HomeMy WebLinkAbout08-24-05
Register of Wills of Cumberland County
PETITION F /OA~R GRANT OF LETTERS OF AllMINISTRATION
Estate of ~.y~_l, /'h G Fig ~al~ k. No.~r ~ ~~ _ ~ U
also known as~~~CJ ~~ lQ~~,~,,, To:
Register of Wills for the
Deceased. County of Cumberland in the
Social Security No. 4'^ Commonwealth of Pennsylvania
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older, appl%e;, t~ for letters of administration
on the estate of
(d.b.n.; pendente liter durante absentia; durante minoritate)
the above decedent.
Decedent was domiciled at death in~4~~ County, Pennsylvania, with h_ last family or principal
residence at_104 VA+t~-~) S.^ - c....~-~ ~,~.bAz.~ /%~ I 1 U `7,~
(list street, number and municipality) A
Decedent, then s years of age, died ~li.G.~ ~t ~ ~ _, 2p 6 s , at ~~> ~p~f
HwP1.~A~ A~ /~•, l~A 1~ o/ t
Decedent at death owned property with estimated values as follows:
(If domiciled in Pa.} All personal property $ ~: 1,oU
(If not domiciled in Pa.) Personal property in Pennsylvania $
(If not domiciled in Pa.) Personal property in County $
Value of real estate in Pennsylvania $ `~"~`
situated as follows:
Petitioner after a proper search ha S ascertained that dlecedent left no will and was survived by the
followings e i _ansc and heirs:
ivame
7L
THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the appropriate form
to the undersigned.
~~
Signature(s) of Petitioner(s) Residence(s) of Petitioner(s) ~ ~ ~ r-,
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Register of Wills of Cumberland County
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH. OF PENNSYLVANIA
SS:
COUNTY OF CUMBERLAND
The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition aze true and
correct to the best of the knowledge and belief of petitioner(s) and that as personal representative(s) ofthe above
decedent petitioner(s) will well and truly administer the estate according to taw.
Sworn to or affirmed ~ subscribed X ~ ~ ~~o.
Be me this _ day of -t-
20~~~
~ Regrst ~-
Estate of ,.,_, Deceased
GR,A, IN-T OF LETTERS OF ADMINISTRATION
AND NOW ~ ~J ~i-*t~.-'h ~r 20~, in consideration of the petition on the reverse
side hereof, satisfactory proof ha i~been presented before me,
IT IS DECREED that
is/are entitled to Letters of Administration, and in accord with such finding, Letters of Administration
are hereby granted to
in the estate
FEES
Probate, Letters, Etc ..............
Will .................................
Renunciation ...................... .
Short Certificates ( ) ............
JCP ..................................
Automation Fee ...................
Bond .................................
Total
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Register of Wills '~` `
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ii~ i~, 1o certify that the inf-TFinatic-n here ~„iven is rlOrrcctly c(~pie~l fro-n ~-n ori~>in~-I ccrtiCi~at~^ L)f ~ie..-tll ~1uly filed with me i-s
I u I'.~~gi~trar. "1'he zn~i,Tinal ccrtificatc will he f(>rwarded t-~ the .`~tatc Vii'tal IZec~~rd~, Officc f~)e ~~crnhulent (filing.
WARNINi3: It is illegal to duplicate this copy k-y photostat or photograph.
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT GF HEALTH • VITAL RECORDS ""° ---
CERTIFICATE OF DEATH ~/
NAME OF DECEDENT (Pest. Middle.. l asl) SEX SOCIAL SECURITY NUMBER DATE OF DEATH (Month, Day, Vear)
,, Charles F. McAndrew z. Male 3 197 - 40 '- b 154 4, e7(.~
ACE (Lass Birtnday) UNDER 1 Y AR UNDER , DAY DATE Of 91RTH BIRTMPIACE (City and Pt ACE OF D ATH Check nl on - s e in lmclion ~ on other sid
Months Days Hours Minutes (Month, Day, Yaar) Stale aFweign Country) NOSPITAI OTHER
5 6 Yis
I / 2 S / 4 9
Mechanicsbur
6 ea'°•°i ~~ EwoelPamm ^ DDA ^ N~r~,~9 DN•r
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' Resbence
Home
(SOeury)
' COUNTY OF DEATH CITY, DORO, TWP OF DEATH FACILI TV NAME (If not inslihidon, give street and numheN WAS DECEDENT OF HISPANIC ORIGIN? RACE -American Indian, Black, While, et
Cumberland
'
East Yennsboro f I_
S
~
~f
~~ No~ Yes ~ II yes, speuly Cuban,
Mezlcan
Puer Rican
ek (Specify)
~Tite
eb. 9 /
/~
r
~[15~, /~!
9a. ~L ,
, lo.
DECEDENT'S USUAL OCCUPATION KIIJU OF Bi151NESS /INDUSTRY AS DECEDENT VER IN DECEDE.NT'S EDUCATION MARITAL STATUS -Married, SURVIVING SPOUSE
(G~v« x~rw of wan mn. eu yy •
ie
eJ
1 U S ARMED FORCE57 Iso•uh only n~ynui prsas wmubbal Na r M d Widowed, 111 wJe. 9,v. ma~an r„m•I
of worxiny iJa. Jo nut Ilse
l~r
l Ye> ~ No ^ Ebm•nbryl5 nary Colbq Divofced ($Vecity)
I„ Tax Examiner „dept. of Revenue 7z 13 (°l~l "'2`s'' ,d.Sin ]e t6.
DECEDENrS MAILING ADDRESS (Slreel Clly/Town, Slate, Zip Code)
y y
O-I Va 1
1 e S C DECEDENT'S
ra. state PA no
ACTUAL 01d
~vae
de°edem wed;r, East Pennsboro
.
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Iwp
RESIDENCE daceoent
Somme r d a l e , PA 1 7 09 3 Is°e instr°uions m,a Ina Nn eecadem bred
Cumbe r I
a n d t
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16. .
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un caner aide) ub. cnnnly
witem aaNal umda ul °iym~i°
FATHER'S NAME (Post, Middle, Last) MOTHER'S NAME (First, Midtlle
Malden Surnaniu)
1B Francis C. McAndrew ,
,9. Margaret Ann Yea er
INFORAIANI'S NAME (TypelPlinl) INFORMANT'S MAILING ADDRESS (Street, Cily/Town
Stale
Zip Code)
zoa. Patricia A. Janis ,
,
zob.345 Lakeside Dr. Roselle Illino' 60172
METHOD OF DISPOSITION I~'I
®
^
• DATE OF DISPOSITION
nwmn
D
v PIACE OF DISPOSITION Name of Cemetery, Crematory
or Other Place IOCATION - City/TOwn, State, Zip Code
Creinahon L)<eniuval horn State
Dunatwn ^ Burial
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ur
(
~-~2-2005 H
lli
21a ort,erlspe°uy) 21b 21c
o
nger Crematory 21d. Mt. Holy S rin s, PA17U65
' SIGNATURE OF FUNERAL SE ICE LICENSEE OR PERSON ACTING AS SUCH LICENSE NUMBER NAME AND ADDRESS OF FACII ITY
. zm ~~.-.-...~ = zzbFD 012774-L zz°.Richardson F.H.Inc. 29S.EnolaUr. Enola I 1
Compl a earns a c onl when certiying _
To best o(my knowledge, death occurred al the lime, dale and place staled. LICENSE NUMBER DATE SIGNED
ph'ysi<ian is not available al lime of death to , iynalure and Tidtl) (Monty, Day, Vear)
cemry ca°se d dean.
13a.
23b.
13c.
Items 24-26 must be completed by TIME OF DEATH DATE PR OUNCED DEAD (Month, Day Year WAS CASE REFERRED TO A MEDICAL EXAMINER /CORONER?
person who pronounces deatR '') / / '
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14. / ~ r 11
M 15. (.~ L 7 Il es
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16, /j
z7. PART 1: Enbr N• a1••••••,1Nari•• o. c.mPnuuon. wnlcn cau•.a In• a•,m. Do no. •n1.r m• moo. of ayln,, .ern •• c•ra1•c or r••Pn•1ory ..r.•1, •norx or nun I•uur•. ~ Appro male PART 11: Other significant wntlitk,ns contributing to death, but
list wiry u~. ~•,,.• on urn u~• . inlenal Oelween not resullln9 n the undedying cause given in PART I
IMMEDIATE CAUSE (Final ~ onset and death
diszd,a °r cunshUn (1 v L Q-1,~ x+C- Lvh , r ~ S E.~ S y
raeenkiy m deann) ~ a
DUE ID (OR AS A CONSEOUENDE Of
(.
4
LA
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I.
Se hall nsl conditions b
~uun y
"
'
d any, leading to immetliale UUE TO (DR AS A CONSEQUENCE OF).
Einnr UNDERLYING
•
CAUSE (Disease or inJury °
' Inal indlalad evenle DUE i0 (OR AS A CONSEQUENCE Of 1.
sulliny on °eath) LAST d __
WAS AN AUTOPSY WERE AUTOPSY FINDINGS MANNER OF DEATH DATE OF INJURY TIME OF INJURY INJURY AT WORK? DESCRIBE HOW INJURY OCCURRED.
PERFORMED? AVAILABLE PRIOR TO
COMPLETION OF CAUSE
Naluial .® Hnm1c'ido ^ (MOnm, Day veer)
OF DEATH? ^
A~udem ^ Pendrn
Im esti
auon Ves ^ Nu ^
Yes ^ Nu ~
Yes ^ Nu ^ y
y
Swudu ^ Could nut vu dewiniaib° ^ 3lla. _ 30b. M. 30c. 30d.
PLACE OF INJURY - P.t home, farm, streaL lactory, otfce LOCATION (Slreel, Gry/Town. Slate)
19a.
29b.
29. anp, sic ISPecily)
)OO. ]gf.
-- ___
CERTIFIER (Cnack only one) __
SIGNATURE AND TIT EOF CFRTIF IER
'CERTIFYING PHYSICIAN (Physiuan cumlyiny ~:eu se ul dualli when enuthui pnysinan has ~r unoun~od deurtr and complulud alum 23) py
To N. heal of my knowledge, tlealh occurred du. to the cauwa(a) and manner as.laled ................................................................ ~`~
31 b. ---'Z
'PRONOUNCING AND CER iIFYING PHY SIGIAN (Physlcan bull pror uum. Tg dedUi and cemly-ny lU cause o/ dualh) LICENSE NUIdBE
()
IvT
~) DATE SIGNED (M Ih Day, Y ar)
r~.
To the best o(my knowledge, daatll occurred at the lime, tlala and plat., antl dw to Iha cauaaa(a) and manner a. slated. ...... ^
........ V
Z
31c. Y z` L
31 tl.
'MEDICAL E%AMINER/CORONER
• NAME AND ADDRESS OF PERSON WHO COMPLETED CAl15E OF DEATH
(Ilan 27) Type or Pnnl Prateesh V] swallathan
On the baala o/ eaaminallon •nd/ur Inve•llgallun, In my opinion, tloalh eccurrad at Ne lime, date, and place, and due to the cause•(s) and ^
' mane.r.,aWl.d....__....._ ...........
.
Ito list f (,antral PA
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3z 4uy
lTer S~. taro e, PA 17(X.3
REGIST 'S SIGNATURE AND NUMBER DATE FILED (MOnlh, Day, Yuall
J3. _~IAav] ~//3'L'LC.~~4 "~,.--A-.= ' / ~JJLCS_~~ ~]
3.. ~ ~~ r ..~ CL` ._.~{ D 05
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