 4990 February 24, 2011 5. Age (Last Birthday) Under 1 ar Under 1 da 6. Date of Birth Monts, da , r 7. Birth lace C' and state or torsi count Ba. Place of Death Check onl one A 94 ~~ Days Hours Moores Hospital: Other: vrs. November 29, 1916 Lemoyne, Pennsylvania Ca - ^ Inpatient ^ ER /Outpatient ^ DOA Jpt Nursing Home ^ Residence ^ Other -Specify: • Bb. County of Death &. City, Boro, Twp. of Death Bd. Facility Name (If not institution, give street and number) 9. Was Decedent of Hispanic Origin. ~ ~No ^ Yes 10. Race: American Irxkan, Black, White, etc. Cumberland Silver Spring Bridges at Bent Creek In yes, specity Cuban, (S Mexican, Puerto Rican, etc.) White t 1. Decedent's Usual Occu lion (Kind of work done Burin most of worki life. Do not state retired 72. Was Decedent ever in the 13. Decedents Educatbn (Specify only highest grade completed) 14. Marital Status: Married, Never Married, 15. Surviving Spouse (If wife, give maiden name) Kind of Work Kind of Business/Industry U.S. Amred Forces? Elementary / Se2ndary (i}t2) College (1-4 or 5+) Wdowed, Divorced (Speci/yJ Clerk Local Government ~ Yee No Widowed 16. Decedent's Maifing Address (Street, city /town, state, zip code) Decedent's pA Did Decedent 2100 Bent Creek Blvd. ActualResklence 17a state Liveina „c. ~,Yee,oeceden,Wvedin -Silver Spring rw Mechanicsburg, PA 17050 I7b County Cumberland Townshlp~ 17d. ^ No,DecedentLivedwithin P Actual Limits of Ciry / Boro 18. Fatftels Name (First, rtdddle, last, suffix) 19. Mother's Name (First, middle, maiden surname) Harry W. Fishel Carrie E. Boyer 20a. InformanYS Name (Type /Print) 20b. Informant's Mailing Address (Street, city /town, state, zip code) Gary Alvin Smith 271 Spanglers Mill Road New Cumberland, PA 17070 21 a. Method of Disposition r ^ Cremation ^ ponatbn 21 b. Date of Dispositan (Month, day, year) 21 c. Place of Disposition (Name of cemetery, cremaary or other lace ~ r P ) 21d. Loption (Ciry/town, state, zip code) w ~ Burial ^ Removal from State r Was Cremation or Donation Authorized Februa 28 2011 ^ Omar- r by I Examiner/coroner2 ^ Yea^ N~ rY Mt. Zion Cemetery Carlisle, Pa. 17013 a ~ 22a. of Funeral Se ~ i as such) 22b. License Number 22c. Name and Address of Fadliry a / Myers Funeral Home, Inc. 37 East Main Street Mechanicsburg, PA 17055 Complete dams c ~ when certitying 23a. T best of my . Beam oc d at t¢ date and place stated. (Signature and title) 23b. License Number 23c. Date Signed ( m, day, Year) physician a rat available at tkne of Beam to / i 't / certify cause of death. `'~, r(../ `~ `~iJ ~ ~ t, / L ? J Items 24-26 must be completed by person 24. Time or Death 25. Date Pronarmced Dead ( net, day, year) 26. Was Case Refer~re/d to Medical Examiner !Coroner for a Reason 0 r than Crematim or Donation? who proraunces death. !j `~ ~ ems' ~M. ~ Z / / ^ Yes ICI No CAUSE OF DEAJTH (See Instructions and examples r Approximate interval: Pad II: Enter other ' ~ I ` ' " 28. Did Tobaxo Use Contribute to Deam? Item 27. Part I: Enter Ure ~ of events -diseases, injuries, or complications .mat directly caused me Beats. DO NOT enter terminal events such as cardiac arrest, ~ Onset to Death but not resulting in the underlying cause given wt Part I. respiratory arrest, or ventnalar fibdllation wilMut showing the etiology. List only one cause on each line. r ^ Y ^ Pabably IMMEDIATE CAUSE (Final disease or ~ ~ ,~ r r No ^ Unknown condition resulting in death) L '~ r ,r -~ a ~ `~ (/!'yi•~--1~ .~jt r ~ l.l.~:'~i~[. ~ Vr %ILN~ l.~~UII'U~'jt~.29.If~yFem~~ale: Due to (or as a core nce of): r , ~ ~a~4ot pregnant within past year Sequentially list caWitiorx, 'rf any, b r tl .... (~/; „ ~ ~ G ~ [] pregnant at time of Beam leadug to the cause listed on line a. ' /-N~,rf /..(~ "t Tr.~)/r - Enter the UNDERLYING CAUSE Due to (or as a consequence of): ~ ^ Not pregnant, but pregnant within 42 days - (disease or injury that initiated the i /rr~ /~~~ ~ cf ~m events resuking in death) LAST. c. r l,Ll~',~'Y d E' s~~~~i.t~ Due to (or as a consequence oQ: r ^ Not pregnant, but pregnan143 days to 1 year ~ batons deaih d. r y - a D;aGe~s ill •~ . r ^ Unknown if pregnant wihin me past year 30a. Was an Au[opsy 30b. Were Autopsy Findings 37. Manner of Deam 32a. Date of Injury (Month, day, year) 32b. Describe How Injury Occurred _ Pedorrtad? Available prior to Completion , j/t~ 32c. Place of Injury: Home, Farm, SVeet, Faaory, of Cause of Deam? ~Wral ^ Homicide ---- 7 ~ / i Office Building, etc. (Specify) ^ Yes .A~AIO (C71~~_ ^ Accident ^ Pend' Investi Lion mod. Time ~W Injury 32e. Irqury at Work? 32f. If Transportation In'u S J~ ;;;/// ^ Yes ~ rn9 9a I ry (peci/y) ~-,{/J , I 32g. Location of injury (Street, city / to~Nn, state) ^ Suicide ^ Could Not be Determined M [~~-~.Ho ^ Ddver/Operator ^ Passenger 1J Pedestrian ^ Other - Specl/y.' ~'L" f~ J------- 33a. Certifier (check only one) 33b. Signature and Title of Certifier / • Certifying physician (Physician certifying cause of death when anomer physican has praraunced deem and completed Item 23) To the best of my knowk+dge, death occurred due to the cause(s) and manner as stated _ _ _ _ _ ~ ~ ~ ,~~ ~ " / -~! • ronouncing and certfying phyaleian (Physician born pronouncing death and certifying to cause of death) 33c. Ucense N m / 33d. Date Signed (Month, day, year) r z To the beat of my knowledge, death occurred at the time, date, and lace, and due to theca _ ^ o Medial Examkrer /Coroner P use(s) and manner as stated _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ / ~ On the bawls of ezaminatbn and / or investigation, In my opinion, death occurred at the time, date, and place, and due to the cau sand manner as stated_ ^ ~ ~(1 34. Name aynd~A~ddress of Person Who Completed ~Lause W Deam (Item 27) Type /Print ~ 35. Re ' ac's Signature and Distric~Number j~L` r vy) [~ tG 11 ,~ ~'1[~ lam/ .S' ~'t r , 36. Filed I ~ t _ z L~ I~ (Monet, day, Year) ,~C%.~ n- ~ 7C 11 Z ~ ICL7/ :~ -.~C/ 5 ~L'~'4if- . ~~~% ~'- / ~ t,2 rr~~ {'~, Jai/^~ !~~ . 1 -- Disposition Permit No._~_~~ 1tt~Y mill rzn~ ~e ~` ~~ ~Vt max.. L "C r ~ ., -. r- 1~.~~ '_ .a _~ ---f ;ice ~~~txrt~n.~ I. LAURA F. SMITH, of the Borough. of Lemoyne, Cumberland County, Pennsylvania, make, publish and declare this to k~e my Last Will and Testament, hereby revoking and making void any and all former Wills by me at any time heretofore made. 1. I direct the payment of my just debts and funeral expenses as soon after my death as may be convenient to my Executor hereinafter named. 2. I give, devise and bequeath all the rest, residue and remainder of my estate to my children, George Smith, Gary Smith and Sharon Smith, share and share alike. 3. If any of my said children shall not be living at the time of my death, I give, devise and bequeath the share of such deceased child to the issue of such child, if and-, and in the case of no issue, then to my surviving child c-r children in equal shares, the issue of any deceased child to receive the share of the parent. ~::.. _~~ j ~ .7 ~ ~' ; .,.' . ~ r'r' 11 ( ~ ~: 4. I nominate and appoint my son, George Smith, to be the Executor of this, my Will. Should my son, George, :Ea.il to survive me or fail for any reason to complete the admin:i-~ stration hereof, I appoint my son, Gary Smith, to be the Executor in his stead. Should my son, Gary, fail to survive me or fail for any reason to complete the administration hereof, I appoint my daughter, Sharon Smith, to be the Exe- cutrix in his stead. IN WITNESS WHEREOF, I hereunto set my hand and seal ~ ~.~ this , ; day of/(,~u~~~rr, ~~~~ 1974. ~l `~;: Laura F. Smith Signed, sealed, published and declared by the above-- named Testatrix as her Last Will and Testament, in the t presence of us, who, at her request, in her presence and in the presence of each other, have hereunto subscribed our names as witnesses - 2 - Register of Wills of Cumberland County, Pennsylvania OATH OF SUBSCRIBING WITNESS Estate of LAURA F. SMITH. Deceased No. ~ ~ ~ ~ ~ - ~~.~/ HORACE A. JOHNSON a subscribing witness to the Will presented herewith, being duly qualified according to law, deposes and says that he was present and saw the above Testatrix sign 1:he same and that he signed as a witness at the request of Testatrix in her presence and in the presence of the other subscribing witness. Le State of Pennsylvania County of ~YY1 ~t~~'~~~ Sworn to or affirmed and subscribed before a this b"t~fi day of 2011. t~l~lJC_- No Public My Commission Expires: (Signature and seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's commission.) 1 A/Johnson et StreetStreet e, PA 17043 COMMONWEALTH OF PENNSYLVANIA NOTARIAL SEAL Gail J. Mahoney, Notary Public Lemoyne Borough, Cumberland County My commission expires February 19, 2014 c7 ,_ , ,.:F:, ~ X.17 _ ~ .....~.,~ ` 1 1 ~ '~ "F"f I'`a.~ 1 ~= 5`_} - -_ -`r-i ' _ - - _ :~) _ . ~ /~ G ~.:~ --r~ r NOTE: To be taken by officer authorized to administer oaths. Please have present the original or copy of Instrument(s) at time of notarization. OATH OF NON-SUBSCRIBING `VITNESS(ES) REGISTER OF WILLS ~i~c~N~l l~ nt;~. COUNTY, PENNSYLVANIA _ "x.1-11- C~'~ ~, Estate of __ ~ (~ ~) ~ ;~~ ~ , ~j m ~ ~} °'1~ ,Deceased ~` ' L i Y7 ~ _t. ~ G ~1 ~ and (each) being duly qualified according to law, depose(s) and say(s) that she / he /they w_ .as /were well- acquainted with _ I.-.. u ~~ rte F ~ rr1 j~ and am/are familiar with the handwriting and signature of the decedent, and that the signature of LC ~,.~~ r'~~ __F= ~J ~'rl ~ to the foregoing instrument purporting to be th Last Will nd Testament/Codicil of r-Ci~ ~- cJ ~Y11 `~j is in his/her own proper handwriting. l ~ ~~' (Signature) ~ ~ ~ v.~rl Y1/1 l ~~ n/l;1 ! ~~c~ (Sheet Address) (City, State, Zip) Execccted in Regist€~r's Office Sworn to or afftr-rr~ed and subscribed before me this ~ `~~ day of ~>> ~ ~ ~ ~ '~ ~\ ~ ' Deputy for Register of f Wills 1 (Signature) -- (Street Address) -- (City, State, Zip) ~ _ ~ - ~^~ -~'I .. _-^ ...r_~ _ -~....~ -~ C L y ~~ ~ , ~' ~ ( ---- _, c. Form RW-04 rev. I0.13.Oci u.~ ~ . FIRST CODICIL TO THE LAST ~"JILL AND TESTARAENT OF LAURA F. Si~~IITH n ~- . ;: ~--.. :: x1 ~~ .. . , ; n N Ci~~ .: ~ ~ ~..- .. ti ,,, z, .::~ o I, LAURA F. SMITH, of the ~3orough of Lemoyne, Cumberland County, Pennsylvania, do make, publish and declare this to be the First Codicil to my Last !~"Jill and Testament dated November 5, 1974_ FIRST: Paragraph 4 of the aforesaid 1~'Vill is hereby revoked and replaced by the following: 4. I hereby nominate, constitute and appoint my son, GARY SMITH and my daughter, SHARON SP/11TH REED to be Co-Executors of this, m,y Last ~"Jill and Testament. SECOND: In all other respects, ! hereby confirm and republish my Last ~."Jill and Testarent dated November 5, 1974 this ~~ y of July, 193~i. ~,,- s Laura F. Smith The foregoing instrument vas in our presence signed by LAURA F. Si`~11 T H, and declared by her to be the First Codicil to her Last t~Vill and Testament dated November 5, 1974. VJe, at her request and in her presence and in the presence of each other, have hereunto subscribed our names as witnesses. . --, ,~ 1~ ~ ~:~- ~.. ~. L~ ~~~ ~' ~- _ ~~~.;~, ,~~-~~~, OATH OF SUBSCRIBING WITNESS(ES) REGISTER OF WILLS CUMBERLAND COUNTY, PENNSYLVANIA ~.1 ~ 1 I - r1~ ~~ Estate of Laura F. Smith C;- ,-, ~ -`i ' C7 '--.~ ; : ) ~ l~ 1 ~ r ; ~ _: _ ; z- -,,.. ~..~ O ~ --~-~, Joel O. Sechrist Deceased (each) a subscribing witness to (Print Name/s) the Q Will ~ Codicil(s) presented herewith, (each) being duly qualified according to law, deX>ose(s) and say(s) that she / he /they was /were present and saw the above Testator /Testatrix sign the same and that she / he /they signed the same and that she / he /they signed as a witness a~: the request of the Testator /Testatrix in her /his presence and in the presence of each other. ~~ -. ,~ gnature) (Signature) ~~ 568 Old York Road (Street Address) Etters, PA 17319 (City, State, Zip) Executed in Register's Office Sworn to or affirmed and subscribed before me this day of Deputy for Register of Wills (City, State, Zip) Executed out of Register's Office Sworn to or affirmed and subscrib(~d before me this ~~'~~ d,~y of ~'yJ~/z < /'/ ~~1~ ~=c -c- N ary Public y Commission Expires: 07 _ ,~, ._,s (Signature and Seal of Notary or other official quali~tied to administer oaths. Show date of expiration of Notary's Commission.) NOTE: To be taken by Officer authorized to administer oaths. Please have present the original or copy of instrument(s) at time of notarization. ~:t~MVlR~C7l~W ~L7'H OF PENNSYLVAWI,4 ~,._... ~...,~.._~..p,.___._ _ _____,_ Form RW-03 rev. 10.13.06 Not~ri~i sea! Pairi~:aa A. Gordon, Notary Public 1=ai~~~iety Twp., York County E'viy Com;n;ssion Expires July 31, 2013 _ Member. Penrvsyluanis~ A~gcx;itttinn of Mnt~nie;~ (Street Address) OATH OF NON-SUBSCRIBING WITNESS(ES) REGISTER OF WILLS r~ ~ :,~' ~lyd~ COUNTY, PENNSYLVANIA i(. ~ _ l ~ - D ~~~ Estate of L~ C~. lJ ~'~~t ~` ~ ~'1 l ~ Deceased -- Ca v'1 ~.~ ~ ~ ~ i'Y1 + ~ ~ and (each) being duly qualified according to law, depose(s) and say(s) that she / he /they v~-as /were well- acquainted with L-- Ll U rc;~ ~ J X71 i t~ and an~/are familiar with the handwriting and signature of the decedent, and that the signature of ' - (A ~ 1'-G'l _ 'I-- . S ~ ~ ~, to the foregoing instrument purporting to be the Last Will and Testamen Codici f _ Lr ~ ~.~~~-r.,~ ~ S m ~ ~1 is in his/her own proper handwriting. (Signatur - (Signature) (Street Address) ~~a, ~~ r» b-~ -~1 ~a ~q 17v 70 (City, Stnte, Zip) ' Execacted in Register's Office Sworn to or affirmed anal subscribed before me t:k~is ~`?' day 1 ~ h of t~? ~ ~' ~ ~ ~- ~_~_ , Deputy for Register of Wills (Street Address) (City, State, Zip) ~ .._ ~ ~ ~- - ~ C~ ~~! x rrm t`~ ~ f,/ i .~ __. , __ .. _' J t i _. / . __ ..:...~ , . r-,-; , ~ -;, ~ ~~ ~ Form RW-04 rev. !0.13.0( ,_, C7 -_ =~. c;, -- --t- ~ ; RENUNCIATI ~ T7''~' ~~- ~= r'~' ;~; -~ t_J REGISTER OF WILLS ' --' -~' ' ~- t /'tt/~'/RPe~ ~~t~/ i~ COUNTY, PENNSYLVANIA ~ ~ry ~~ ~ ~ ' T, Estate of ~ ~ ' ,Deceased - , m my capacity/relat>onsht,p 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 (Date) ,% -"~-~, r ' ~ (Signature) ~C-- (Street Address) (City, State, Zrp) Executed in Register's Office Sworn t or aftirme ~ an~ ubscribed befor this da ~~'~ ,~~~_i D uty for Register of Fills Executed out of Register's Off ice Before the undersigned personallly 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