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HomeMy WebLinkAbout08-10-11IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA REGISTER OF WILLS PETITION FOR PROBATE AND GRANT OF L~;TTERS .~--~ , Estate of ,Deceased ESTATE NO: 21- ~` Q a/k/a: a/k/a: ss No: ~l o - S 7- oab~'~' 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 aforemen 'one Letters - under the last Will of the above-named Decedent, dated ~ 4 7 ~ 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 pr ceeding 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 (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~except as follows: ~- u Name Address Ilia shi to l~redent ~~~~~`~ ' _x. ~~~ {tom. i' y c:_y ~ 0 :u, ~._.. ,,~. --+~ USE AUDI"CIUNAL SHEETS IF NECESSARY THIS SECTION MUST BE COMPLETED: Decedent was domic'led at death in Cumber~d ~ounty, Pennsylvania, with At ~ouo 7 ~i G ~, c5'T .f _>~ r // n~ _Srorr ne~~ ~... 4. S..W~ _ - L .+ `• / -`t-t last family or principal residence (Street address with Post Office and Zip Code, Mu>~ipality: ~l'ownship, l~rough, City) l Decedent, then ~ years of age, died ~ 7 ~ 02.0 ~l at Or 04J~ S ~ ~~ (Month, Day, Year of death) and State where death occurred) ~t~mated value of decedent's property at death: / If domiciled in PA All personal property $ ~S~d • ~O 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 $ 5"DO• aQ Location of Real Estate in Pennsylvania: (Provide full address if possible.) ~/ A Signatures) Name(s) & Mailing Address(es) ~ nPS - ~ c ~ 7-s~. ~Jo~~ S7-• s ~ ur F 3 37D z lntenm t+orm RW-02 revised 12.26.10 by Cumberland County pending action by the Court J Page l oft 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 ].aw. Sworn to or affit~med-and s~~bscribed fo me this ~ ~ ~~' day of ,~A ~~ ~ y~ n ~_4,~ or the Register Estate of ~J ~_ ~h •:~ `T` C-3 ~~ i- ~.: C"' .. DECREE OF PROBATE AND GRANT OF L,ETTER~~ ~' - ' ,~ ~ ~, ~_ .J r: } ~-~ ~ G t ~ -~, R' /'/~ Q ~ e ease File Number: 21- '~ ~== -;._ _~ ; . AND NOW, this /~)tday of ~~ , in consideratio of the Petion one --~Is~ t reverse side hereon, satisfactory proof havin been presented before me, ][T IS DECREED that Letters Testamentary of Administrat' arE; hereby granted to: ~"~ If applicable, enter c.t.a., d.b.n., d.b.n.c.t.a., etc.) ~r~ ~~~ ~~ ~ ~' ~©/,~ CS ~' ~C~~rnSkl / in the above estate and that instruments(s) dated admitted to probate and filed of record as the last Wi described in the petition be Codicil(s) of Decedent. FEES: /~ ~~ Letters ....................$ ~," Will ....................... ., ' Codicil(s) ............... (~ Short Certificates ` ( )Renunciations....... Bond ............................ Other ............................ Automation FEE......... 5.00 JCS FEE ..........:....... 23.50 r TOTAL ................ $ /` `~ Signature of Counsel k2equired to Enter Appearance Atty's Signature _ PRINTED Name: _ Supreme Court ID N~o.: Address: Phone: _ _ Fax: Interim Form RW-02 revised 12.26.10 Uy Cumberland County pending action by the Court Page 2 of 2 Register of Wills G~'~~M~~(v`7" ~~~~4~3~~456 NE1N JERSEY DEPARTMENT OF HEALTH AND SENIOR SERVICES STATE t^tLl NUMR>"R: CERTIFICATE OF DEATH 2o~t`~aw4~386 ~~ o~ a ~ E` ._ a r O ~- -.,. M. ~C cx. ra F .a c i1 ~~ n Q o c U m~ 0 o ~ ~ c r. ~H u~ M 0 , ..~ o e~ ~~ w `~' z~ Record contains Amendment 1a. Legal Name of Decedent (Flr~ Middle, Last, Bollix) Tracy Marie Moody 'tom 1b. Also Known As (AKA), If Any (First, Middle, Lasf, Suffix) L 2. Sex 3. Social Security No. 4a. Age 5. Date of Birth (MaJDay/Yr) Female 410-57-0205 40 Years 12/26/1970 ~" t3. t3irthplarx~ (Ca7y b &atelForoign country) ~ •~ Chita a IL :~~ 7a. Residence-State 7b. County 7c. Municipality/City ~~~ PA Lebanon Palm ra 7d. Street and Number 7e. Apt No. 7f. Zip Code 7g inskle City LtmHs ~ 1200 East Main Stree 213 17078 Yes 8a. Ever in US Armed ForcesT Bb. If Yes, Name of War. 8c. War Service Dates (From/To): Yes' none 9. I>cxnestic Status at Time of Death 10. Name of Surviving Spouse/Partner (Name gmen at birth oron birth certificate) Married Brian McMillan 11. Father's~Name (Fist Middle, Last) Bud Adams 12. Mother's Name Prior to First Marriage (First, Middle, Last) Doroth June Beadle 13a. Name of iMomtant 13b. Relationship to Decedent Aretha Jones-Jachimski Sister 13c, MaNing Address (Stroet and Number, Ci7y, State, Zip Code) 8231 7th Street North, Saint Peterstturg, FL 33702 14. Mettrod of Disposition 15. Place of Disposition (name of cemetery, cxematory, other) 16. Location- City 6 Stale/Foreign Country Cremation Allied Crematory LLC Bensalem, PA US 17. Name and Complete Address of Funeral Facility Eu ne J Zale Funeral Home Inc, 712 N White Horse Pike Stratford NJ 08084-1116 18. Electror~c Signature of Funeral Director 19. NJ License Nwrhkdr ,~ Zafe 23JP00368100 20. Decedent Education 21. Decedent of Hispanic OriglnT 22, Decedent Ftace Bachelor's degree (BA, AB, BS) Mexican, Mexican American, White Chicano 23.Occupaticur of Decedent (Type o/wiwirdone most of6fe, evenifroKrod) 24. Kind of Businessllndustry Care Giver Childcare 25. Name and Address of Last Employer Neidl Regal , , 26. Date Pronounced Dead (Mo/Oay/Yr) 28. Name of Person Pronouncing Death 07!2112011 ?fytfow ~1'ark 27. Time Pronounced Dead (24-hr) 29. tJcense Number 30. Date Signed (MoiDay/Yr) 1155 25MA02590400 07/21/2011 31. Dale of Death (MolDayWr) 32. Time of Oealh (24-hr) 33. Was Medical Examin®r Contacted? 34. Plac® of C?eath Approx-07/18!2011 Presumed-2300 Yes Hotel 35a. Facility Name (ll not instRution, give stroet and number) 6641 Black Horse Pike E Harbor Tw 35b. Municipality 35c. County E Harbor Townshi Atlantic CAUSE OF DEATH: 38a. PART 1- tMMED1ATE CAUSE -final disease or condition resulting in death. Subsequently list condition®, if any, leagin~ tq the cause tlsted on Line a. Enter the UNDERLYING CAUSE disease or in that Initlated the events reaultlh -in deaGr I.id~ST~ Immediate Cause tntervaf tletwieeit Ori~et erect heath a. As h xia due drownin a few minutes Due to (or as a consequence ofJ: b. - Oue to (or as a consequence o!): c. Due to (or as a consequence off: d. 36b. PART II -Enter other significant corxfltions contributing to death but not resulting in 37. Was an Autopsy Performed? underlying cease given in PART I. YeS 38. Were Autopsy Findings Available to Complete Caui#e c+f Death? Yes 39. Date of injury (ti~folf?a,IdYr) 40. Time of Inj~y (24-hr) 41. Place of Injury (e.g. home, constrvctlon sde, rostaurant) 42. InJ~ary at wvrfic? 07118/2011 Unknown motel roam No 43a. Location of Injury {Number and SdBet, Zip Code) 43b. Municipality 43c. County dad. State 66410 Bieck Horse Pike E Harbor Townshi Atlantic NJ' 44. Describe How Injury Occurred 45. tf Transportation injury: Drowned self with her baby in tub water Not Applicable 4t3. Mariner of Death 47. Did Decedent Have 48. Did Tobacco Use 49. If Female. Pregnancy State Diabetes? Contribute to Death? Suicide Unknown No Not pregnant, but pregnant +t3 daya #qa 1 year before death ' 50. Certifier Type 51. Name, Address, and Zfp Code of Certifier Medical Examiner Hydow Park, M.D. 201 Shore Rd., Northfield, NJ 08225 52. Electronic Signature of Certifier 53. License Number 54. Date Certified' (Mo/Dey/Yr) ?f cfofw ~Par~, 25MA02590400 07I21t2011 55. Electronic Signature of Local Registrar 56. DisMct No. 57. Oate Received -Carte #D l~umber• 9of~ ~D ~enarr, fir. .V04fi5 08/03/2011. 1448~i48 ~~ Date Issued: August 3, 2011 Issued By: Stratford Borough/Vital Statistics This is to certify that the above is corgi ~g~,q~air., Registrar from a record on file in my office. ~F~ • Certified copy not valid unless the raised Great Seal of the State of Nevv Jersey __ .~~._.._ .. ..._.~~.~ or the sea! of the issuing municipality Jose h A Komosinski, State Rec)istrar or county, is affixed hereon. Bureau of Vital Statistics - REG-42B ~~ JULY 04 ~.,...~ ... ~-i,~ r"'f' i ~ C ~ _~", {...ter /..,.. -~t.._ lrrx! _.-k.. r ..t ~ ' ~ -~ r a.... . uirre