HomeMy WebLinkAbout02-07-12PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF Cu ftiRh COUNTS', PENNSYLVANIA
Petitioner(s) named below, 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 Informaliion
Name: tflv~(]t'I 0 F-"t-1~ File No: ~~ -
~~a' (Assigned by Register)
a/k/a:
~~a' Social Security No: 1'11~1~ ~.12F
Date of Death: ` (lOlk~)(!i lU. ~01~-
-~--~ Age at death„ ,~
Decedent was domiciled at death in (~nnh2xl(Inrl County, O(1 (stare) with his/her last
principal residence at ~_(~,~(~ i,(1 (lY~l~ p~ --~(il~ .lN~~lOI'1l1(~
Sheet address, ost Office and Zip Code City, Township or Borough Count
y
Decedent died at 'ILD (~PX(U 1.(!fl t (I1r~~,~ Pn 1'(01'h ~;~` ~,~~~~~ k ~ ~ti.,~~ p~•
Street address, Post O nce and Zip Code City, Township or Borough County State
Estimate of value of decedent's property at death:
If domiciled in Pennsylbania ............................ A.11 personal property $o~'j' ~~ ~ ~
If not domiciled in Pen~tsy[vania ........................ Personal property in Pennsylvania $
If not domiciled in Pen~sylvania ........................ Personal property in County $
Value ojreal estate in ennsylvania ......................................................... $
TOTAL ESTIMATED VALUE.... $~`~, -Q G
Real estate in Pennsylvania situated at:
(Attach additional sheets, i/necc!~ssary.) 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 a/they is/are the Executor(s) named in the last Will of the Decedent, dated
thereto dated
State relevant circumstances (eg, renunciation, death ojexecutor, etc.)
and Codicil(s)
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 whetrein 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 eras 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., pendente life, durante absentia, durante minoritute
If Administration, ¢.t.a. or d.b.n.c.lra., 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 die grounds for divorce had been established as defined
in 23 Pa. C.S. § 3323(g) ~nd was neither the victim of a killing nor ever adjudicated an incapacitated person.
(~NO EXCEPTIONS ' ^ EXCEPTIONS
Petitioner(s), after a proper search has/have ascertained that Decedent lefr no Will and was survived by the following spouse (ifany) and heirs (unuch
uddrtionul sheets, ifnece.{•sary):
.a.•
F~,~n, aw-nz ~•w. inilliznlt Page 1 of 2
r `~
~, IL~
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA }
} SS:
COUNTY OF }
ier(s) Printed Name
- - - ~,tr~
-. 1
L[~12~~.6-l ~~~~' 1~
~~
The Petitioner(s) above-na personal~Re ~ esentative(s) of the Decedenh tl erPetitioner(s) willrwel~l anddtruly administ rthe estate ac^c7ording to awelief
of Petitioner(s) and that, as P ~ ~ ~ ~~~ Dat~ `/
Sworn to or affirmed nd subscribed before ~u/-+/ _( ~
Date
me this ~ da o ~ ~~ ~ Date
$y; ~ ~ Date
For the Register
To the Register of Wills:
BOND Required: ^1'ES NO ,,.____ __........., 4..oParance by my signature below:
FEES:
Letters ...................... $_~
( ~ )Short Certificate(s)...... ~-
( )Renunciation(s)......... ~-
( , )Codicil(s) ............ .
( )Affidavit(s)............ _----
Bond ........................ -_,---
Commission .................. --------
Other •••••"' ----'
Automation Fee ...............
JCS Fee .....................
TOTAL ..................... $ r~• _~TT
Estate of
a/k/a•
Attorney Signature:
I Printed Name:
Supreme Court
ID Number:
Firm Name:
Address:
Phone:
Fax:
Email:
DECREE OF THE REGISTER
;'-~-- File No• _~ ~ ~ ~ ~ ~-
~~!~1~-, in consi ra ion of the fore oing Petition,
AND NOW,
been sent before me, IT IS DECREED that Let, ters 1 ^ ~ ~ 1 S r~~ ~ , n ~ ~
satisfactory pro ng p ` ~_
re hereby granted to 1`~-l`~ ~ ~ ~- in the above estate and (if applicable) that
the instrument(s) dated
described in the Petition be admitted to probate and filed o~~ rd as; he last
of
(and Codicil(s))
2
Farm RW-0? rev. 10/11/2011
RENUNCIATION ~;
~.~ '~
- ~;
~
REGISTER OF WILLS
'fir ~
w n
`~~_ COUNTY, PENNSYLVANIA ~csi~ =~ ~~ s.
~~~ ~
~~ _
' ~b~' ry ~
,.
N .~
C+
Estate of ~ ~t~G~, ` ~ ~ `~~~ ?
,Deceased
I' ~~ 1~'~ ~ ~ ~ ~ ~~ 2-- _, in my capacity/relationship as
~~ ~ ~~ (Prtnt Name)
of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
~ ~~} a
(Date)
Executed in Register's Office
Sworn to or affirme and subscribed
before me this day
of
Deputy for Register f Wills
I
Form RW-06 rev. !0.13.06
(Signature)
`7 l hp E~ ~~-,
_.
(Street Address/n)
(City, State, ZipJ ~'~'d
Executed out of Register's Office
Before the undersigned personally appeared the
party executing this renunciation and certified
that he a~-sl3e~executed the renunciation for the
purposes stated within on this ~ ° day
I
Notary ublic
My Commission Expires: D~ . t 3 t X3.01 ~
(Signature and Seal of Notary or other official qualified to
administer oaths. Show dates of expiration of Notary's Commission.)
COMMONWEALTH OF PENNSYLVANIA
NOTARIAL SERI.
MARY ANN C. (dARBARINO, NOTARY PUBLIC
SILVER SPRING TWP., CUMBERLAND COUNTY
MY COMMISSION EXPIRES DECEMBER 13, 2012
-- - - - -
LOCAL~~~T~f~'S CERTIFICATIONI OF DEATH
WARNIN~G~~~~~e'~gaf~,~1~~~plicate this copy by photostat or photograph.
I~0l7~~R-7 ~t~~}•~n
ree ror mjs cemncai~e, ~o.u~ - ~ - ~ -- f ~f I I j • c( This is to certify that the information here given i
correctly copied from an original Certificate of Deat
~~RK (~~ duly filed with me as Local Registrar. The origin-
~~~'S ~~~~ certificate will be forwarded to the State Vita
C(.~l'~F~(, ~r~~ ~~~ ~~ Records Office for permanent filing.
P 18227035 '~~, ~ ~
Certification Number I Local Registrar Date issued
Type/Print In I COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
Permanent
Black ink CERTIFICATE OF DEATH 9bt Fil N ,>..
1. DeudMt's Lfgal Name (First, M ddle, fart, Suffix) 2. Sax 3. Seclal SfcuHty Number ! 4. Date of Death (MO/Day/Yr) (Spell Mo)
Michael D. Fritz Male 177-42-2125 January 19, 2012
Sa. Ap-Last Birthday (Yrs) Sb. Un er 1 Year Sc. Under 1 Da 6. Date of BIRh (MO/Dw/1'ear) (Spell Month) 7a. BlKhpleu (City end State or Forolgn Country)
57 Mon ha Dws Hours Minutes A
t 2
1954
ugua
,
7b. BlRhplacf (County) Cumberland
Sa. Residence (State or Foreign Co eery) 8b. Residence (Stroet and NumWr -Include Apt No.) ge. Dld Decedent Livf In a Township?
PA 76 Cherry Lane ®Y.a, dfc.afnt Ilvfd In ~1ldd leaex twp.
sd. R.ald.nc. (County)
Cumberland ~ 8!. Residence (Zip Code) 17015 QNO, dfcedfnt Ilvfd within limits of city/barn.
9. Ever in US Armed Forces? 10. Marital Status at Tlme of Death Married Widowed 11. Surviving Spouse's Name (If wife, give name prier to first marNap)
Q Yes ®No Q Unknown ®Divoreed Q Never MarrNd' Q Unknow
12. Father's Name (First, Middle, st, Sufflz) 13. Mother's Name Prior to First Mlarrlage (First, Middle, Last)
Glenn D. Fritz Doris Shearer
14a. Informant's Name I 14b. Relationship to Decedent 14c. Informant's Malling.Address IStrelT and Number, Clty, State, 21p Code?
Doris Fritz Mother 76 Cherr Lane Carlisle PA 17015
~
...................................................
H Death Oocurrfd In a Hoaplfal: ...... .. ..~e.~......~?.......~-.o~.yon. ..............................Py
..... .....-....-....... _ asa,~~
....................
}~ Inpatient }If Duth Occurred Somlwhlre Other Than a Hospital: y Mospie~ F~elllty ~ ~~~~~~~~~~~~d1•~Dlc~Aen!'s Home
~ Emerge Room/Outpa<i!n Dud on Arrlvel Nursin Home/LOn -Term Gro Faculty Other (S fee )
35b. Facility Nama (H not InseNUtlo , give strut and number; SSC. City or Town, Sbte, and 21p Cede 3Sd. County of Duth
~ 76 Cherr Lane Carlisle PA 17015 Cumberland
16a. Method of Disposition Burial Cremation 16b. Date o/ Disposition i6c. Place o/ DlsposRlon (Name of Cemetery, crematory, or other plan)
Q Removal }rom Stets
Other (SpeeNy) Q Donation /~ ~ ~O ~
~ Cremation Soc ie t;y of PA
16d. Loeetlon of Disposition (City o Town, State, and 21p) 17e. Sign Ore o1 Funeral Servlee Uc u or Py} n In Charge of Inbrmfnt 17b. Uunse Number
Harrisburg, PA 1710 J`ef~'~ _ ~ ~'' ~ -~ FD 138312
17c. Name ana complete Atldross f Funeral Facility Auer Crematio Services of Pannayivania, Zne.
r~ 18. Deeltllnt's Education -Check [ !box that bast describe tM 19. Decedent of Hispanic Orlgln - CMCk the 20. Decedent's Rae! -Chick ONE OR MORE races to indicate what
highest tlegref or Iwel of school c mplated at the Hm! of tlaath, box that Wst descrlbfs whither the decadent the decedent considered himself or herself to be.
Q 8th grade or less Is Spanish/Hispanic/Latino. Check Ma "NO" ~ Whhe Q Korean
® No diploma, 9th - 12th Lrode box If decetllnt Is not Spanish/Hispanle/Letino. Q Black or African American Q Vietnamese
Q High school gfaduata or GED ompleted ®No, not Spanish/Hlapenic/Latlno Q American Indian or Alaska Native Q Other Asian
Q some collegf credit, but nod grea Q Yfs, Mexican, Mexican American, Chicano Q Asian Indian Q Natlw Hawallan
Q AssociKe degroa (e.g. AA, AS Q Yes, Puerto Rlun Q Chinfsf Q Guamanian or Chamorro
Q Hachelor's degree (e.g. BA, A BS) Q ye, Cuban Q FIIIPino Q Samoan
Q Master's dagroe (e.g. MA, M MEn4 MEd, MSW, MBA) Q Vas, ether Spanish/Hlspenit/Latlne Q Japanel.a Q Other PleHic Islander
Q Doctorate (e.j. PhD, EdD) or rofesslonal degree (Specify) Q Other (!ipecl
fv)
. MO DDS OVM LLB D
21. Deudent's Single Rau Self-Of Ignatlon -Check ONLY ONE to indlub what the tlecedant considered himself or herself to be. 22a. Daudent's Usual Occupation - Intllcab type of work
® Whi[f Q japanee Q Samoan done during most o7 working Ilfe. DO NOT USE RETIRED.
Q BIltk or African American I Q Korean Q Other PacMc Islander
Q American Indian or Alaska N• rtlve Q Viftnamis! Q Don't Know/Not Sure LayanC are
Q Asian Indian Q Other Asian Q Refused 22b. Kind of Business/Industry
Q Chinese Q Native Hawallan Q Other (Specify)
Q Filipino Q Guamanian or Chamorro Sel£ Emp lOyed
IT[ - M B! P
BY PERSON WNO PRONOUNCES D 23a. Dab Pronounc Dfa Mo Day r 3 gnKUro Penes Pronouncing Daet n y w !n app lu • 23c. Ucense Number
R
QRTIFIg4 DEATH ) / a~~aZ
V
G-~AC'J [
S U / 3 2
{
23d. D to Signetl (MO/Dfy/Yr) 24. Time of Death
l Q ~ _
C lC r i pia ~
~
1 ~2. j ;~ ~ L ,
/ - . !'~ . 25. Wfs Medlin Examiner or CoroMr Gontacted7 ye Q No
CAUSE OF DEATH Approximate
~
26 Part 1. Enter the -dlsfases, injuries, or cemplicatlons-that tllrectly caused tM duth. DO NOT enbr terminal vents such as cardiac arrest
Interval:
respiratory arrest, or ventrl ulcer flbrillatlon without showing the etiology. DO NOT ABBREVIATE. Enter only onf cause on a Ilnf. Adtl additional Ilnes If neussary ~ Onset to Death
IMMEDIATE CAUSE -------------
' r ~ ~ 17 '
> a. '
(Final disease or condition I Due to ( s s cons quence of):
i
rosulting In death) `
Segwntieily Ilst conditions. Du! to Ior es a c s quenu oT):
~
if anY. Ifading to the cause I ~[
Ilstetl on line a. Enter the j ~
~~`
T
UNDERLYING CAUSE
~ Dua to (or es a consequent! of):
[
(disuse or Injury that L /•
Initiated the events resulting ', d. /~ U (- t'L / ( [ ~J ,[, /~ r /~~
in duth) LAST. ~ pu! to (or as a consequence o•): '
~ 26. PaR 11. Enter other but not roauking In the underlying cause given In Part 1 27. Wea en autepry pert edi
aa i Y!s o
I 2B. Were autePSy findings available
S ~ to complfb the uusf of tllKh7
Yes No
29. If Ffmale: 30. Did Tobacco Use Contribute to Duth7 31. Manner of Death
Q Not prognant within past e t
a Q Yes Q Probably atural Q Homicide
Q prognant at time of death Q No Unknown Accident Q Pending Investigation
~' Q Not pregnant, but progna t within 42 days of death Q Sulclde Q Could rest W determined
Q Not pregnant, but pregna t 43 days to ]year blforo dealt 32. Date of Injury (MO/Day/Yr) (Spill Month)
~ Vnknown H Prunenx with n the Past ear 33. Time of Injury
34. Place of Injury (e.g. home; con traction site; Tarm; school) 35. Location of Injury (SLroK antl Number, Clty, State, Zip Gotle)
36. Injury at Work 37.1 Tronf ortatlon Injury, SpeeHy: 38. Describe How In)ury Occurcfd:
Q Ves Q Driver/ perotor Q Pedestrian
Q No Q Peseng r Q Other (SPecity)
39a. GRlfler (Check only one):
GRlfying physician - To the est of my knowledge, duth occurrod due to the cause(s) and manner seated
Pronouncing a GrtHying ph
w
slclan - To the best of my kno ledge, death occurred at the time, date, and place, and tlue to the cause(s) and manner stated
Q Medial Examiner/Coroner - n tM basis U
r Investigation, in my opinion, death occurred at the time, dab, and place, and des to the cause(s) and manner stated
Signature o1 urtlfler: ~ !+ THIe of urtlfler:~'? License Number: USG (T Z ~_
39b. Name, Address and 21p Code f P Completing G f Death (Item 26) 39c. Date Signftl (MO/Day/Yr)
L ~...~N~cc. ?.» t.. .. ~%Ya.LO.-ter S~ C~v .J /.D 1-~- ~d~~
/ z - iz
40. Regirtror s District Num er 41. Reg stror s Slgrvt r! 4 . Reg rtrar to Mo Day r
f
e
0?07- C~ - - s - 2 0 . z
e
r -
43. Amendments I
' /\j_ /} ~ 1 C ~ H105-143
' DlsposlHOn Parmlt No. C1llJ `~ 04 J REV 07/2011