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HomeMy WebLinkAbout07-28-11IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA REGISTER OF WILLS PETITION FOR PROBATE AND GRANT OF Estate of ~ LETTERS a/k/a: ~~©~~~~ ~ f Deceased ESTATE NO: 21_ / - ~ ~~, a/k/a: a/k/a: Petitioner(s) who is/are 18 yrs of age or older, apply ies for• applicable: ( ) . ^A. Probate and Grant of Letters Testamenta or and aver that Petitioner(s) is/are entitle ~ k~'4 '"` the last Will of the above-named Decedent, dated reme SS NO: ~ ~~ COMPLETE SECTION `A' or `B' AND «C„ as ' istration c.t.a. r d.b.n. mplete Part C also) ~~ under ~- an c ' ' s dated I~ ~ ---. (State relevant circumstances e. `\` Except as follows, Decedent did not m ~ g• renunciation, death of executor, etc.) ~'ry, was not divorced, and did not have a child born or adopted after execution instruments offered for probate; was not the victim of a killing, was never a ' ' Patty to a pending divorce proceeding at the time of death wherein rou ~ud'cated an incapacitated person, and was not a 23 Pa. C.S.A. § 3323(g): g nds for divorce had been established as d ' eflned m ~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 Dec following spouse (if any) and heirs (If Administration c.t.a. or d.b.n,~ dent left no Will and was survived by the heirs); was not the victim of a killing; was never adjudicated an Inca a ' t.a., enter date of Will in Section A and complete list of proceeding wherein grounds for divorce had been established as provided ' p citated person; and was not a party to a pending divorce in 23 Pa. C.S.A. § 3323(g), except as follows: Name ~fl , ~ - 3 USE ADDITIONAL SHEETS IF NECESSARY THIS SECTION MUST BE COMPLETED: Decedent was domiciled at eath in Cumberland Coun ,Penn; At ~ (Street address with Post Office and Zip Code Munici ality. Toy Decedent, then _~~ years of age, died Q 0 /1 Estimated value of decedent's roe (Month, Day, Y ar of death) If domiciled in PA p p ny at death: ~,.~ ~-:_ `' ° =r' i %7 ~~ ~ c~ ... ~-.:? lvania, with his/her last famil ~`` ~~ ~ `. ~ "~ Y al r ~~~'~~' .7 /1 .~ c deuce _ -~z ship; Borough, City) --i ~ ~ '- `T'i •' ~ `~7 Clt C-r' "'Y'.1 C:,', ( ~ and State where death occurred) _If not domiciled in PA All personal property $ ~ ~ /.~ ~~,,.~ _If not domiciled in PA Personal property in Pennsylvania - ' _Value of Real Estate in Pennsylvania Personal property in County $ Total Estimated Value $ Location of Real Estate in Pennsylvania: (Provide full address if $ possible.) ~ ~ , ~ ,) , , Signatures ~~,~~ // Name(s) & i~iailing Address(es) 'G - -- , v rw i 1 ' S~ ~ ~ Interim Form RW-02 revised 12.26.10 by Cumberland County pending action by the Court ``L~ Page 1 ot'2 \~` ~ ._J '~' ,~-~' OATH OF PERSONAL REPRESENTATIVE ~~- c7 ~; o ..~.. Commonwealth of Pennsylvania ~-~~, {-~-~ r -~~' County of Cumberland SS .'' ~~ ~~-.. :~~ `~~] -~~? `.r r-- c:.. -- ,_ r . _ ~.~ r The Petitioner(s) herein name ~ ~j ~~ ~. ~ ~~.~-~ d swear or affirm that the statements in the fore oin .. ~ ~~ ` correct to the best of the knowledge and belief ofPetitioner s -~ ~~ ~ ~ ~~ Decedent, Petitioner(s) will well and g g Peti~n are trn~e;:and ~.~ Q ()and that, as personal representative(t~) of the ~' truly administer the estate according to law. Sworn to or affirmed and subscribed be e me his _~ : ~~ - day of ~' __~ ~~~ . -._ z R~biste~ ~' ~ ,. DECREE OF PROBATE AND GRANT OF LETTERS Estate of ~jr ~-~~~ I Deceased File Number: 21-_ ~ _ ~ ~~, AND NOW, this ~ day of , the reverse side hereo ,satisfactory proof hav' ~ ~ , in consideration of th Testamenta 1 g been presented before me, IT IS DECREED thatet>ihon on rY of Administration Letters (If applicable, enter c.t.a., are hereby granted t0: . ~ !"~ d.b.n., d.b.n.c.t.a., etc.) the above estate and that instruments s d admitted to probate and filed of reco d a ated _ s the last Will and Codicil(s) of Decedent ribed in -the :petition be FEES: Letters ... c~L~~`U(~ ................. Will........... $ Co icil(s) ....... . . . . . .. . ( Short Certificates l~ ( )Renunciations... ... Bond ............... . Other ............................ Automation FEE ......... JCS FEE . 5.00 ................. 23.50 TOTAL ................ $ __=~`~~~ .+.aavl U! Register of Wills Signature of Counsel Required to Enter Appearance Atty's Signature PRINTED Name: _ Supreme Court ID No.: Address: Phone: Fax: Interim Form RW-02 revised 12.26. ] 0 by Cumberland County pending action by the Court In iT ~~ Page 2 of 2 OCAL REGISTRAR'S CERTIFICATION OF pE WARNING: It is illegal to duplicate this copy b hot ATH Y p ostat or photograph. Fee for this certificate, $6.01") P 17644511 Certification Number This ;is to certify that the information here given is correctly copied from an on duly filed with me as Loc IlRegctrar.l The(orDeath certificate will be t~~rwarded to the State Vita] Records Office for permanent filing. Local Registral- ate Issued n _ . ~.. f `-: i - ~ . ~ C7 -~ ~- ~ -~ n~ ~ ' H10S1~3 RE1/ 11/2008 i• ~ ~ ~'~ ~..J TYPE / ~~ ~ COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HE BLACK INK C' } 'Tj ALTH • VITAL RECORDS ~ str Uonis a d O D (See i^ u c 1. Name a Deprbnt (First, rrtidde, last, sutthc) ^ ex ampl es on reverse) Mary Anne K. ,! ~^y,~is 2 ~x STATE FILE NUMBER ~ t~:i l 5. Aga (Last Birdtday) 3 ~~ security Numper lbrder , FE~I131e U"~' 1 ~ 6. Date a BiM Monet, da , a 189 ''"°"°" ~ Haas za lap - 30 - 4905 ~"'~ and state or can 8 72 4. Dale a Death Month, ( ~. Yid 7/26/2011 Yrs. e. Place a DeaM ChecM dr1e Hospital: ab. County a °°°"' omer • 5/10/1939 Pine Grov Bc Ci • . e ty, Boro, Twp. of Deem , PA rat ~-uuiwGi land 8d. FeaMty Marna (tt ~ ~a~, ~ street and number) L4lnpnient ^ ER !Outpatient ^ DOA ^ Nursing Home ^ Residence ' ^ Other - $ e tt East Penns Was De 9 d t ~pro . ce , ent a M ispanic Origin? No ,,. D•c.aaM': Ikual y Spirt t Hospital (" r~8, sP•ahr c~ba,,, ~ a worts dot. most a p c Y ^ Yes 10. Race: Ameripn IraSan el a tile. Do not state retired 12. Was .~. Puerto Rican. etc.) Kad a Work KiM a Business / I Decedent ever in the 13. Deceda,fs Eduptlon (Spedly ydY ry~ryest Floral pegi '~Y U.S. Am•d Forps? 9rada corryleted) , a 4 wNte, eor:. (~h'1 Whl to ~ ,4. Madre status: Marred. Never • 16. Decedent's ~ ~ l~"r ~ ~ ~ 1 2 S~~ (D'1~ College (1-4 a 5+) W~'ed. Dnarced (Spe~yfyl Married, 15. Surhvin9 SPOUSe (tt wRe, give maiden name) ~n9 Address (Street, / e>w.r, ^ Yes P ) 4608 S 1 D~"t'a Widowed C erZr'VieW Dr A t c ual Residence 17a. state pA Did Decedent Hill PA 17011 ~,,,,,~.,^Y7.,,,,.,~ mina t7c.Yes,oecaeenlLived'^ 17b. Canty ~-~`uX~ ~qt ~ 18. Famefs Name (First y. j Township? middl l ~~1'~d,P I1 , . , -___. e, . ast. sulfa) 17d. ^ No, Decedent Lived wimm Twp. c f f 19. Motl,els Name (First middle, maiden sumeme) Actual Lirtyts a 20a. Informant's Name (type / Prinq r City/Bom Robert W. CrOCl'lUllls 20b. laorrnenrs Maifng Address (Street, dlry /town, state, • eta. Method a oispoeitia, ~ ~) 5629 Aiken Rd, - ^ ~ eddm ~ ^ Cremaoa, ^ Daratia, lib. Date a Dispositlon (Monet, ea MCKeeS ROCks PA 15136 Removal hen State r Was Cremation or Y. Yaer) 21c. Place a Dtspoaition (N A'~0~ d ame of axne • ' ~diC+l ExarNner/Coror~l ° 7/30/201 1 tBf1'.~r^atoryoromergace) 21d. Locuial ^ Yes^ No St . JOhns C ' z2a. ~'h"`a N/own (~ slate a acting as such .ell~tery • ~ ) ~ License Number 22a Name and Address a F c«rplete' duly Fllnera Hane FD 013239 L I , , p gyp) t, ~ ~ ~'~Ci td111C ~ PA 17050 y a„rye,g 230.7 ~ I1C: 3401 Market $t~ I ~ d e~ at time a deem ro ~ °~~ at me time, date and place stated. (Signature and tltle) CaInp Hi ll ~ PA 1 101 1 / , `~ ~ / 23b. License Number _ IEerrrs 2426 moat be ddfllpleted by person `~ ~ „ . / 2~. rrne a Deem ' -~~' `~j' f ? ,, ~ ~ who pmnaaroes deem. 25. Dare 23c. ate S' (Monet, day, ye~l (Monet, day. year) L M. ~ 26 Wa C . s ase Referred ro Medical E CAUSE OF DEATH (~ irutruct a~ exa V ~ / 'antt18r l ~~ a R Item 27. Part I: Enter the ^ Yes file mar ~ remalion or Donatron? -diseases. inlurres, or Iss) No respratory arrest a ventric 001^Wl~ons -that directly posed the deem l D A ar ~ d u . O NO enter terminal events such as r PWoXknata interval: Pan II: Enter other ' MM~ED4ITE CAUSE IFnal drs~se a s~~ ~ e~y List only one pose on eacfr Gne. p~ artesL ~ Onset to Deem but rwt resul~~~o i° dam 28. Did T C naltitidn rearlting ut deem) ~ ~~ r r eng v, the undedying pose given in Part I. ordribrrte ro Deem? -~ a. ~ r ~ Yes Probaply r Duero (a as ~~ r ^ No U Y a let ax,dtia,s, d any ea,s•Quenp ~~ r b. ' ----~ b pose kled on 6ne r nown 29. ~f Female: r a, ErAar L11~ERLYING CAUSE Duero or as a r ~'- (diesaee a injteY that kitiabd the ( e a): r r~ ~ Na Pregnant wimin past year _ - ~~ resttltirg n ~) ~. c ~ Pregrrent at tiros a deem Duero ar as a i Pregtant. but pregnant wi1Nn 42 d. ' ~-_ ~a days 311e. Was M ' -'---- ~ 3(b. Were Autopsy Ferdrgs 31. Manner a Deem ' ' - ~ PregrtanL but Dregnant 43 days ro 1 year ~- Avetlable Prior ro Campletron 320. Date a Injury (Mash, day, year) 32b. a Cause a Dean? ~TJaiurel ^ ~~ Describe How Iryury Occurred - before dean ^ ~~ if '- Pregnant wimin the ^ Yea .~No ^ Yes ^ Wo ^ Aoctiderq ^ P 32d. Tone a I e'~ng In~~tion n~"t' 32s I past year 32c. Play or Injury; (S acrory, ~L F Olfip ~Idkq etc ~'// , . . P Y) njury at Work? 32f. tt Transportetbn Iryury (Spaiyng ^ ~'~ ^ Count Not be Date ~. Lopiwn a uyury (SUeet, pY /town, state) 33e. Certdkr (rfieck anty one) maneU M, ^ Yes ^ Ho ^ DrNer/Opereta ^ Passenger Q P edestrian Other - Speriry.• ~~ T ~. dMtlt oaurnd due>o t~ mss) PhYs"dan has Wondunced deem and camplebd Ibm 23) 33b. SigneWre and Tibe d caraA. Pmnorrreing and rerrytyj~ OhYNdiarr (fin Gam manor ore statsd _ _ _ Tomb.aamyknaraydga,de.mocax,watm.elms ~daamandceraryir,gropuseadeam) ----------------- ~ Medicar place, and due to rM dauae(e- and manner ss atrded_ _ _ _ - - - - - - - - - - ~ Ontha6a /Corona -- __ ^ a><amkrtlon ant / or k+wKdgatbn, h my opinron, d~th oecurred at the time, - - - - - - - - - dsts, and Place, end due to the auee(a) and mansr a stated_ ^ 3+. 35. ~~~ ~L_11_ I ~ ~ ~ ~ ~ ~ ~ 'Date Fibd (Mdrah. del', Year) rl oil DiePdeitidn Parrott No. ~•_9 ~sa - -~_ .. ..y~eu I m, pY. Year) J ~ -3 s i 1 z. - ~.L~ / / ~ A^of Person yVho Cornp~~ Cause a Dnam ~"-~ ~~ (GC~.O ( ~) TYPe /Prim '113 ~ ~ T r f ~ ~R ~~~~~ ~A~ ~ p P.,r4 - i ~