HomeMy WebLinkAbout01-20-12PETITION FOR GRANT OF LETTERS
REGISI~~ER OF WILLS OF (~, V M ~ ~ 1 ~~_ COiJNTX, PENNSYLVANIA
Petitioner(s) named blow, who is; are 18 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 Informa ion
Name: w1 1~1 F (~ ~ ~ (Z, ~ R~Z.1 Al -~ --~~'~-~.
a/k/a. A File No:~ -` ~ p~
a/k/a: (Assigned by?Re/gister)
a/k/a. Social Security No: ~pQ ~ 3 8 - Q
Date of Death: _~ __~ Z~ ~
Age at death:
Decedent was domicil d at death in CV µ~~,E„~ County,
principal residence at 00 l.~t (Stare) with his/her last
R. ~~ ~ v ~
Street address, lost Office and Zip Code ~'~'~~ T~~
City, Township or Borough M ~~uu~ounty t7O55
Decedent died at (00'~ ~[Ol 1 ~T A C.tsc l~? pQ F{ ~efi~ Nl C tit t ~>>tlr' ~
Street a~dress Post Oftice and 7rp Code Crty, Township or Borough County t t~~--Pi~
Estimate of value of deceden 's roe at death: Y State
I domiciled in Pennsyl~ ania ................ All personal property $
........... ~ ~ ODi C70p . 00
I not domiciled in Pen p p ~
l sylvania ........................ Personal property in Pennsylvania $
If not domiciled in Pen syh~ania ........................ Personal property in County $
Value of real estate in nnsylvania .................................................. .
.$
TOTAL ESTIMATED VALUE.... $~ Gp ~ QaO . Od
Real estate in Pennsylvania si~uated at: N ~ Nt
(Attach additional sheets, ijnece.~sary.) Street address, Post Office and Zip Code City, Township or Borough Count
Y
A. Petition for Pr bate and Grant of Letters Testamentar
Petitioner(s) aver s) he/s e/the is/are the Executor(s) named in the last Will of the Decedent, dated !~ ~ 2 Z- t ~~
thereto dated and Codicil(s)
State relevant circumstances (e.g. renunciation, death ojexecutor, etc.)
Except as follows: after tl~e execution of the instrument(s) offered for probate Decedent did not marry, was not divorced, was not a party to a pending
divorce proceeding whet m the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(g), and did not have a child born or
adopted; and Decedent w~s neither the victim of a killing nor ever adjudicated an incapacitated person.
^ NO EXCEPTIONS ^ EXCEPTIONS
^ B. Petition for Grant of Letters of Administration (Ifapplicable) rte=
.~.. ~
c.t.a., d.b.n., d.b.n.c.t.a., pendente lite, durance a ' , duranteq~tnorit ~ T- ~.
If Administration, c~i:a. ord.b.tt.c.~a., enter date of Will in Section A above and com lete I rs. ~ ~ }
Except as follows: Decedent was not a parry to a pending divorce proceeding wherein die grounds for divorce had ~ ~~ ~ g-tr~
in 23 Pa. C.S. § 3323(8) aMtd was neither the victim of a killing nor ever adjudicated an incapacitated person. e~tshed~definetl~.' ~,~`
^NO EXCEPTIONS ^ EXCEPTIONS --~} O ~~. ~;
.~'' %`+i
Petitioner(s), aftera propetjsearch has/have ascertained that Decedent left no Will and was survived by the following spouae~(if~ity) and hem (attac~t~
additional sheets, ifneces.~ary): ]f~~. ~ {'~~
~i
Name Relationshi Address
~hW 1trt~ R Z~i'st SOt~ TV SG JJ C.T
G~~ cz P~! ~ olt
I~
Fa-ntltW-02 rev. 10/ll/201/
Page 1 of 2
- -
Oiath of Personal Representative
COMMONWEALTH Off' PENNSYLVANIA
COUNTY OF
To the Register of Wills:
Please enter my appearance by my signature below:
~(~i1,~AN 20 P1~ 2~ 2Z
Petitioner(s) Printed Name Petitioner(s) Printed
~~ P ~o~
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 Deceden the Petitioner(s) will ell and truly administer the estate according to law.
Sworn to or affirmed an subscribed before - Date , aU c~0 la,
me thi da of C~ ~-- Date
By: ~ -
- Date
For the Register Date
BOND Required: QY1~S 4~"O
FEES:
Letters ...................... $ ~'"jd
( j~ )Short CertificateQs)...... t.~p-
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)............ .
Bond ........................
Commission ................. .
Other \n) ~ ~~ ........ lej"'~
........
Automation Fee ................ !7-_
JCS Fee. ..... '12 e.cT
TOTAL ..................... $
Attorney Signature:
~~~
Printed Name: ~ A R k ~y t N`T'E R
Supreme Court
ID Number: ~, ~ t ~~
Firm Name:
Address: ~ ~
1i~ K S ~t~i ~~/ PA L O
Phone:
Fax:
Email:
DECREE OF THE REGISTER
}
ss:
}
,~` /'~
Estate of +~ S i o l` - ~ ~`~-~ ~n ~ File No: ~I ~'~
a/k/a:
AND NOW, ' ~ C'.~ a- , in c Sider tion of the foregoing Petition,
satisfactory proof having~be prese ted before me, IT ECREE that Lett ~
are hereby granted to ~ _ ~ „ ~,
in the above estate and (if plicable) that
the instrument(s) dated _ / ^ ~ ^ '~
described in the Petition
Form RfV-Q? rev. !0//112011
and ttled o ~ e rd as the last Wi (and C'odicil(s)
Re ister of t
i ~J `
Page 2 of 2
__
H105.805 REV (yJl n ~ - - - - _ - __ -_ _ _ _
~ . ~~~~~~~~E~RAR'S CERTIFICATION OF DEATH
W ,~(~ ~f„is~,~f~al to duplicate this copy by photostat or photograph.
Fee for this CPrtifiratt~ ~~nn?itl~ i~u 7n DW ~~ 9`2
"~"" "" "' ' ' "' This is to certify that the information here given is
correctly copied from an original Certificate of Ueath
{~ duly filed with me as Local Registrar. The original
~j certificate will be forwarded to the State Vital
a ~ ~ Records Office for permanent filing.
P 182~?6483 ~, ~ /'
Certification ]Number ' j ~ 17 ka~uir2
Tyw/Print In '~ Local istrar
g Date Issued
Permanent COMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF HEALTH . VITAL RECORDS
a~
98
CERTIFICATE OF DEATH
It, Middle, st, Sufflx) State Flle Number:
2. Sex 3. Seclel Security Number 4. Date of Death (MO Day/Yr) (Spell Mo)
d R. rezina etnala 360 38 5013 ~4rvcr_cc..R~ ~ e7~1e1
z v d 1 I
Ves ~NO- J~Unknown 1 [~ Diwrcad
Edward R B a
a Ir Dean oct~rr.a m a Nospltal:
Eme envy Room/OUtPatlent -iriv+:ii:ni
py
SSb. Fac111tY Neme (lf not Instltutlon, glw street end
LL 5 ! (.1 '~
16a. Method o Dlspeaitlon url 1
Q Removal from State
Other (Spec) o) Donetlon
36d. Location of Dlaposltl n (City or Taw , Sbte, an.
Hershey PA 17033
17c. Name and Compl.H Address o1 Fun ral Facility
ffi is oe w
March 1S, 1914
mbar -Include Apt No.)
len Drivo
Nwer Married
decedent Ilwd In Up.~
decadent IlVed within limits of
ant s EducKlon -Check the box
highest degree or level of school wmplet that best describes the 19. Decedent o7 Hispanic Orlgln -Cheek the
d et the ti
f d
h
Q 8th grade or less me o
eat
. box that best describes whether the decadent
Q No dipleme, 9th - 12th grade Is Spanish/Hlspanl4Latlno. Check the "NO"
Nigh school graduate or GEO eompl box N.decedent Is not Spanish/Nlspanic/Latino.
ed
~ Some wllege credit, but no degree not Spanlsh/Nlspenl4Letlno
Q Yes
Mexi
M
l
0 Asseclab degree (e
g. AA, AS) ,
can,
ax
can American, Chicano
Q Vea
PueKO Rican
e
Q Bachelor's degree ( .g. BA, AB, BS) ,
~ Ves, Cuban
Q Master's degree (e.g. MA, MS, MEn MEd, MSW, MBA) {] Yes, other Spanish/Hispanic/Latino
~ Doctorate (e.g. PhD, EdD) or Profes tonal degree
. MD ODS OVM .LLB lD (Specify)
21. Decedent's Singla Raca Self-DesignaH
ja'Wlllte n -Check ONLY ON[ to IndluN whet the decedent [ansldered himself or
Q Black or African Amerlean ~ Japnese ~ Samoan
~ Korean 0 Other PO<Ifl
I
l
d
q
'
(
O American Indian or Alaska Natlye c
s
an
er
0 Vietnamese 0 Don't Know/Not Sure
~ ~ Asfan Indian 0 Other Arlan Q Refused
0 Chinese 0 Natlye Hawaiian Q Other (SPeeify)
~ FIIIPIno O Guamanian or Chamorro
It'[Mg 2ga - 2 MLL RF miser __ _ _____ ____ _ _...- _ -
S34-L
twp.
K ONE OR MORE races to indicate-what
e decade considered himself or hanelf to ba.
'White ~ Korean
Sleek or African American 0 Vietnemasa
Amerlean Indian or Alaska Native 0 Other Asian -
Asien Indian 0 Natye Hawaiian
Chinese Q Guamanian or Chamorro
FIIIPIno (] Samoan
le Panese Q Other Pacifle Islander
Other (Specify) - _
f to W. 22e. Decedent's Usual Occupation - Indlcab type of wort
done tluring moat of working Ilfe. DO NOT USE RETIRED.
o J °~ o~1s,- ~. l~fu.t_ `' I2)NS ~ !ms's / 15 L
py~
S
~'
v
26. Part 1. Enter the chain of
wants--tl
apses, InJurles, or eemplicatlona-that directly caused the death. DO NOT en[er ter
i
l I APProxlmate
respiratory arrest, or yentrlcular fl m
na
wants such as cardiac arrest
rlllatlon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on • Ilne
Add additi
l Il
f Interval:
€
IMMEDIATE .
ona
nes i
nece
J ~
° ssary
Onset to Dpth
CAVSE --------
(Fi
l dl
----> a.
Cam{ ~P~-~c
„a
cz. .
~/v»~/
f 4
T~
na
spaa or condltlon
resulting In death) Due to (Or as • q ee o})
cons
//~J
~ i
s
ll b. ~ ~ ~
~
~O'J~O'7~1 trki cr T+r---~-.+ ~! _J-t ~' + ' /~ sLS'
( y
equenna
y Ik;t eonaluon:.
n any, leading to the cause _ Due to (or s a tonsaquence ot): `•
listed on line a. Enter the
UNDERLYING C
c ~~/ Q X~ ~ z0 ~Q~
AUSE
(dlspse or In
th Ow to (or as a consequence of): F
Jury
at
Inla.tw the went: reawnne
in dpth) LAST
d.
~-«r./> h1./'a-~ ~/~SG.ce~lt/ Q[~.S-~~5' e (
)
. Dw to (or as a consequence ot): i
26. Part 11. Enter other but not resulting In the underlying cause given In Part 1 27. Was an a utoosyloerformada
to complete the cause of death?
29. It Female: 30. Dld Tobacco Use Contribute to Death? YH NO
.~ Not pregnant wlMln Past Vear 31. Manner of Death
Q Pregnant at time of death ~ Vas 0 Probably .Natural ~ Homicide
p Not PregnanQ but Pregnant withi 42 days o/ dpth a No Q"fJnknown 0 Accident p Pending Inwstlgatlon
Q Not pregnant, but pregnant 43 de to 1 year before dpth 32. Dah of In u Q Sulclde ~ Could not be determined
~ Unknown H pregnant within the p st year ) ry (MO/wy/Yr) (Spell Month) __ _
_ `"~ lyry aiccurree:
5@'NO ~ Pauar^gOperator ~ Pedeftrlen
p other (speelty)
Grtiflar (Check only ohs):
~.CertHying physician - To the best of y knowledp, dpth occurretl dw to the cause(s) and manner staled
~ Pronouncing i Certllying physician - o the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated
~ Medical Examiner/Coroner - On the Gals of examinatlo ,and/or Inwstlgetlon, In my opinion, deat/Ah~oc~u~-rred at the time, data, and place, and due to the cause(s) and manner stated
Signature of u ~ Title of certltler: !~ License Number:~S00 (p !f (f.~GL=
Nam dress d Zip Code of Perso Comyleting Cause o Dpt (Item 26) 39c. Date Igned Mo/Day/Vr)
~-+!'i7/~ ~ ~Lt'c ~-~ b-0 /l~vms~l(/LB.o /~sC /11tG/c.6riiees''6w ~--~i e ~ o !Z.
egistrar s DISYNCS Num 41. Registrars gnature a eg stray I a ate Mo sy
°Za`'` ~ t - ~t-aofl'
Shr.:~cl rPr,'c~'.~ o'~1Q1'ci~ lS ~ ~ 91 3
~Ct ~-1 7 ^~~~?C I ~
Dlsposklon Permit NO. 0697OS6 H1O5-143
REV 07/2011
_. -. -. _ _..I
LAST WILL AND TESTAMENT
OF i=
c_...
WINIFRED R. BREZINA
' ~ ~a
Q
I, WII~IFRED R. BREZINA, of Hershey, Dauphin tom.
Pennsylvania, being of sound and disposing mind, me~~ an
~~
understanding, do hereby make, ~;ubl=sh and declare this to be y
Last Will anal Testament, hereby revoking and making void any and
all prior wi~ls, codicils, or writings thereto, made by me at any
time prior t~ the making of this Will.
ITEM I:~I I direct that the payment of my debts and the
expenses of Imy last illness and funeral shall be paid from my
estate as anj administrative expense as soon after my death as
convenientlylmay be done.
I direct that my personal representative be responsible for
making all nelcessary arrangements for my burial.
ITEM II$ I give, devise and bequeath my entire estate,
consisting o~ all realty, personalty and mixed, wheresoever
situate, as follows:
A) TWO-I,THIRDS (2/3) to my son, EDWARD R. BREZINA, of Camp
Hill, Pennsylvania, PER STIRPES;
B) ONE-~IXTH (1/6) to my grandson,
Baltimor~, Maryland, PER STIRPES;
SCOTT EDWARD BREZINA, of
~i !'~.
i., c_..;
r , ,i-"r"
-,
~ ..'
...;
^u
~o
WTNI RED R. BR ZINA (SEAL)
C) ONE-SIXTH (1/6) to my granddaughter, STAGY LYNN BREZINA,
of Bethlehem, Pennsylvania.
ITEM I$I: No interest of any beneficiary under this Will or
any codicil) shall be subject to anticipation or voluntary or
involuntary~lalienation.
ITEM IV: All taxes, interest and penalties thereon payable by
reason of m~r death with respect to property comprisin m
g y gross
taxable estate, whether or not passing under this Will, shall be
paid from the principal of my residuary estate.
ITEM V~ In addition to powers given to him by law, my
Executor anc~ his successors shall have the following powers,
applicable tp all property held by him, effective without Court
Order and uni~il actual distribution:
a) To (retain any property received by him, in the form in
which it~ is received, until actual distribution;
b) Tol sell real estate for any purpose, publicly or
private]~y, for such prices and on such terms as he deems
proper ,! without liability on the purchasers to see to
application or the purchase monies;
c) To compromise controversies;
d) To djistribute in cash or kind or both at. such valuations
as he may fix .
ITEM VI:I I nominate, constitute and appoint my son, EDWARD R.
BREZINA, of C~mp Hill, Pennsylvania, Executor of this my Last Will
ii r ~~
III WINIFRED R. BREZINA (SEAL)
and Testament, but should my son, EDWARD R. BREZINA, predecease me,
or for any reason fails to qualify as such Executor, or having
qualified, ails to serve as such Executor, I nominate, constitute
and appoint, my daughter-in-law, BONNIE BREZINA, of Camp Hill,
Pennsylvania, as Alternate Executrix. No fiduciary acting
hereunder shall be required to post bond or enter security in any
jurisdiction.
IN WITLESS WHEREOF, I have set my hand and seal to this my
Last Will an~.Testament, consisting of this and two (2) other pages
at the end o~ which I have also set my hand and affixed my seal for
greateffr sec~Zrity and better identification, this ~~ day of
~~~t I ~',I A.D. , 1999.
W~ ~~ ~~ r
~ ( SEAL )
WINIFRED R. BREZINA
WITNESS:
residing at Q~ (./1•t5/ d P~
'residing at ~--c
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF D~,UPHIN
I, WIN$FRED R. BREZINA, whose name is signed to the attached
or foregoing instrument, having been duly qualified according to
law, do hereby acknowledge that I signed and executed the
instrument ~s my Last Will and Testament; and that I signed it
willingly; ~nd that I signed it as my free and voluntary act for
the purpose, therein expressed.
Sworn ~r affirmed to and acknowledged before me, by the
Testator, this "~.'`'n day of ~~~,'
1999.
~' G~ ( SEAL )
WI IFRED R. B EZINA
Notary Publi
My Commissio
DIANE D~FRITZ N t
Hershey, PA Dauphi
My Commission Expires
fires:
Public
$' 1999 AFFIDAVIT
COMMONWEALTH~OF PENNSYLVANIA
COUNTY OF DA PHIN
We, A.
whose names
being duly g
were present
her Last Wil
as her free
that each of
Will as wit:
Testator was
sound mind a~
Sworn to and
before me thi
day of DPa~
Mark Winter and Marilyn J. Cichelli, the witnesses
ire signed to the attached or foregoing instrument,
~alified according to law, do depose and say that we
and saw Testator sign and execute the instrument as
that she signed willingly and that she executed it
nd voluntary act for the purposes therein expressed;
is in the hearing and sight of the Testator signed the
esses; and that to the best of our knowledge the
at that time eighteen (18) or more years of age, of
3 under no constraint or undue influence.
Witness (SEAL)
i^
fitness (SEAL)
ub ~~ ibed
1999.
Notary Public
My Commission expires:
NOTARIAL SEAL
DIANE D. FRITZ, Notary P~jblic
Hershey, PA Dauphin Cou ty
My Commission Expires Nov. $, 1999
--e____