HomeMy WebLinkAbout10-11-11IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
REGISTER OF WILLS n ~-
~" _ w- 7~~ _~~
PETITION FOR PROBATE AND GRANT OF LETTERS ~, ~ ~' ~ ~ ~'j _ _
__ ;~,-
Estate of - : S ~. J - Cis s ,Deceased ESTATE NO: 21- -= ~,~=
a/k/a: SS NO•_ l 7 _. ~ - 7 ::~ 3 . _ ;=:r;:
L,, ~ 0
~.~' °n
Petitioner(s) who is/are 18 yrs of age or older, apply(ies) for: COMPLETE SEC'CION `A' or `B' AND "C" as
applicable:
^ A. Probate and Grant of Letters Testamentary or ^ Administration c.t.a., or ~i.b.n.c.t.a. (complete Part C also)
and aver that Petitioner(s) is/are 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
23 Pa. C.S.A. § 3323(g):
^ B. Grant of Letters of Administration
(If applicable, enter d.b.n., pendent life, 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 (lf Administration c.t.a. or d.b.n.c.t.a., enter date of W i ll 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. (:.S.A. § 3323(g), except as follows:-
u
Addrecc
Relationship to Decedent
---
~ ))! 7r73 v
)~/S.7 Q c~~ D!' IR"ttc~cn.'• /~ ! c3 -SO/\ y`°
5,~,. iS 1~ ¢cf t7~~
USE ADDITIONAL SHEETS IF NECESSARY '
THIS SECTION MUST BE COMPLETED:
Decede~/nt was domiciled at death in Cumbe+rlandnCotunty, Pennsylva(n`ia, withh his/leer last family or pri>~cipal residence
At ~ Z ~ ~ ~ i' c Cb •~ r ~ ~/L~ 1 al r /l 1 7a Z ~ `L c.~ ~ i~'C...l /1 ~~ n,_ I ;~ rn S`~ D
(Street address with Post Office and Zip Code, Municipality: Township, Borough, City)
Decedent, then ~! l7 years of age, died ~ ~ S~ 12.t~ t 1 at ~'~~ l ~ r'.- _.. b ~-1 ~,.~ G~.- ~. ; , •~ A -
(Month, Day, Yeaz of death) (City and .Mate where death occurred)
Estimated value of decedent's property at death:
If domiciled in PA All personal property $ So~dy& `~ `%
If not domiciled in PA Personal property in Pennsylvania $
If not domiciled in PA Personal property in County $
-Value of Real Estate in Pennsylvania $ 2, %~~ ~ ~ `~ J
Total Estimated Value $ Z ~~ ~ ~ vr:
Location of Real Estate in Pennsylvania: (Provide full address if possible.) J? `f y S~ i '~ ~, y ~ ~ ~~~ ~`s P ~ l 7~ 25
Signature(s) , Name(s) & Mailing Address(es)
157 '~ ~~'t~l ~)r m('CVICif1i(:S fir' ~~4 l7USC~
Interim Form RW-02 revised 12.26.10 by Cumberland County pending action by the Court Page i of 2
n
~~ -~
OATH OF PERSONAL REPRESENTATIVE =~ , _! z-'
c~ -
- ~ t--
_.. ~ r, ; ...__
Commonwealth of Pennsylvania SS -'`= =~~' ~-,' --
.,
County of Cumberland -, ~, _ -
_.
'~~ -
=~
The Petitioner(s) herein named swear or affirm that the statements in the foregoing Petition are trt~. 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 law.
Sworn to or affirmed and subscribed ~~) n ~~~~
1 ~
I' ~_ 6, J~
bef~~ one this ~' /`~~~~~y of
the Register
DECREE OF PROBATE AND GRANT OF LETTERS
~' 7~~
Estate of _ ,Deceased File Number: 2',1-~~-
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:
([f applicable, enter c.t.a., d.b.n., d.b.n.c.t.a., 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 De~~edent.
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 ................ $
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 Uy Cumberland County pending action by the Cow~t Page 2 of 2
_ _ _ __ __
Z hi, is to certify that this is a tote copy of the record which is on file in the Pennsylvania Department of Hea th in accords u:: with
t},c ~'i:al Statistics Law of 1953, as amended.
~., U-~ WARNING: It is illegal to duplicate this copy by photostat or photograp .
- _~ ~-
w"~ ~ ~ c~ C.'.
• C~; -.
--- --- ~~~ Marina O'Reilly Matthew
w~
r.,,. , State Registrar
_ ~...._ CJ T_ i_:
t;_ ~~ ~r~
cc`s . _`_ -- O ~
-: 636021 ~UG297011__
No.
Date'
CORRECTED ITc~r~S: 3
H1ns.144 REV nr2oos COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS }
PERMANEMI" ~~ FD DATE: 8/29/2011dy CORONER'S CERTIFICATE OF DEATH '~~~.~~,,
BLACK INK (See instructions and examples On reverse) STATE FILE NUMBER
0
z
w
0
0
iF S S-U itS
2
Sez
3.Sadal Security Number
4. Date of Death (Mamh, day, year)
1. Name of Decedent (RrsL middle, last, sol(o) .
ale
F 18Z 601• 7873 2011
June 5
Lisa J Goss
em _
,
Age ILast Birthday) Under 1 year Under 1 day 6. Dale of BiM IMonlh, day, year) 7. Bidhplace (C'dy end slate or loreign county) Ba. Place of Death (Check only one) _
5
.
Months Days Mows Mkwtes Hospital: Other
Pa
Lewistown
,
46 Yrs. Februar 2, 1965 ^Inpadent ^ERIOulpatienl ^DOA ^NursingHOme Residence ^OlherSpecify
County of Death Bc. City, Bo f Death Sd. FadM1ly Name (II not instuudon, gne street and number) 9. Was Decedent of His{ank Origin? ®No ^Yes 10. Race: Amorkan Itxdan, &ack, While, etc.
• Bh
i
C
b
(~~
.
u
an.
(If yes, spec
ty
White
Mexican, Puedo Rican, etc.)
Cumberland East Pennsboro 740 Sterlin Court
11. Decedent's Usual Occ ton Kind al wod done dud most of work Ige. Do not state relir 12. Was Decedent ever ut the 13, Decedents Education (Spedry Doty highest grade completed) 14, w~do red3Drv rod jSp s~jgr Martied, 15. Survivbg Spouse (If wife, give maiden name)
Kind &rsi Indu U.S. Armed ForcesYY? Elementary /Secondary (P12) CNlege (1-4pr Sr)
A~dmlmstrative 9~rc~il~ec~iral ^Yes ^ND 1 Divorced
• 16. Decedent's MaVutgAddress (Slree4 city sown, state, np codel Decedent's PA Did Dncedent ~~yy art eons oro
DecedentL'wedk Twp.
17o[~yTes
740 Sterling Cit. ,
Actual Residence 11a.Slate Township?
Neawdhin
D
d
m
Cumberland nd.C]
Enola, PA 17025 A~
l~e
~
o'
citylBaro
17b.Counry
13. Fameks Name (First. middle. last. soda)
Clifford E. Goss 19. Mother's Name (First, middle, maiden surname) Jenny Hummel
I Prinq
20a.lnfamanra Name (Type
ik 20h. Inlomtant's Mailing Adders (Streetary 1 town h zip c
PA 17050
Mechanicsburg
1457 Dylan r
ey
Rebecca A ,
.
21a. Method of Disposhbn ^ mal'ron ^ Donation 21b. Dale of DisposAion (Month, day, year) 21c. Place of Disposilkn (Name of cemetery, aenakry or other place) 21d. Location (City I town, state, tip aria)
^ Burial ^ RemovallromState i WazCremationorponationAuthoriaed
• June 8, 2011 Hoffman Crematory
^ Dlher. ~h~ j by Medical Examiner l Coroner? ^Yes ^ No ~ -
~ 22a. Sigtamre of Funeral Service Licensee for person aming az such) 226. License Number 22c. Name and Address of Facility Sullivan Funeral Home 51 N. Enola Dr. Enola, PA 17025
_ FD-13845•L
Complete Gems 23as oMy when ceduydrg 23a. To the best of my krwwledge, death oaurred al Ne time, date and place staled. (Signature and title) 2~. License Number 23c. Date Signed (Monde, day, year)
physidan a not avadabe at fine of dean to
cedity cruse of deaN.
• Lme of Death
24 25. Date Pronounced Dead (Month, day, year) 26. Was Case R=.terred to Medcel Examiner I Conner for a Reason Other Char Cremation or Donation?
dams 2426 must he completed by person . Yea ^"°
whopronounceedeam A rx. 12:45 P. M. June 5 2011
CAUSE OF DEATH (See insWClions and examples) r Approomate interval: Pan II: Enter other sig2tcent condmons conMbudne to death,
iven in Pad I
lti
in the untled
in
cause
t
t
b 28. Did Tobacco Use Contribute to Deam?
^Yes ^ Pmtebty
Item 27. Pad I: Enter the chain devents -diseases, injuries, or canpliratians -that directly caused the tlealh. DO NOT emer terminal events such as tardac am+sL t Onset to Death .
resu
ng
y
g
g
u
no
respiratory artesL or venldcular libolladon w4houl showing the etidogy. List only one cause on each line. i ^ No [] lMkrromt
IMMEDIATE CAUSE IFiral disease or r
cond4ion resu4sg in death)
GllRS110t t0 Head i 29. II Female:
nant within
ast
ear
^ N
re
t
,~ a. p
y
g
o
p
Due to (or as a consequence o(1: ~
,
^ Pregnant at time of death
tl an
list condlims
r
dal
S
,
y, 6,
ry
equen
~ ^ Not pregnant, hul pregram wiUan 42 days
leadup to the cause listed on lute a. Due o (or az a consequence of):
Enter he UNDERLYING CAUSE ~ of deaN
' (disease or iryury dial oilialed the
c.
events resuting in tlealh) LAST.
,
^ Nol pregnud, but pregnant 43 days to 1 year
Due to or as a copse uence of ~
( q I~ r before tlealh
r ^ Unknown'.f pregnant wdho the pall year
~ d.
30a. Was an Autopsy 3W. Were Autopsy Findngs 31. Manner of Death 32a. Date of Injury (Monts, day, year) 326. Describe How Irpury Occurred 32c. Place of Injury: Home. Farts, Street, Fackry,
Ofice BuiHmg, eta (SpedyJ
Perlom~ed? Avaaade Prior to Completion
of Cause of DeaN? ^Nawrw l~iHanirade June 5 2011
~ Shot b known Assailant -- Hand un Home
^ Accident ^ Pending Inveslgadan 32d. Time of Injury 32e. Inury at Work? 321, If Trensportaron Injury (Specify) 32g. Locatbn of Inury (Street, city Mows, stale)
^ Yes ~ No ^Yes [] No d
^ C
k N
b
D
i
^ Aprx . ^ yes ~ No ^ Dmer I Operate ^ Passenger ^Pededrian
ne
Suode
oo
cl
e
eterm 12:45 P.M ^Olherspecily Star i Court Enola PA
33a. Certifier (check only one) 336. Si lure and Td _
CertUying physician (Physician cerNydng ease of deaN when another physoun has pronounced dealt and completed Item 23)
_____________________ ^
death occurred due to the cause(s)and manner as stated
knowled
e
f m
th
b
t
T QQ
, ~ ~' or one r
____________
g
,
y
es
o
o
e
• Pronouncing and certdyMg physician (Physician boN pronaatcing deah and certityirg to cause of dealt)
^ 33c. License Number 33d. Date Sgned IMorM, day, year)
To rite best of my Imowledge, death aaurred at the time, date, and place, end due to the cause(s) and manner as sated_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ June 6 , L 011
• Medical ExemirKr/Coroner
and due to tie ware(s) and manner as stated_ ~
and place
death occurred et the time
doh
in m
o
inion
ti
ation
d 1
i
i
e 1 Print
n Campeled Cause of Deah phm 27
T
f P
,
,
,
y
p
,
nves
g
,
on an
or
On the bazis M ezaminat )
yp
erso
34 Name and ress o
Tod C. Ec~cenrode, Coroner
36.Regislrer's ands ~ N tb_ ' ~ ~ 3s. taRlaryMymh,aa,year
" ~ 6375 Basehore Rd., Suite 4I1
- (mot " ~j
/ Disposition Permit No. D ~0 "'-~^'