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HomeMy WebLinkAbout02-21-12t' - ~ t ,Iw `- ~I. 'o '' •'. ~ -1 PETITION FOR GRANT OFiI~.~~~~$ ~~ ~ R ~ ~ ~ ,. REGISTER OF WILLS OF __ wyrl l-j r r ~~ ,~~~ COUNTY, PEIv~1SYLVANIA CLARK ~J~ , r Petitioner(sj named below, who is; are 18 years of aae or older, appl~'•~~t~~s~&pecified below, and in support thereof aver(s) the following and respecttlt?ly request(s) the grani~~~X~ th '~ppropnate form: Decedent's Information Name: _ of ('~ ~ ~ ~i[~ /t a/k/a: a/k/a: alkla: Date of Death: O V P tm 6~ t r 3 __~_Q~-f Decedent was domiciled at death in principal residence at 1 ~ ~ ~ Street address, Post Office and Zip Code Decedent died at 1 ~ ~ 1n/,o ~~ s ~I'i /~ l~`) 2 Street address, Post Office and Zip Code Estimate of value of decedent's property at death File No: ~ ~~~ - ~j~c~5 (Assigned by Register) Social Security No: ~ 7~. ~ d ~ - g ~' 7y% Age at death: q 7 County, ~~P~i r~; .f ~~ r~ tQ . (stare) with his/her last --T _~ t? ~h a~Ls ~ bvr-g C' v r->^, b e. ~•-l G,~ ~ City, Township or City, Township or County County State Ijdonriciled in Pennsylvania ............................ All personal property $ , ~ 7 3 !f not domiciled in Pennsy!vania ........................ Personal property in Pennsylvania $ If not domiciled in Pennsy/nania ........................ Personal property in County $ Value of real estate in Pennsylvania ......................................................... $ Q TOTAL ESTIMATED VALUE.... $_ ~ 7 Real estate in Pennsylvania situated at: (Attach additional sheets, if necessary.) Street address, Post Orrice and Zip Code City, Township or Borough ^ 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 W i11 of the Decedent, dated thereto dated County and Codicil(s) State relevant circumstances (eg. 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 itt 23 Pa. C.S. § 3323(g), 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.t:., d.b.n.c.t.u., pendentelite, durante absentia, 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 Petitioner(s), after a proper search has/have ascertained that Decedent lefr no W ill and was survived by the following spouse (if any) and heirs (attach additional sheets, if necessary): Name Relationshi Address C ©r~s ~~l n c e ~. ~ ~/ ~~ / h - 35 f'~trle ve ..___ ~~ rn~ ~ 0 h ~ v" W v ~ ~' h !o r. ,~ ~ sc~ l 3L? '~ Fnrm RW-02 ,~~~, tnitv2nlt Page I of 2 ~i a[;~_i'~I~ Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA } c~~t e ~ JJ } SS: COUNTY OF ~ at"(~ } 2~12~EB2! A~i~i~ 4~ 'na Petitioner(s) Printed Name Petitioner(s) Printe C r-5~{' r1 ~ ~ . E 35 ~'ar~e V~ ~ m pZi3o The Fel:itioe~tr(s) ai~d'Y~F-named swears) or affirm(s) the statements in the foregoing Petition are true and corcect to the best of the knowledge and belief of Petitioner(s) and that; s€~Persanal Representative(s) ofthe Decedent, the Petitioner(s) will well and truly administer the estate according to law. Swart! tQ,tar affr~ni~i~ attd subscribed before Date _ me ~ AA day of r ~, Date o2 02 ~, By~ K,. . ~ .Q` _ Date ° Date For the ltegiKer~ ~ - BOND Required: Q YES ~ NO To the Register of Wills: FEES: Please enter my appearance by my signature below: Letters ...................... S ( )Short Certificate(s)..... . ( )Renunciation(s)........ . ( )Codicil(s) ............ . ( )Affidavit(s)........... . Bond ........................ Commission ................. . Other ...... Automation Fee .............. . JCS Fee.......... ....... . TOTAL ..................... $~~ Attorney Signature: Printed Name: Supreme Court ID Number: Firm Name: Address: Phone: Fax: Email: DECREE OF THE REGISTER Estate of File No: ~?~ - ~,~ - ~o~a a/k/a: AND NOW, , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters are hereby granted to in the above estate and (if applicable). that the instrttment(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 ~~ Form RW-~2 rev. ln~uiznu Page 2 of 2 H105.905 RF.V.(A/ll) This is to certify that this is a true copy of the record which is on file in the Pennsylvania Department of Health, in accordance with the Vital Statistics Law of 1953, as amended. r. r+,~, _~~~I~legal to duplicate this copy by photostat or photograph. ~~~2 ~EE3 2 i A~i I 1 ~ 12 `YY~°'^^^^~ o•l~-~`s~'-w~- Marina O'Reilly Matthew C~K ~~ State Registrar ~,}aRPHAN'S COURj No. Date ,_ H10b143 REV 1120D6 COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OP HEALTH • VITAL RECORDS 109333 ~ TYPErPRINrIN CERTIFICATE OF DEATH PERMANEHr 111A(g( lNlc (See instructions and eXample8 on reverse) STATF FILF NtIMRFR 0 i 0 U O 0 1. Name d Decedent (Prat, nidde, last, sdfa) 2. Sex 3. Sodel SaaaiVy Nmr6a d. Dale d OaaN (IAaM, dry, Year) Mary B, Egan Female 172 -01 - 8874 Nov 3 2011 5. Age (Last Bir6day) Under 1 Under 7 6. Dde d BiM Mmlh, de , 7. ' and state a 6a Place of Dedh Check one Mmme payc Hwa Mrm1m HospilaY: Other: 97 Yrs, Dec 28, 1913 Enola, Pa ^tnpa0ed ^ERralpetient ^DOA ^warskrgHoma}~flas~e ^omm~spemYy ' Bh. Camq d Death &. City, lyao, Twp. d Death fid Pacify Name (6 not iradhrkm, ghe sired and nrn6er) 9. Was Decedent d Hapadc Orlph? ~No ^ Yes 10. Race: Arrarican hdan, &ed4 WIYN, ek • (g Yss~ aP~?Y ~, (i Cumberland Mechanicsburg 199 Woods Dr, Mech, Pa "'~n~~"°~'n~~~) ii. Decedatrs Us>td tim daakd one most d is Da rotstete 12 Wes Decedatd ever n the 13. Decedent's Edcadm (Spedly artly highest grade cemp kted) 14. Merkel SmNa: Meded, Never Marred, 15. Surviving Spo use QI vde, yAe maden came) KnddWork ICeddt3usnesslhtdstly U.S. Armed Fmsrs? Ekmterlary I Secardary (a12) Cogege 174 a 5r•) Wdor•d Oivaced () ^ Yea f3CNa Widow - 16. Decedinpa Meng Address (Bheet, dty/bwn, elate, zip code) Decedmrs ~ Dd Da«a3wmtd Pennsvlvania I.iveeta ,Tc.~Yea,tkoadadlrved'n S; 1vPr G~nr_.j,ly~ Twp. Acttalliesidence,re.slaY 199 Woods Drive , Cumberland T°""~'tp~ 7rd.^NO,I7ecederaLivedwitlln 77b. cmmy Acflroltiutiad CltylNaa 16. FaOrers Name (Pest midde, lest, suia) 19. Motlats Nmre (First rddde, mddm sumeme) Samuel R, Bitner So hie Gra bill 20a. ldamartys Noma (Type r PdnQ 20h. Wamed'a Meig Address (shad, dN / bnn, stele, z4 ~) Noel Eqan 199 Woods Dr., Mechanicsburg, Pa 17055 2taMetlioddDbpOSiOm i ^Cremegm ^Dalekm 21h.Datedl7ispoaidonlModh,dey,Yam) 21c.PlacedD~eltlm(Nernedcemdery,aanebryaotlrerplace) 27dLaWion(Cityltawn,slde,zpcode! Btdal ^ gemovalhom5lere ~ ~~ w Nov 8, 2011 Rolling Green Mem Park Camp Hill Pa ^ ~ ^ Yes^ ~ co . , savioe Liwaee grim ~ as suds) ~ 2?a. F 72h. Lareree Nuriber 22c. Name end Addess d FeoNty Sul 1 i va n Fune r a 1 Home - ~ FD011 7- Campkle 23at ady when certitying 23a To tM bestd ,d~Ih artared el Metkre,da0e andplaoa sided. )Sigrekee andftle) Z'Yv. license llmter 23c. Date silted (F1odh, dry, Year) ghysic®n a rpt eveteNe at Yre d deatl~ b ~ /, J rJ ~ ~ L ~j 3 aedrywweeddeaii. ~ ~~ j hens 2426 mat be mrtplded by person 24. Tore d Death 25. Date Piaeaaed Dead (klmlh, day, year) 26. Was Case Adored b Medical Examner I Cornier br a Reasm Otlrer Men Gertetim a Daedm? ~ Pmnaaces d~ ~ L M. ~ i '~~ ^ Yes No CAUSE OF DEATH (See inatructlorra and exarrplea) ~ Agprodmde i~Nat Pad II: Err dher ' 26. Did Tobacco Use Cadrbub b Dedh? Item 27. Pad I: FNa the T~B.PL9~- dam, iqudes, a cos4RCetims - tlet dredly weed Me dmlh. DO NOT eder familial everts such as urerdec areal, ~ Onset b Death but not resu0kig n the uMedyirg cause given m Pad I. ^ Ves ^ PmbaNy respkeNryemesLavEddaYrtdmis6mw11au1slwxi~gPz~obg/.lslMymeausem~gne. i i ^ ~ ^ U MNEDUIE CAUSE IFmel daease a yy~~ r " 29. N Female: reMimresd rign ) _~ a. V I'i i erdwitlrkr ssl eaz r ^ Nd Due to (a ss a omsequanae ~, r i p eg y P ^ Pregnard ar Wne d death rmi wrerPoms, d any, b. ^ to was I~ m pre a r Nd pregenL W pregent vrilhki 42 days Frder INlDERLYIhIG CAUBE Due fo )a as a caaeWencs oQ: ~ d death (dense a kMaY tlret hiahd tle ~ °' d 43 da s Po 1 b ^ N t i events reaAting m deaN) LAS,. y yw u pregna d pagrent Due d (a es a consequence ~: i bakre death • d ~ ^ Unlmown g pregred vddkn Oe past Year 30a. Wes an Aulapsy 30b. Were Aubpry Fmdngs 31. Ayp~r d Oealh 32a. Dale d hpey psodh, day, Y~V 3ffi. DesaAe Huv Ir~ury Ocarted 3a. Place d Njay: Home, Farm, Sheet, Faday, Pafamed? Availada Prior b Cmpledon d Cause d Death? J ^ Naheel ^ Flomidde Ogwe Bueding, ale. (Spedty) ~'I~ ^ Yes ^ Yes ~ ^ Accidml ^ Pendng YwesOgadm 32d Tore d MIaY 32e. IrNay at Wok? 321.0 Tretepoda0m Inryry /Specify) ^ ^ ^ 32g. Locedm of injury (Street, city I bnn, stale `Y'om ^ S icide ^ Chud Nd b Dak med ^ Yas ^ No Passenger Pedestrian DrivalOperator u a m M. ^ Olher.6peaay: 33a. Ced6er ( only me) ~ / • CediYisiPMskws l~Nsr~ce~gceuseddaarfi vden anodrer pfysicimtYespmnarted death and mnpleled aetu 231 ~ ~ ~ / ,~ %//' To d1e beet d my ImavvNd~ deNh oauned dne ro the araela) and manner os atddd _ "--' -- - ----' --- , _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ • Praaundng and artlly4g phyddm(Ftrydraan both orataecngd~aM cer9yingto waeddealh) Tode beetdmylmowkdge, death scarred at the ime,dme, end phce,erd due to the aueaa)end rromaae ahled______^____-___-__^ 33c. License Numhm ~ f1/J o/S7~fQ~ 33d Date (Maeh, dsY~Yssr) /• a(~~ • NedialEreldnerlCaoner On dre baslsdezmnhetbn arid/almeatlgetion, In my oplnbn, deaM occared at the 0me, tlak end plea, end due to the cause(s)end menreres ateted_ ^ 34, Name and Address of Persm Wlw Comgeled CauaedDealh p1em 21~Typel Pdnt cNnc ` •(" ' ' ~ ~ Cr ~v, 35. Pe~shafs end N 36. re Ftled (MaMh, fir, Y•ad W a ~ V Diapoai0m Pamit Na. C.Yo Y~u a - _ ~~E~~~~2~ ~~~1~ ~~ RENUNCIATION ~~ ~ ~ (Signature) REGISTER OF WILLS L~ ~l~d COUNTY, PENNSYLVANIA t~~-1a-c~a~-5 Estate of ~~ < ~~~~ ,Deceased I, ~ LY" ~ ~ ~ G- G~G~ rl , in my capacity/relationship as (Pant Name) ~;!~ fi~ of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to ~ ~ ~~ (Date) Executed in Register's Office Sworn to er affirmed and subscribed before me this r~ ~ day n r ~ I 1,- ~ ~i eputy for Register ills CLERK Cf ORPHLU`S CURT CIJ~.~Rf=~?~ /~~~~ ~C~.. PA. ~ 9 ~ ~~ ~ (Street Address) ~~~ !//(, 17b j b (City, State, Zip) Executed out of Register's Office Before the undersigned personally appeared the party executing this renunciation and certified that he or she executed the renunciation for the purposes stated within on this day of , Notary Public My Commission Expires: (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission.) Form RW-06 rev. 10.13.06