Loading...
HomeMy WebLinkAbout01-18-12PETITION FOR GRANT OF LETTERS REGISTER OF WILLS OF t~Grn~c,~~i~~e ~~COUNTY, PENNSYLVANIA Petitioner(s) named below, who is'are 1$ 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 Name: ~~dl/C°~ ~ `7Qy / 1'`~ a/k/a: a/k/a: alkla: Date of Death: (~ I - % ~i ~ o~i~ /.~- Decedent was domiciled : principal residence at ~/ Street death in C Eile No• d ~ _ , ,~ _ CT~j~~..Q (Assigned by Register) ~ /'7 Social Security No: 7 ' ~d •' 7 / g Age at death: ~~ (state) with his/her last Post 6ft"ice and Zip2ode City, Township or Borou h Decedent died at l V~ ~i~~ ~ ! Street address, Post Oftce and Z' Code City, Township or Borough Estimate of value of decedent's property at death: Ijdontici[ed 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.... $ County State 33 l Real estate in Pennsylvania situated at: (Attach additionai sheets, ijnecessary.) Street address, Post Office and Zip ode City, Township gr Bor ugk County ~ H• Petition for Probate and Grant of Letters Testamentary ~y, Petitioner(s) aver(s) he(shelthey islare the Executot(s} named in the last Will of the Decedent, dated ~ ~ ~°' ~ Wand Codicil(s) thereto dated State relevant circumstances (eg. ten-u~ciation, death ojexecutor, etc.) Except as follows: after the execution ofthe instrument(s) offered for probate Decedent did not marry, was not divorced, was not aparty to apending 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.u., d. b. n., d.b.n.c.t.a., pendentelite, durunteabsentia, duranteminoritate 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(8) and was neither the victim of a killing nor ever adjudicated an incapacitated person. ^ NO EXCEPTIONS ^ EXCEPTIONS Petitiarer(s), after a proper search has/have ascertained that Decedent lefr no Will and was survived by the following spouse (if any) and heirs (attach additional sheets, i~'necessary): Name Relationshi Address -~ Fa,-n,nwnz ,•~~. initiiznlt Page 1 of 2 Oath of Personal Representative - - Official Usc Only ' COiv4~tONWEALTH OF PENNSYLVANIA } ~ - ~- i } SS: COUNTY OF ~~}rti'~-j~~(_;E,~~ } ~ ~ .' ., ~-;. Petitioner(s) Printed Name Petitioner(s) Printed .a dtlest~~~ -.. 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 Representative(s) of the Decedent, the Petitioner(s) will well and truly administer the estate according to law. Sworn too • affirmed arad subscribed before ~-1 S~ ~ ',~ g,,~V~ r~ 4 t Date ` o~ ©~ a me t, ' ~_ dnay of ~ ( (l, ~ ~ 'Z Date $Ye( 1 I ~ ~{ .(n ~' U (.~~ 'C~_ Date For the Register Date BOND Required: AYES ~NO To the Register of Wills: FEES: ``''tt'' Please enter my anoearance by my sienature below: Letters ...................... $ ~ (~ )Short Certificate(s)..... . --~~ ~•~-~- ( )Renunciation(s)........ . ( )Codicil(s) ............ . ( )Affidavit(s)........... . Bond ........................ Conunission ................. . Other ........ ........ Automation Fee. .............. ~> G JCS Fee . .................... ~ ~ ~ TOTAL ..................... t- . $ Attorney Signature: Printed Name: Supreme Court ID Number: Firm Name: Address: Phone: Fax: Email: DECREE OF THE REGISTER Estate of ~~~~ ~ ~ ~ ~~'i lT ,1. ~ ~ \ File No: ~~ ~ ~ ~ U G2~ (..~ a/k/a: T AND NOW, ~ ('y 4~;~,y r LF ~ 'r~ ~ a , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that L tters are hereby granted to ~~~~ L ~ YLQ (,U ~(',{ r ~ ( , in the above estate and (if applicable) that the instrument(s) dated i ~ U-] described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent. ~ ~ i egister of Wills , „'" Fnrm R6V-01 rev. !0/1 /i201! Page 2 of 2 LO~AtL REGIS~Tt~AR'S CERTIFICATION OF DEATH WARNING:. tt is ilfegtaT to duplicate this copy by photostat or photograph. F~~e for this certificate, $6.00 `: i ; .v r 'This is to certify that the r)~fgnnatictn here given is correctly ca>pied from: an Original Cer~ific~te of Death r I, _ ~ duly filed with.mc as Local Registrar. l'he original ~"~~~ - - certificate will be forwarded to the Mate Vital ( ' " ~ Records Offi - ~o.~ Zanent film ~i `~ ' g~. ~, . ; ; • Certification Number „ ~..._, (~._._:..._.._. Typa/Prlnt In Permanent a x.v~„ul iw ~x~uw ~ LdLC 1,1111CU COMMONWEALTH OF PENNSYLVANIA _ DEPARTMENT OF HEALTH _ VITAL RECORDS CFRTIFILOTF AF 1'fFATH 1. Oeudent's LegN Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number 4. Date of Death (MO Day/Yr) (Spell Mo) Ro e r ~. 197-20-4791 3 Sa. Age- rt Birthday (Vnt) Sb. Under 1 Year Sc. Under 1 D• B. Date of Birth (MO/Day/Year) (Spell Month) 7•. Birthplau (CIty~ nd State or Forel Country) 83 Monthf D•ya Hpura Mlnut.s November 26 1928 Harrisbur PA , 7b. Birthplace (County) 8.. Reald•nu (State or Foreign Country) 8b. Rpidenc• (Street antl Number -Include Apt No.) Sc. Did Oeudent Llye In a Township? Penns lvania 6331 Brandy Lane QYes, decedent Ilyad In Twp. ad. Real a (county) Cumberland ge. Resldana (Zip Code) 7 pNO, decedent INed within limits of ME'_ChaniCS btl rf2 City/boro. 9. Ewr In US Armed Forces? 10. Marital Status at Tlme of Death Ma Med WI owed Il. Surviving Spouse's Nam• (If wife, give name prior to first marriage) Yes Q No Q Unknown Q Ohrorud Q N•wr Married Q Unknow 12. Father's Nam• (First, Mitldle, Lart, SuMx) 13. Mother's Nam• Prior to First Marriage (First, Middle, Last) W 1 JJE! Ur8 a~i-ew~aker 14b~R$ulgogst ~=D•utlent 14t. Informant's Melling Address (Str.•t and Number, Clty, State, 21p Code) ~ G S ......................................................... ......................................... ........~:...~e~..°.....eat-.- ... Vic,. on.y one .............................. N Death Occurred In a Hos Ibl: ~ In ati•nt (II Death Occurred Som• Mre Other Than a Hos Ital~ ~~-~~-~~~~~~~~~-~~-~~-~~-~-~~~~~-~~ -~~~-~~~~---~~-~--~~~~~~~----~~~~- P P w p t~ Hospice Facility y Dautl•nt'a Hom• Eme en Room/OUtpetl•nC Oead on Arrlyal Nursin Hom•/LOn -Term Care Facility Other (Specify) lSb. Facility Nam• (M not InrtKUtlon, {Iya rtreK and number; 1$C. City or Town, State, and Zip Goda iSd. County of Death Harrisbur Hos 3ta1 Harrisbur PA 16a. Method of DlspoaRlon Burial Cremation 18b. Data o1 Disposftion iBC. Place of Disposition (Name of cemetery, crematory, or other place) p R.moY.lfromsT.ee p Donation oen•r( eery) 1/16/2012 $itner Crematory, LLC 18tl. LCx'aHOn of Disposition (City or Town, State, and 21p) 17a. Signature of Funer• • Llunsea or Parsers In Charge of Interment 17b. License Number Harrisburg, PA FD-014404-L Nam• a d leb Address of Funeral FaeIIRy e ~~ i nl F tr c c tner uneral Home, 3125 Walnut St_ Harrisbur PA 17109 ~' 18. Decedent's EduuTlon -Check the box that 6ert describes Th. 19. Daudent of Hispanic Origin -Cheek the 20. Deutl•nt's Race -Check ONE OR MORE rates to Intlica[e whet ~ highest degree or level of school completed at the Hme of death. box That Wst describes wMth•r the decadent the decedent considered himself or haraeH to be. Q Bth grade or less Is Spanish/Hispanic/Latino. Cheek the "NO" QCWhita Q Korean Q No dlPloma, 9th - 12th grade box If decadent is not Spanish/Hlspanlc/Latlno. Q Black or Afrlun American ~ VI•tnamase (~ High school graduate or GEO compleced a] No, not Spanish/Hlspanl4Latinp Q American Intlien or Alaska Natiye Q Other Asian Q Some wile{e credit, but no degree Q Vas, Mexlun, Mexlgn American, Chicano Q Asian Indian Q Natiye Hawaiian Q Associab degrN (e.g. AA, AS) Q Ves, Puerto Rican Q Chinese Q Guamanian or Chamorro Q Bachelor's degree (•.g. BA, AB, BS) Q Yas, Cubin Q Filipino Q Samoan Q Martar'z digr•• (e.g. MA, MS, MEng, MEd, MSW, MBA) Q Yes, other Spanish/Hispanlc/(.aTlno Q J•Panaae Q Othsr Paclflc Islander Q Doc orate (e.g. PhD, EdD) or Professional d•Srea (Sp•cffy) Q Other 5 ( peeify) •. MD DDS DVM LLB JO 21. Decedent's Single Race Self-Oealgnatlon -Check ONLY ON! to Indicate what the decadent considered hima•N or hers•It to be. 22a. Decedent's Usual Occupation - Indicate type of work ' S ] White Q Japanese Q Samoan done du~ing moat of working Ilfe. DO NOT USE RETIRED. Q BlaekorAfrlcanAmerion Q Korean Q Oth•rPaclflclslander E1OCT.r3.C Tech. Q Am•rlun Indian or Alaska Natiye Q Vietnamese Q Don'T Know/Not Sure Q Asian Indian Q Other Asian Q Refused 22b. Kind of Business/Industry Q Chinese Q Natiye Hawaiian Q Other (SPecify) Q Filipino Q Guamanian or Chamorro UG= cat 111.1 ie3 U BE M L D 23e. Date Pronounud Oea Mo Day 2 Ignature o Parson Pronouncing D•at On y when app Ica 23c. License Num e r BY KRSON WMO PRONOUNCES OR y~ 9 23dn F {n df 3 ~~ Da e 51 (MO Day/Vr) 24. Time of •ath W 7/ 1 25. Was M•dlul Examiner or Coroner Contactetl7 Q Yes ~ No CAUSE OF ~EATN ~ Approximat. 26. Pert 1. Enter tM Chain of w•MS-diseases, Injuries, or compllutlons-that directly caused the death. DO NOT enter terminal wenis such as cardiac arrest Interval: , respiratory •rrert, or yentrlcular flbrllla[lon without showing the etloloN. DO NOT ABBREVIATE. Enter only one cause on • Ilne. Adtl additional Tines i( neossary Onset to Death ~C IMMEDIATE CAUSE -------> a.~dY S7'~~I.Yr...~, ~•~/L•./I /r~J~ ~ Final disease or conditlon ~ or a ~~ ~y n to ( equence of): e sultan{ In Berth) ~t L L ~ _r~ / S b. SNtf /!'. c ilN,/l~,/ yJlj$ F. ~I.c~ S•gwntlalW list conditions, ~( ~^ Du• to (or as • ns qu•nu of): : If any, leading to the cause Ilrted on Ilne a. Enter the c UNOERLYINO CAUSE Due to (or as a consequence o?): (disease or lnjurythat F Initiat•tl the w•ntz resuting tl. ~ In death) LAST. Oue to (or as a consequence r of). i 26. P•R I1. Enter other sl Ifl t Bari t ibutl t d th but not resulting In the underlying cause glwn In Part 1 27. Was an autopsy p med7 Yes No 28. Were autopsy fl Inge ayallable to complete the cause of death? Q Yea No 29. H Female: 30. Dld Tobaeeo Vse Contribute to Death? 31. Manner of Desth Q Nat Pregnant within past Year Q Yef Q Probably Natural Q Homicide '~' Q Pregnant at time of death Q No ~$s'lJnknown Q Accident Pendln Inyesti Q g priors N t b Q o pregnant, ut pregnant within 42 days of death Q Suicide Q Could not be tlet•rminetl N ~ Q ot pregnant, but pregnant 43 days eo 1 year before death 32. Data o1 In Mo/Da /Yr 5 jun' ( Y ) ( Pell Month) Q Unknown if prgnant within the past yur 33. Time of Injury 34. Place of Injury (e.g. home; construction site; farm; uhool) 35. Location of Injury (Street and Number, Clty, State, Zip Code) 36. InJury at Work 37. If Tranzportatlon Injury, Specify: 38. Describe How Injury Occurretl: Q Yez Q prayer/Operator Q Pedestrian Q No Q Passenger Q Other (Specify) 39a. Grtlfl•r (Check only one): f~ C•KHying physician - To the best of my knowledge, death occurred due to the cause(s) antl m stated Q Pronouncing L Certifying phyficlan - To M• bert of my knowledge, death occurred at the tlme, date, and plan, and tlue W the cause(s) antl manner stated Q Metllul Examiner/Cor n r - O th b i f o e n e as s o •xaminatlon, and/or Inyertiptlon, In my opl nlon, death occurred at the time, d T•, and place, and due to the c ause(s) and manner stated l Signature of e•r[Ifler: ~ dl TRIe of certifier: License Number: Otl ~/.S f~~ 39b. Nam•, Adtlress and Zip Code o Person Completing • of Dea[h (INm 2g) /~~~ ' 39c. Date Signed (MO/Day/Yr) ' ~ O 40. R.g~~ Tract mbar 4 g st s natur ~~ ~ 42. Raglst a ab Mo Day 43. Amendmen ' ~ DlspoaRion Permit No. d ~ '~ ~~~ H305-143 REV 07/2011 / ) / /y ~~ ~ ~ ~ ~ ~ ~ ~ ~ ~~ ~ -S-~~/~/G~' ~~~ ate/ ~ ~>'~S' ...~ /~ ~ ~ ~ ~~ ,~ ~~,. _~~ ri n'~a' 4rarn,v~lri,~ ,a ~/?/oy~~~ ~ a~~ ~ . ~- t ~ ~ ,~ y ~1.// ~,~~a9 ~~'~' ~ read '~'/~~J_ j ~ ~~~i~f~~' ~,%/~ ao~'~ li~l~~ D11Y~ -~ 8 ~ / /~ 1~~a~~~l!'~J ~06.1~i~~.r~ ~P~~i.1,o aS~a.7/v ham' ~~~~~~ ~-~jr' S-~v /~'„~~/'~ ~~ J~/~o/~.~~d f~~'al~ay ~~~a~~~5~~~y~' -/~J~ ~ls~' / ylG~//" ~ p~ si ~ ~'~~~~ aJ ~/ / 1 ~ ~ ~ ~ / L~ ~~'~9/J. ~~/dGl~ ~s~u/~ ~ ,~y~4Ll/~~ ~h'~ ~JY/~1 G~'/14~ ,t9 /~Y~~~ _._~ .y ~ ~ ~~~ ~ ~ ,~ / 9 ~ d ~ ,,3rd`, ~ -,~'L ~,~ ~~ `_ ~,~ ~G ~.~•'~~~/sue,/ ~iyt./ ~>~~ -~5~,., 7,~'~" I~Od~~ 0~1 ~,~ { ~~ ,,~~. ~' ~ f~'~`7 ~ ~~~ 4 I~~~~ ~{ ~ 7 d~ ~~: ~(J Ir °'~-1 ~' ~ ~ ( ~~ ~ ~ Z. ~~~ ~~~ ~V1 ~ ~ ~~ ~ ti ~~ ~~ ~ti~~ ~ ~° ~~~ -~~ y .~~ ~ '' 4 ~% ~~ b ~ l 1~~'~ ~~ ~~ 6 1Y~~obV~~~~''~~~~ ~ ~~ ~ ~a~~,ar\~~ ~~ I ~ ~ ~ a~ ~~ ~~r~~ l' \ ~~~~~G~ sa~~d'~) ep,~a~~s~~~ ~~ ~C E f~ ~~ ~~ ti ~~ ~ t ~~~ / ~~ -~ ~~ ~~, /~- . t~_ ,~~ ~ ~~ ~~~~ ~~ w ~ ~ 1-sue '~~'~ ~ ~~ OATH OF NON-SUBSCRIBING WITNESS(ES) /, REGISTER OF WILLS ~LW11~~2111'/~f~ . COUNTY, PENNSYLVANIA ~~ .- .~ Estate of Deceased ~~aJ 'E...~J `C ~ ~ ~ ~~~ 'C C w~ A IC.P +rr and ~A ~~~ _ (each) being duly qualified according\to.,law, depose(s)\and say(s) that she / he /they was /were well- acquainted with `~~~ O~ a C 'Q L. k ~yti ~~~ and am/are familiar `` with the handwriting and signature of the decedent, and that the signature of ~U ~-t ~P ~ ~ ~=M ~~ T~ ~ ~1 to the foregoing instrument purporting to be the Last Will and Testament/Codicil of ~ ~j,.,,, ; ~~~~_ is in his/her own proper handwriting. 1 ~ (Sig h ' - ..L.." .o .. _ r ~~ (1 ~ n i (StFeet dd~dre`s~s) _ - " f__~.,/'lam ~M~ Uv1A~~Q ~~ (~ (City, State, Zip) Executed in Register's Office Sworn to or affirmed and subscribed before me this day of C1~~~,~- ~1~;~ ~ .t ~ ~~ ~~ ~- , I°~1DC9 ~ G,~ ~~,~1 Deputy for Register of Wills r r G~ gna ) ~~~ ~~y~~ (Street dress) .r it ,State, Zip) ~ - ,-~ , _~, Forrn RW-04 rev. !0.13.06