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PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF Le:_ I ~s ~,1 COUNTY, PENNSYLVANIA
Petitioner(s) named below, who is/are IS years of age or older, apply(ies) for Letters as specified below, and in
support thereof aver(s) the following and respectfully request(s) the grant of Letters in the appropriate form:
Decedent's Information
n
Name: 1 'r: t- r r r, File No
a/k/a: r Fr1m,,To, (Assigned by Register)
a/k/a:
a/k/a: Social Security No:
Date of Death Age at death: 7
Decedent was domiciled at death in C 1r, nCount
6 Y, (Stare) with his/her last
principal residence at _ I (f, t ( j~: n T ; _r f
. ~ N H r 1 ~t t
Street address, Post Office and Zip Code City, Township or Borough County
Decedent died at I(c~r,r f'tr-.r } , -i,, : J PA I
Street address, Post Office and Zi Code S
P City, Township or Borough County nty State
Estimate of value of decedent's property at death:
If domiciled in Pennsylvania.. . ..............All personal property
If not domiciled in Pennsylvania Personal property in Pennsylvania $ If not domiciled in Pennsylvania Personal property in County $
Value of real estate in Pennsylvania $
TOTAL ESTIMATED VALUE....
Real estate in Pennsylvania situated at: ? -
(Attach additional sheets, //necessary.) Street address, Post Office and Zip Code City, Township or Borough Fount
❑ 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 and-Codicil(s)
thereto dated
State relevant circwnstances (e.g. renunciation, death of executor, etc.)
Except as follows: after the execution of the instrument(s) offered for probate Decedent did not marry, 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
® B. Petition for Grant of Letters of Administration (If applicable)
c•.t.a., d.b.n., d.b.n.c•.t.a., pendente lite, durante absentia, durante minoritate
If Administration, c.t.a. or d.b.n.c.t.a., enter date of Will in Section A above and complete 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(g) and was neither the victim of a killing nor ever adjudicated an incapacitated person.
[gNO EXCEPTIONS ❑ EXCEPTIONS
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 (attach
additional sheets, ifnecessaty):
Name -Relationship Address
Forni aw-n2 rev. 10/11112011 Page I of 2
Oath of Personal Representative Official Use Only
COMMONWEALTH OF PENNSYLVANIA }
} SS:
COUNTY OF oU,mbc lrolcc }
Petitioner(s) Printed Name 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) urd that, as Personal Representative(s) of the 6ecedent, the Petitioner(s) will well and truly administer the estate according to law.
Sworn to or affirmed and subscribed before Date L~ C l
?S t)
met isr. Na,a of PCembc;,c3L`I! Date
By (k n C w "o Date
For the Register Date
BOND Required: Q YES E ]NO To the Register of Wills: i
c;
FEES: Please enter my appearance by my signaturO~Py:
Letters $ J (~t Attorney Signature: t -
Short Certificates
D i
( i ) Renunciation(s).........
( ) Codicil(s) 7.7
( ) Affidavit(s)............
Bond Printed Name:
Commission Supreme Court
Other ID Number:
Firm Name:
Address:
Phone:
Automation Fee Fax:
JCS Fee . S2 ! Email:
TOTAL $ C ~L - C-
DECREE OF THE REGISTER
Estate of I M- L C Ct Nn n i File No: - 0 a/k/a: -7 1
AND NOW, f LlA H 0 in consideration of the foregoing Petition,
satisfactory proof having been presen ed before me, IT IS DECREED that Letters & an t lvl is r~
are hereby granted to n (Y) f ,S Lo, i ( ta't,,
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.
Register of Wills
kfrl ~111 Vf~_
Form RW-02 rev. 1011112011 Page 2 0 2
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