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PETITION FOR GRANT OF LETTERS ~-°n
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REGISTER OF WILLS OF COUNTY, PENNSY;~ ~A ~
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Petitioner(s) named below, who is/are 18 years of age or older, apply(ies) for Letters. as si d be18~,
support thereof aver(s) the following and respectfully request(s) the grant of Letters in -the approprpta~y form: i.
Decedent's Information ~ ~
Name• VSA ~ `JOh1 OVv4 J.~
a/k/a:
a/k/a:
a/k/a:
Date of Death: ~ (o cJLz , a0 /~
Decedent was domiciled at death in L
principal residence at ~l L•QA4 P
f*~a
21- 12.-00 ~6 ~~,
File No•
(Assigned by Register)
Social Security No: X03 ' ~/ 2' 8357
Age at deaAath• Coo Yid
~/~ /.croro- with his/her last
Street address, Post Office and Zip Code City, Township or Borough County
Decedent died at / Sd4 S~St~l1c~lgUt>rtie ~R . ,7ay/tiWat L~91/c~gST P~ .
Street address, Post Otlice and Zip Code City, Township or Borough County State
Estimate of value of decedent's property at death: /
If domiciled in Pennsylvania ............................ All personal property $ ~ [ Ste'
Jf not domiciled in Pennsylvania ........................ Personal property in Pennsylvania $
If not domiciled in Pennsylvania ........................ Personal property in County $
Value ojrealestatein Pennsylvania ......................................................... S
TOTAL ESTIMATED VALUE.... $
Real estate in Pennsylvania situated at:
(Attach additional sheets, if necessary.) Street addrexi, Post Otlice and Zip Code City, Township or Borough County
^ A. Petition for Probate and Grant of Letters Testamentary
Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated
thereto dated
State relevant circumstances (eg. renunciation, death ojezecutor, etc.)
and Codicil(s)
Except as follows: after the execution of the instrument(s) offered for probate Decedent did not many, was not divorced, was not a party to a pending
divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(8), and did not have a child born or
adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person.
^ NO EXCEPTIONS ^ EXCEPTIONS
[~ Petition for Grant of Letters of Administration (If applicable)
e.t.a., d.b.n., d.b.n.c.t.a., pendente life, durante absentia, durante minoritute
If Administration, c.t.a. or db.n.c.ta., enter date of Will in Section A above and comalete list of heirs.
Except as follows: Decedent was not a party to a pending divorce proceeding wherein the grounds for divorce had been established as defined
in 23 Pa. C.S. § 3323(8) and was neither the victim of a killing nor ever adjudicated an incapacitated person.
^NO EXCEPTIONS ^ EXCEPTIONS
Petitioner(s), after a proper search has/t-ave ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs (attach
additional sheets, if necessary):
Name Relationshi Address
M~ CNAi,~ S - ~.~c~NOU ~I ~ LI~SBA t~D S"~ tr,,Z~I4~/c1,?,~ ~Q• CLIC SPltt NlcS
Ul~rv2ta. v2`IJi_ ~A17ltil-1~ lO~f~7~~L Mt ~ ca, ~,WcoCN vul v. A.
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and ink
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Fnrm RW-01 rev. JO/t 1/20U PagE 1 Of L
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Oath of Personal Representative
COV[VtONWEALTH OF PENNSYLVANIA }
} SS:
COUNTY OF }
Petitioner(s) Printed Natne Petitioner(s) Printed Address •
'.:~~
The Petitioner(s) above-named swear(s) or affirm(s) 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 Fcepresentative(s) of the ec the Petitioner(s) will well and truly administer the estate accordi/ng to law.
Sworn t affirmed an subs ribe b o % ( -- Date JA~~ ~O ~Z
the t >, ~~' day of ~ Date
By: Date
r~{he Regisler Date
BOND Required: Q YES ~ NO To the Register of iVi!!s:
FEES: Please enter my appearance by my signature below:
Letters ...................... $ ~ ~b Attorney Signature:
( ~) Short Certificate(s)...... , O6
( ~ )Renunciation(s)......... .aj_ (~
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................ Printed Name:
Commission .................. Supreme Court
Other -~--........ ID Number:
;`l YIY~--{- A Tl(,~~(,~U~. UV Firm Name:
........ Address:
........ Phone:
Automation Fee ............... ~ Fax:
JCS Fee . .................... 4Q Email:
TOTAL ..................... $
~ , ..
Official 'sc Qnly
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DECREE OF THE REGISTER
Estate of USQr) ~~ //D/)Dl/Q2 File No: ~ ~ - ~~C. ~ 6 ~-~
a/k/a:
AND NOW, ~-~~~'( ,6.~.~~ ~~ u~ consideration of the foregoing Petition,
satisfactory proof having been present d before me, IT IS DEC/REED t at Let s /7 ~ ~d/I)r j~/,S,f/-a ~/O/~
are hereby granted to ~~ C`7Gt L S ~4/70{~Q 2
in the above estate and (if applicable) that
the instrument(s) dated _
described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent.
egtster of Wills
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Form R6V-0? rev. !0/IIi20/1 Page 2 of 2