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Home My WebLink About05-26-11 r IN THE COURT OF COMMON PLEAS OF CUZViBERLAND COIJrNTY, PENNSYLVANIA REGISTER OF WII~LS PETITION OR PROBATE AND GRANT OF LETTERS ~ ~ t ~ Deceased ESTATE N0.21- D~~ Estate of a/k/a: a/k/a: ' 2 a/k/a: SS NO: ~ y J Petitioner(s) who is/are yrs of age or older, apply(ies) for. COMPLETE SECTION `A' or `B' AND KC" as applicable: A. Probate and Grant of Letters Testamentary or ~ Administration c ter., or d.b.n.c.t.a. (complete PaR C also) and aver that Petitioner(s) isJare 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 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 defined in Pa. C.S.A. § . Grant of Letters of Administration ptapplicablG eater d.b~a., peadeat rr~ daraste abseati~t, daraste minoritatt) C. Petitioner(s), after a proper search, hasJhave 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 Pa. C.S.A. § except as follows: Address to Decedeat _ ~ , _~i rY~ C.T.# ..,sky-+ T ~„J USE ADDITIONAL. SHEETS IF NECESSARY ~ E"''- ~r-~ THIS SECTION MUST BE COMPLETED: ~ ~ Deced as do ' 'led death in Cum end Co ty, P lv with h' 1 t amity or ~ ' resi~nce At - ~ (street adamss with Post office and Z code, Munici i :Township, city) Decedent, then years of age, died at Day, Year of death) (City and State where death occurred) Estimated value of decedent's property at death: If domiciled in PA All personal property $ If sot domiciled in PA Personal property in Pennsylvania $ _If not domiciled in PA Personal property in County $ Value of Real Estate in Pennsylvania $ Total Estimated Vetere $ I.ocati f Real Estate in Pennsylvania: (Provide full address if possible.) ~ ~ l ~ l igna ~ NameEs) & icing Address(es) w - ~ ~ tiG 2 Interim Form RW-02 revised by Cumberland Caunty 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 P ' 'oner(s) and that, as personal representative(s) of the Decedent, Petitioners} will well and truly admini r e to acco g t law. Sworn to or affirmed and subscribed is ~ t~ da f fo eth ~ ~p ~?l~• f F e Register ~ DECREE OF PROBATE AND GRANT OF LETTERS ~ Estate of ,Deceased File Number: ''O~Oo~ ~ AND NOW, this day of , in considerationthe Peti~n on`e' the reverse side hereon, satisfactory proof having been presented before me, IT IS DECREED that Letters Testamentary of Administration are hereby granted to: (if ap~licabk, ewer ats., d.t~.n., ~.~o.ata., etc.) 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. Glenda Farner Strasbaugh, Register of Wills FEES: Sisnatere of Coansel Required to Enter Airpeannce Letters Q .Od Will . . Atty's signature C oil(s) b ( )Short Certificates PRINTED Name: ( )Renunciations....... Supreme Court ID No.: Bond Other Address: Automation FEE......... .iCS FEE Phone: 3 of ~ Fax: TOTAL Interim Form RW-02 revised by Cumberland County pending action by the Court Page 2 of 2 ? Yes l~° ? Yes ? No ? Suidde ? Could Nd be Determbred M ? Y~ ? ~ ? Driver I Operate ? Passenger ?Pedeslrien Otlrer - Specdy: 33a. Certifier (drer;k only are) 33b. Signature r ' C•rof yth9 ptryekien (Physidan cerafyirp cause d death when another physidan has proraurxred death and corpleted Item ~ - Q = Totlxbatofmylmowbdge,dalhoawrredduebtheaute(s)endmenneraebbd--------------------------------- ~ .T~ Praauncing end artllying phyeklen (Physiden both pronorexing lath and aatllymg b cause of death) 33c. Lt~o bar 33d. D (Month, , To the last nt my IorowNdge, doer oaxtrred et the time, deb, end place, end due b the aute(e) end manner a ebted_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ? 1 w ~ Medial PxenrNMr 1 corarx ~ l S ` C ' (Z On are beet: of examinetlon end 1 e InveedgNion, in my opinion, death oxurred et the time, deb, end plea, end due b are auee(e) end manner u efeted_ ? 0 Name d Pled ~ ~ tli (aen Type 1 Print w R ~ and .Date F9ed (Month, day, year) /~~S/~ ~ Q / • G1.G~~ ~ ~ f ~l ~~a P~' / r'di Z . Disposition Permit No. ~ 810NIJlN1E AND7RlE OF CERTIFIER •CBR~SIO/IIYfIGAN~Y~+n~MR'Oewraddwl~wlw+arn/wp~yrehnlwPa~o:ncWOarnanoeomCrMd J Ti Et•laaR el my 1uNwMdpR daaYe eoennaa /w Y Yea eaera(s) aM raewear a• stead (~,/1(r ~ •?RONOUNtBaANOCerTrtrBaF~nf,:e.neanw«w.ne+ww.wanac«~Mrwwcaw.ada.n? f~ D D~~~' H ~ MQi2.~1, ~H Tb elw but w my loadadpe. daatle aaevM M Bn Mnr, dat. and ptcs, and dw t dw eawa(a~and m.mwr as aealaa D NAME AND ADORERS OF vERSONVV?1o COMFlETEO CAIJBt Of oERN ~ - ~v. i~ . •t+E01cAt.EXAMINEWCORONER ~ CLAUD~N Y. L~,A-R.1 P~ 0 ~ aR 11?o e.a. of •:«nin.aoe and/« enwstlgatlon, in my opnlon, a.sM oeeurrae ae eha lima. dalo, and pteo. elnd du. to Beo e.u : ane D i OL.~ V (Li IL i1 ~ L G 1 P A - I ~ f N / rren« eu seated.......... aa( 7,a 7 REGISTRAR'S ADD ~ I 1 I I 1 I DATEFN.EDIMa~.ONt1Mj1aAR 2 2 . ,r F i . ~ I REW3a8 Ex 3 4 6 0 0 0 J ESTATE INFORMATION SHEET Pennsylvania FOR REGISTER'S OFFICE USE ONLY 1)EPARTMkNT OF NEVENUE Coun Code Year File Number DECEDENT INFORMATION: Eimer data a: R will appear on all ~ ~ ~ ~ a documents submitted to the Department. Decedent's Social Security Number Dat f Death Da f Birth ~ ~ Last Name Suffix First Name ~ f MI ~ l TYPE FILING: FIII In oval to fndicate the nature of the return to be filed with the department. ~ Probate Return O Joint Assets Only OMon-probate Assets Oniy O Litigation Purposes (no other assets) LETTERS GRANTED: Fill In oval to Indicate the nature of the proceedings at the Register of Wills Office. (Attach additlonal sheets M explanation is necessary.) O Testamentary ~ Admin(stration O No Letters O Other (Please Explain.) ATTORNEY/CORRESPONDENT INFORMATION: Enter all information for the attorney or individual to recehre tax Information and correspondence. Last Name , Suffix First a MI ~ Supreme Court I.D. # Telephone Number 2 ~ ~ ~ Attorney/)C ~ s ent's e- ail . l l1'~ ~ ~~p~ „ First Une of Address Sec Line of A ress ~ ~ .1J . ~ ~ ~ ~ ~ Ci .Post Office ~ a?"+ tY to ZIP Code i"~~ y'am' PERSONAL REPRESENTATIVE INFORMATION: Eirter all information for the personal representative(s)' estate rte. ``n ~i authorized by the Register of Wills. Executor/Administrator Social Security Number Telephone Number Last Name Suffix First. Name MI First Une of Address OFFICIAL USE ONLY Second Une of Address TIRANSACTION COUNT City or Post Office State ZIP Code Complete general assts Inbrmation questions and indicate additlonal personal representatives on reverse side. PLEASE USE ORIGINAL FORM ONLY Side i REV EX Decedent's Social Security Number Decedent's Name: Co-Executor/Adminirtrator Social Security Number Telephone Number Last Name Suffix First Name MI First Une of Address Second Une of Address City or Post Office State ZIP Code Co-Executor/Administrator Social Security Number Telephone Number Last Name Suffix First Name MI First Une of Address Second Une of Address City or Post Office State ZIP Code General Inrtructions: This form should be filed with the Register of Wills of the county of which the decedent was a resident at death. Please be aware the correspondent identified will receive all correspondence from the department. It is the responsibility of the personal representative to notify the department (f the correspondent contact information changes. The department is authorized by law, U.S.C. (c)(2)(C)(i), to require disclosure of Social Security numbers in connection with adminlstering state tax laws. The department uses the Social Security number to identify the decedent and personal repre- sentatives of the estate. The commonwealth may also use the information in exchange-of-tax-information agreements with fed- eral and local taxing authorities. State law prohibits commonwealth personnel from disclosing confidential tax information except for official purposes. Side 2 J