Loading...
HomeMy WebLinkAbout08-16-11IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA REGISTER OF WILLS PETITION FOR PROBATE AND GRANT OF LETTERS Estate of ~ r- ~ c ~ S~'e~,/i~~ ,Deceased ESTATE NO: 21- ~ ~ _ a/k/a: alk/a: ~ 1 u -- ~~ _ 7 ~ ~~ ~~ tea' 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: 1a A. Probate and Grant of Letters Testamentary or ^Administration c.t.a., or d.b.n.c.t.a. (complete Part Calso) and aver that Petitioner(s) is/are entitled to the aforementioned Letters '~`~'under the last Will of the above-named Decedent, dated 7 f 19 1 ~ I and codicil(s) dated ~-- --== -~-,-~-~-~' ., _.a ~.~ :.~ luj rte- r~ _ .:~ r f t ~ T'T'Y ~..., J~`..: (State relevant circumstances, e.g. renunciation, death of executor, etc.) ~ ~f~ ~ ~~ Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after, a~ultion o€-~he ~ , instruments offered for probate; was not the victim of a killing, was never adjudicated an incapacitated p~an'd was-~iot a '-~~ party to a pending divorce proceeding at the time of death wherein grounds for divorce had been est ~bli~ed as dined i~ ~*~~ 23 Pa. C.S.A. § 3323(g): ~ ~ ~ O '' --r~ ..-. ^ B. Grant of Letters of Administration ~~i appucao~e, 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:- Name Address Relationship to Decedent USE ADDITIONAL SHEETS IF NECESSARY THIS SECTION MUST BE COMPLETED: Decedent was domiciled at death in Cumberland County, Pennsylvania, with his/her last family or principal residence At ~ 5 ~ -~vl~` 17 ~' ~ennsb reet address with Post Office and Zip Code, Municipality: Township, Borough, City) Decedent, then ~~ years of age, died 8 .2. at __ ~,~~-,5~~r,, = ~,~ci (Month, 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 $ ~' `j ~ --~ _If not domiciled in PA Personal property in Pennsylvania $ _If not domiciled in PA Personal property in County $ -Value of Real Estate in Pennsylvania $ `10r DO c~ -- Total Estimated Value $1Yy. U . oC~ Location of Real Estate in Pennsylvania: (Provide full address if possible.) Si nature(s) Name(s) & Mailing Address(es) '- ~~L50,...1 Interim Form RW-02 revised 12.26.10 by Cumberland County pending action by the Court Page 1 oft OATH OF PERSONAL REPRESENTATIVE ~ ~. Commonwealth of Pennsylvania ~ ~ ~~ ._ ~, • SS ~- ~ _r, , ~~ . 'r 3 ~ ,P- - ~. County of Cumberland }` ~~''~"' ~~, ~ .._ TC~ 4- . L~ 3 `-- ~-J, . The Petitioner(s) herein named swear or affirm that the statements in the foregoing Petrtb®2i~e tru~'and ~' s ~~ correct tote est of the knowledge and belief of Petitioner(s) and that, as personal repres~tative~) of tl~ ~=~ Decedent, Petitioner(s) will well and truly administer the estate according to laW. ~ 1,~, ~:~ Sworn to or affirmed and subscribed t. ~,.~ b fore me this ~ ~ day of ~~,~ / For the Register Estate of Deceased File Number: 21- - AND NOW, this day of , in consideration of the Petition on the reverse side hereon, satisfactory proof having 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.) 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: Letters .................... $ Will ....................... Codicil(s) .............. . ( )Short Certificates ( )Renunciations....... Bond ............................ Other ............................ ................................. ................................. Automation FEE......... 5.00 JCS FEE .................. 23.50 TOTAL ................ $ in Signature of Counsel Required to Enter Appearance Atty's Signature PRINTED Name Supreme Court ID No.: Address: Phone: Fax: Interim Form RW-02 revised 12.26.10 by Cumberland County pending action by the Court DECREE OF PROBATE AND GRANT OF LETTERS Page 2 of 2 ^ 7~~r nnr~o~ n, e. , RENUNCIATION ~~ =~~= =~~ ~~. _ ~:~ . T.., ,,, .... RE ISTER OF WILLS t ° ~ `~' "` --^ ~r.4 ~.~ .~~ - ' COUNTY, PENNSYLVANIA ~ ~-~~~ ~-~-~: _ ra, ~ L. i ~.`` Estate of C~ ~ C ~ s ~~5 Deceased I, ~C .Jcc~ ~i,,t I5~ rintName) , in my capacity/relationship as ~ ~ ~C~`C(~t~p(` .. ~a~ C ~ ~• ~ of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to i C C" ~ ~~ Ca,, ~~ (Date) (Signature) ~~~ ~. ~ (Street Address) ~1~ ~'~ I ~~~~ (City, State, Zip) Executed in Register's Office Sworn to or affirmed and subscribed befog me this __ 1 (~ t-~~ day Of ~,, ,~ ~ 1 ~ ~ -{-- ~ ~• ~ ~ i ~ r Deputy for Register of Wil s i Executed out of Register's Office Before the undersigned personally appeared the party executing this renunciation and certified that he or she executed the renunciation for the purpo es stated within on t is ~ day of _~ Notary Public My Commission Expires: (Signature and Seal of Notary or other official qualified to administer oaths. Show date ofexpiration ofNotary's Commission.) Form RW-06 rev. 10.13.06 OCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat c-r photograph. Fee for this certificate, $6.00 P 17728531 Certification Number ITEM # SHOULD READ AS FOLLOWS: 3 REV 11/2006 /PRINT IN RMANENT .ACK INK COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH (See instructions and examples on reverse) ~T.r~ ~„ ~ •,,,,,,,~„ t. Name d Decedent (Fkst, middle, last, suffix) Eric T. Stevens 2. Sez Male 3. Social Security Nurt~er 218 _ 3$_ 7128 4. Date of Death (Month, day, Year) 5. Age (Last Birthday) Under 1 r Under 1 de 8. Date d Birth Month de 7. Bill C end state or f rau 6 a. Place of Oeatlf Check on one Au 2 2011 5 O Mralllro Days Hours Minutes v Hospital: Other: y,5 April 27,1953 Harrisburg, Pa .t~Hospice ^ Inpatbnt ^ ER / Outpetlent ^ DOA ^ Nureing Home ^ Reaiderv:e ~ Other - S ecif p y Bb. County d Death !k. City, Boro, Twp. 01 Death Sd. Facil Name If not inedtullon, ity ( ghre street and number) 9. Wes Decedent d Hispenk Ongin? [~ No ^ Yes 10. Race: American Indian, Black, White etc. ~ , (d yes, sPectlY Cuban, (,~~ • Dauphin Harrisburg Central Pa Hospice Residence Mexican,PuenoRkk~n,etc.) • 11. Decedents lhad IOnd d work done d most d life. Do rat stele retl 12. Wes Decedent ever In dre 13. DecedertPe Educetbn (Specgy Doty highest grsde completed) 14. Mendel Status: Merrbd, Never Married, 15. Survlvhrg Spouse (d wde give maiden name) , Kmd d Work Kmd d Business /Indus U.S. Ambd frorces? ~' rt Elemenbry !secondary (o-12) cofiege (i-4 or s+) '^~0N'ed~ D"0~d (sveahl Warehouse Giant Foods ^ Y « r.,aNe U k Widower ,6. oetxsdertt'a Mailing Address (street, ~ mown, stela, zip coda) Decedents P e n n s y 1 va n i a °~ °~edeM Aduel Resid 17 ence •. stale - Live In a nc. )~ Yes, Decedent Lived in _ F. a ~ t- P _ n n ~ hc~ r n T,,,p 4 2 6 Ridge Ave T°"""~'~? , 7d. ^ No, Decedent Lived within Eno 1 a P a 17 0 2 5 , 7b. County C» m hP r 1 a n r3 Actual Limits d City I Boro 18. Fathers Name (First, midde, lest, suffix) 19. Mothefs Name (Flret, mldde, maiden sumeme) Patrick Stevens Elizabeth Trautman 20e. Informants Name (Type I PdM) 20b. IMorrnants Mailing Address (Street, dty I town, state, zip code) Thomas Stevens 227A Orch r R w ~ 21a. Metlad of Disposition r ~{Cremadon ^ Donadon 21b. Date d Dlapositlar (Month, d•Y, Y•er) 21c. Place d Disposition (Name d tamale creme r ry, tort or other place) 21 d. Location (City I town, state, zip code) ^ Burial ^ Removal h r St t n o a e r Wa 1lemetlon rx DonNion Authorlaed ^ onbr- rbylAedlwE:emhrer/corwun ®Ya^No 11 Hoffman Crematory Carlisle, Pa • ~ Fin. ( ) ~ 2zb. ucenee NDmber 22c. Name and Address d Facillry S u 11 i va n F u ne r a 1 Home .~ Complete 23et only when certllyhg phyaldan k rat eveilebb at time d death to . To the best my ,death rred et the date and place stated. (Signs and dtb) ~ 23b. Lkenee Number 23c. Date Signed (Month, day, Year) airy d death. ~ ~Gl/~J'i-eti.. ~,~ ~ ~'`~~.28 ~ G~~" c~ Z z~ /~ eA 24~ ~~cortpleted by p•r~n • 24. Time of Death [~ ~ ~ 25. Date Pronotraed Dead MaMh, des ( Y, Y••r) 26. Wes Ceee Referted to Medksl Examkrer /Coroner for a Reason Other Cremation ar Donadon? -I M• Q Z ~ ^ Yes ~No CAUSE OF DEATH (See Inatructioru and exemp ) r Approximate interval: Ibrn 27. Pan is Enter the drain devents -diseases, injuries, or complications -that dkecNy caused tlro death. DO NOT enter terminal events such u cardiac ertest, r Onset to Death Pert II: Eller other ' but not resudi In the undo n9 nytn9 cause given k Pen 1 26. Dk! Tobacco Use Contribute to Death? ^ ^ reapketory arrest, or ventricular fibrfibtion without showing the etiology. Ust Dory one cause on each line. ~ . Vea Probeby ^ No ® U k r DUTE CAUSE (Final dsease or ( n nown r carMltion resullhg in death) -~ a. M b Q l~ C. +'y~ r ~Q , 29. If Female: ^ Duero (o< as a consequence d): T fst condtlons, A arty, b , Nd pregnant within pest year Pregnant at time o1 death ~ r~ Ys<ed ~ ~ a. r Enter UNDEI~YMIG CAUSE Due to (or as a consequence d): r ^ Nd pregnant, but pregnant within 42 days ( ar wry ~ ~~~ ~ BVenb 1lBdhrlg In de8111) LAST. ~' ~ ~ 0( death ^ Due to (or as a consequence of): r r Not pregnant, but pregnant 43 days to 1 year r • d. r before death ^ Unknown A pregnant within the pest year 30e. Was en Autopsy Penom>ed? 30b. Were Autopsy Fxrdrgs AvaReble Prbr to Compbtbn 31. Harmer d Death 32e. Date d Injury (Month, day, Year) 32b. Deeaibe How Injury Oocurted 32c. Place of injury: Home, Farm, Street, Factory, d Cause d Death? ®Natursl ^ Homidde Office Budrdng, etc. (SpecilyJ ^ Yes ®No ^ Yes ®No ^ Aak1~ ^ P•~MA Inveadgatlan 32d. Time d Injury 32e. Injury at Work/ 321. N Treraportetlon Injury (Spedty) 32g. Location of Injury (Street, city /town, state) ^ Suk:ide ^ Coukl Not be Determined ^ Yea ^ No ^ Driver/Operator ^ Passenger ^ PedeeMan M Other • Spedly: 33a. Cerdfier (d'ad` Dory one) 33b. signature and rnle or certlfler • C•rtlMni l~Y•kbn ( ~dYk+9 cause d death wtam another physiden has pronaaroed death end completed Item 23) To the bat of my tmorrbdgs, death occurred due to the ease(s) end manner a ebbd _ - _ _ _ _ _ ~ -------------------------- ~ ' ritA • Pronou~9 ~ ~YMW PhY~ebn (PhYs~•n ~ Prong deeM and c•rofYMA to cause of datlt) 33c. lkenee Number 33d. Date Signed (Month, day, Year) To the bat of my IorowNrlye, death occurred at the tlme, deb, and pba, and due b the ease(s) errd manner a stated _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ _ _ _ • w.ew Eremirrer/Co-orrer M D U ~'~ 7 O (~ ~ d e i 1 On tM bale of exemk>atlon and / or Inveetlyetion, In my opbdan, death ocarrod et the tlme, deb, end plea, end due to the due(s) end manner a ehbrL ^ 34, Name and Address d Person Nita ~~~.«or~r~WpIetad Cause d Death (Item 27) Type / Pdnt ' ' Registrars Signature and District Number I ~ f ~ ~' ~ I ~ I 3e. b y, yea ~ Mat•~r`i"( -KrGhcrc M1D ~ o d ox S.SO }{ /v- ~ , This i~.s to certify that the information here given is correctly copied from an original Certificate of Death duly riled with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. ~.~~... %`~ a ~ ~~ 1~ Local Registrar Date Issued c~ ,~_.,~ ~--- -~. -~, - l~ ~ '~ ~:-.. -~.r, ~ ~ - - :~~~~ } c~ -,~ ~ ~ ~ ;:_~ ~~ ~. ~~ ~ ~, Disposdbn Pertnh No. ~ / ~ I O ~+ / C] v -linc Inc Or.\~ ,n. •n^.~ _ - __ _- - - _ _ _ LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $6.00 This is to certify that the information here given is correctly copied from an original Certificate of Death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. P 17~2826~ Certification Number /~-vn,. ~ A ~ 0 1011 i~J Local Registrar Date Issued ~,..,.. ~ _ __ __ _ _ __ . __ _ __ . _ __ ~...W - , .~ ~ ~ ~~ ~-' P _~.. ~ rn ~~ _~_ ___ . - ~n -~ r ~;..~ r .,~ ~~ _ _ _ __ ____ ___~_ ~__ ..~ ._,,. ~~ r_: ~ - Cf --- ~ , _a°,. ..~ ~,. 3 REV 1112006 I PRINT IN COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS ~c"u"ic I~ CERTIFICATE OF DEATH (See instructions and examples on reverse) 1. Name of Decederd (Flrst, midde, last, auHlx) STATE FILE NUMBER 2. Sex 3. Social Secudy Nwtrber 4. Dees of Death (Month, day, year) Eric T Stevens A 5 L t Bi md . Male 218 _ 3$_ 7128 Au 2 2011 ge ( . r as ay) Under 1 Sys Under i da 6. Date of BIM Month r 7. Birth anti state a cam 8a. Piece of Death Check on one Hours ~ ` 58 yrs. Hospital: Other. April 27,1953 Harrisburg, Pa ^ Inpatient ^ ER I Ou~etlent ^ DOA ^ ^ Hospice Nursing Home Res~derice ~] Other - Spedy: Bb• Cow1Y d Death tic. City, 8oro, Twp. of Deem 6d. FectlRy Name (It not instltiriian, glue street and number) g. Wes Decedent of Hispenk: Origin? [~ No ^ Ves 10. Race: Amedcan Indian, Bledc, White, etc. • Dauphin Harrisburg Central Pa Hospice Residence (~ R~,e~,) ( • 11. Decedents Usual IOnd o1 work done du ' most of ie. Do not stab re 12. Was Decedent ever In the 13. Decedents Educatbn (Seedy ony higtreN grede completed) 14. Madbl Statue: Monied, Never Married, 1 S. SurvNing Spouse (If wde, give maiden name) wrrd a work and or Business r Industry u.s. Amrod ForcesT Elementary /Secondary (a12) college (1.4 or 6+) widowed, Divorced (Specrry~ Warehouse Giant Foods ^ Yes C~No U k Widower 16. Decedents Maifmg Address (Street, city /town, state, zip code) Oecedents Did Decedent 4 2 6 Ridge Ave Aat~l Res~ence 17a. state Pennsylvania Lfve in e 17c. ~ Yes, Decedent Lived in F. a S ~' P a n n e hn r ~ Twp • E no l a P a 1 7 0 2 5 17b. Count' -C umb P r 1 a n f~ T~~hip7 17d. ^ No, Da~edenl Lryed wrtnm Actual LimRS of Ciry/ Bao 16. Father's Name (First, middle, lest, suffix) 19. Mother's Name (Flrst, middle, maiden surname) Patrick Stevens Elizabeth Trautman 20e. Informants Name (Type I Print) 20b. Irdarmente MaNing Addreea (Street, dry /town, elate, zip soda) Thomas Stevens 227A Orchard Rd N w - 21a Memod d Dispositlon r rematlon ^ Donation 21b. Dote of Diepoeitlon (Month, de Diepositbn (Name o1 tamale cremato a other dace • r ~ Y. ro~J 21c. Place of ry, ry 1 21d. Location (City/town, state, zp code) ^ Burial ^ Renavel from State r Was Crsrtotlan a Donation Authorized ^ 01Ae/• 'Dy"'°~°'~'"°'/~0r01"'' ®Y.e^~ 8 4 11 Hoffman Crematory Carlisle, Pa • 22a F ( ~ ) ~ 22b. Lbertee NunrDer 22c. Name and Ad~ess of Pacify ~ Sullivan Funeral Home • Conpbte ~ 23et any wfxm oertNyMig 3a. To the beet my ,death et the tl date and physfaen is not avarabla et time of death to P~ . ( ~ title) 23b. Lkenee Number 23c. Dote S aertlly cause or deatl,. ,~~~ J j~,~~ cManth, day, year) 2a. nme of Deem Ibms 2426 must be completed by person 26. Date Pronounced Deed (Monet, day, Year) U (~ 26. Wes Case Refaned to Medical Examiner /Coroner fa a Reason Omer an Cremation or Donation? ~ wfa prarorrroes deem. I ~/ ~ M. ~ c7._ / ^ Yes ~'1Jo CAUSE OF DEATH (Sss Instructions end sxamp ) r Approximate Mlerval: Pert 11: Eller other f ` Ibm 27. Pert I: Enter the ahdn of events -diseases, NlfUflee, a complbafbns • met directly caused the death. DO NOT enter terminal events such ae carder arrest, r 26. Did Tobacco Use Contdbute to Deam7 raepiratory arrest, a ventdcubr hbdtletion without shows the e r Onset to Deem but not reaultlng in the underlying cause given m Part I. ^ Yes ng tkdogy. List Doty one cause on each line, r ^ Probably ~~~~ r ^ No ® Unknown ~b'onArasWdng~deaM sasses or [~ r -~- a. Y t'Y1 ~ © ~~ ~- ~1ra r ~rQ 29. It Female Duero (a es a consequence m): , ---~ ^ Not pregnant wimin pest year bat carMitlorrs, N arty, b r ^ P rant at time of deem b cause Ilebd on fine a. r ~C.~~_ re9 Eder UI~EALYiNi CAUSE Due to (or as a consequence of): r , ~ ~ ~~ c. i ^ a ~egnant, but pregnant wfthin 42 days • Due to (or as a consequence of) ~ ^ Not pregnant, twt pregnant a3 days to 1 year d. r before deem • 30e. Was an r ^ Unkrx>wvn R Autopsy 30b. Were Autopsy Flrx6gs 31. Manner of Deem 32e. Dote of I u Pregnant within me past year Perfomred? Available Prior to n) ry (Harm, day, Year) 32b. Describe How Injury Occurred of Cause of Deem?A~~ ®Naturel ^ Homidde 32c. OfAce 8uil g, etcrt (' F~ry)S1reeL Factory, ^ Yes ®No ^ Yea ®No ^ Accident ^ Pending Invsetlgetlan 32d. Tkne of Injury 32e. Injury at Work? 32f. tl Transportation Irtfury (Spotty) 32g. Locator of Injury (Street, cfy /town, state) ^ Suicide ^ Could Not be Determined M ^ Yea ^ No ^ Driver/Operator ^ Passenger ^ Pedestrian Omer - SpecNy: 33a. CertHier (dreclc Doty one) • ~Ytni DhY•~en (PhYa~an aer111Ying cause of deem when endher pttysidan has prawrxrced deem and 33b. Signature and TRb of certifier To the best of ~) canpleled Item 23) aryknowbdge,deemoeeurrodduetomea sendmsnnerastebd--------------------------------- ~ ~ y ~ • Tom e~ ~~ phYetaan (Phyeipan born proraurx:kp deem end certllying to cause of deem) 33c. License Number sad. Date s~gr>ad (Monet, day, year) my iaaarbdge, deem oxurred et the time, dab, and piss, end due to the gues(s) ertd rnennar o atsted_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ f Y1 D v ~d- 7 a L ~.. • waits F.tumIMr/Cororwr ~ o ~ 1 On the trab o} examination and I or InvMtigetlon, In mY opinion, deem oceurrod at the time, deb, end place, end due to the cease(s) end mMnsr ee sated, ^ 34. Name and Address of Person Who ~" Cause of Deem (Rem 27) Type /Print 36. Regfstrafs Signature and District Number m0.rt~ fCi"~ '~ Cliff( M~ ~ I~,I ~ ~I /I /I 38. b Y, Year) ~a v4 ox SSI~ }{/NL DisposRion Permit No. t / ~~ l d 3 7~S