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Home My WebLink About02-24-12Reset PETITION JFOR GRANT OF LETTERS REGISTER OF WILLS OF Cvt~s~t b,~~~~ COUNTY, 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 Information Name: ~o~D~-'tF' A ~ia(.~~nn~1-- File No• c~ ~ - `;~ ~ a~~~ a/1c/a: . (Assigned by Register) a/k/a: a/k/a: Social Security No: Z / O - Y ~ - 6 ~ 7j,Sr Date of Death: L '~ l ?~- Age at death: O Decedent was domiciled at death in County, P~ (ware) with his/her last principal residence at Z O ~ r- a~. ~~ Street address, Post Office and Zip Code City, Township or Borough my Decedent died at ZQ 3~ Go.,1ct } uflr~- .~ 1~~, rp ~~, ~,~, ~ >~ Street address, Post Office and Zip Code ~r City, Township or orough County State Estimate of value of decedent's property at death: If domiciled in Pennsylvania ............................ All personal property $ j^ ., Q OQ If not domiciled in Pennsylvanut ........................ Personal property in Pennsylvania $--' If not domiciled in Pennsylvania ........................ Personal property in County $ Value of real estate in Pennsylvania ......................................................... $ _ p 'TOTAL ESTIMATED VALUE.... $~ e-- Real estate in Pennsylvania situated at: Zq 30 ~rGO.~a.. 1~.Q ~~- ~~~~ CL~iQ~~~ (Attach additional sheets, if necessary.) Street address, Post Office and Zip Code City, Township or Borough ~unty A. Petition for Probate and Grant of Letters Testamentary ~ ~ ~~"rr'~~" ~i~ Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated ~ ~ C7 and ~5piticil(s~;; ~ j thereto dated ~ fU - , ;, ;.. ~ ~„ j. ~' ~ 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, w s >~ a party t~endi~~'.~ r~ divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(g), and di~ot~ave a chihi born bra adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. N~ ~.J o NO EXCEPTIONS 0 EXCEPTIONS B. Petition for Grant of Letters of Administration (If applicable) c. t. a., d. b. n., d. b. n. c. t. a., pendente life, durante absentia, durante minoritate If Administration, c.t.a. or d.b.n.c.l~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. NO EXCEPTIONS Q 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, if necessary): N a me Relationshi Add r ess / ~ ~ / / -J"'F Eir?'- `~ a-~A Ur L,ti ~ ~ A j ~ ~ l Z'~ ?l' O ./YTC4.~R a'~!d' ~i' a-a t C s E n / /~C ~wr ~ l'a Nt' ~tl~ . ~ SG ~ ~~ ,~~6y Form RW-02 rev. 10/11/201 ! Page 1 of 2 ~~ ~~-- ~~ Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA } } SS: } COUNTY OF Get; ,~. ;,,,~ ~ ~,, ~i~i2 ~ ~ B 24 F'~~ 3~ ~'8 Petitioner(s) P 'nted Name Petitioner(s) Printed A 1V~ ~~a ~ Z o ~-r .~4. RQ/ . `~ aE~ ~ _s- The Petitioner(s) above-named sweaz(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 Petiti a 'll well and truly administer the estate according to la~w~ ~ 9 Sworn to or affirmed and subscribed before Date -~~~i, v «- me t ~ day of ~ "' ~~ Date BY ~ Date or the Register Date BOND Required: Q YES ~NO FEES: Letters ...................... $ ( 15) Short Certificate(s)..... . ( )Renunciation(s)......... ( )Codicil(s) ............ . ( )Affidavit(s)........... . Bond ........................ Commission ................. . Other Automation Fee ............... c~"~S• JCS Fee . .................... -`~~ TOTAL ..................... $ - 00.00 To the Register of Wills: Please enter my appearance by my signature below: Attorney Signature: Printed Name: ~ ~ l ~ [ st„r., f! ~- Supreme Court ~ d g ~ u ID Number: 7 7 Firm Name: Address: yQ Y ~VpK9 c J-~' _ _~}QJ~T[ S v ~, f 7 f O Phone: ~~ 7 - 6 S ~ ' 8 Fax: TI ? ~iG 7 3 z1 Y '3 Email: _ DECREE OF THE REGISTER Estate of ~~~ ~ .~ a . ~1C~1 ~1'' File No: ,~ ~ -~ a - r~~'~ a/k/a: AND NOW, ~. ~ iZ C~..t~-1 ~ C%[ ~ (~ , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters~- ~ CI V~ 1 c'1 ! ~ {~ C,t are hereby granted to ~~ ~~ ~ i~ ~ q ~ ~,, i7( ~ 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. egister of Wills Form RW-01 rev. 10/!1/20/! Page 2 of 2 LO~tArC?~~O~AR'S CERTIFICATION OF DEATH WAI~ ~ is~il,l~~~ to duplicate this copy by photostat or photograph. r Y =rl~~? ~ ~ 2~i Fee for this certificate, $6.00 P ~~ 3' ~$ This is to certifti~ th~(t the informatic)n here given is correctly copied from an original Certificate of Death ~~~~ ~~ duly filed with me a~ Local Registrar. "the original certificate will he for~~~arded to ~:he State Vital ORPHAN S CQI;RT j ~ ~,~ P~ R.ecords Office for perrnancnt filing. CUMRFRI_ ~)~l~, , 1 ~ ~ 6 0 5 81 ~~m__ 1' ~ a.~ F~2 2~0~2 Certification Number Type/Print In Permanent Black ink O Sao 2 Local Registrar ~~~' .Date [ssaed COMMONWEALTH OF PENNSV LVANIA ~ DEPARTMENT OF HEALTH _ VITAL RECORDS CERTIFICATE OF DEATH 1. Decedent's Legal Name (Firs[, Middl<, Last, Suffix) 2. Sex 3. Social Security Number 4. Dale of Death (MO/Day/Vr) (6pe11 Mo) Robert A_ Adler Malmo 210 - 44 - 6935 Februar 20, 2012 Sa. Age-Last Birthday (Vrs) Sb. Under 1 Vear Sc. Under 1 Da 6. Date of Birth (MO/Day/Vear) [Spell Month) 7a. Birthplace (City and State or Foreign Country) Months Days Hours Minutes Harrisbur PA 50 December 29 , 1961 7b. Birthplace (County) Dau hin Ba. Residence (State or Foreign Country) 8b. Residence (Street and Number -Include Apt No.) 8c. Did Decedent Ltye In a TownshlpT Penns lvania ®Ves, decedent lived in Upper A11en ty,p. Stl. Residence (County) 2930 Arcona Road Cumberland Be. Residence (Zip Code) rJ ONO, decedent Ilyed within limits of city/born. 9. Ever In US Armed ForcesT 30. Marital Status at Tlme of Death ®Married ~ Widowed 11. 6urvlving Spous<'s Name (If wif<, give name prior to first marriage) ~ Yes ~ No Q Unknown ~ Divorced ~ Neve r Married Q Unknow Nataliia T khonova 12. Father's Name (FITS[, Middle, Last, Suffix) 13. Mo[Mer's Name Prior to First Marriage (First, Middle, Last) Stanle D. Adler Jr. Bett Jean Reiber 14a. Informant's Name 14b. Relationship to Decedent 14c. Informant's Malling Address (Street and Number, City, Sta[<, Zip Code? Nataliia Adler Wife 2930 Arcona Road, Mechanicsbur , PA 17055 ................. ......_.. .5a. P ace p Deat ~ qr.r. o~~ .. ~~ ~ s If Death Occurred In a Hos ital: In p patient p ~~~ ~~~~~~~~~~~~~~-~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~-~~~~~~~-~~~~~~~~~~ If Death Occurred Somewhere Other Than a Hospital: `[~` ~HOSpice Facility ~ Decedent's Home Emergency Room/OUtpatlent Q Dead on Arrival • Q Nursing Home/Long-Term Care Facility Other (Specify) 16b. Facility Name (If not Institution, give street and number, i5c. City or Town, State, and Zip Code 15d. County of Death 2930 Arcona Road Mechanicsbur PA 17055 Cumberland 16a. Method of Disposition 0 Burial ~ Cremation 16b. Date of Dlspositlon 16c. lace of Disposition (Name pf cemetery, crematory, or other place) $ '€ p Removal from State p Opnatlpn Other (Specify) Februar,~rV 21 , Evans Crematory 2 Q 1 L Z 16d. Location of Disposition (City or Town, State, and Zip) 17a. 6lgnaf ure of Funeral Service n r Person In Charge of Interment 17b. License Number Schaefferatown, PA 17088 ~, FD 013 340 L 17c. Name and Complete Address of Funeral Facility ' Parthemore FH & CS, Inc., P.O. Box 431 New C mberland PA 17070 ~ 18. Decedent's Education -Check [he box that best tlescribes She 19. Decedent of Hispanic Origin -Check the 20. Decedent's Race -Check ONE OR MORE races to indicate what ~- highest degree or level of school completed at the tim¢ of death. box chat best describes whether the decedent the decedent considered hfmself or herself to be. ~ B[h grade or less is Spanish/Hlspa nlc/Latino. Check the "NO" ~ White ~ Korean ~ No diploma, 9th - 12th gratle box if decedent is not Spanish/Hispanic/Latino. Q Black or African American ~ Vietnamese Q High school graduate or GED completed m No, not Spanish/Hispanic/Latino 0 American Indian or Alaska Native ~ Other Asian Q home college credit, but no degree (] Ves, Mexican, Mexican American, Chlca no Q Asian Indian ~ Natiye Hawaiian ~ASSOCiate degree (e.g. AA, AS) O Yes, Puerto Rican Q Chinese Q Guamanian or Chamorro ~ Bachelor's degree (e.g. BA, AB, BS) Q Yes, Cuban 0 Filipino ~ Samoan ~ Master's degree (e.g. MA, M6, MEng, MEd, M6W, MBA) ~ Ves, other Spanish/Hispanic/Latino Q Japanese Q Other Pacific Islander 0 Doctorate (e.g. PhD, EdD) or Professional tlagree (Spe<Ify) ~ Other 5 ( pacify) . MD DDS DVM LLB JD 21. Decedent's Single Race Self-Designation -Check ONLY ONE to In dicate whet the decedent considered himself or herself to be. 22a. DecedenT's Usual Occupation -Indicate type of work Q White ~ Japanese ~ Samoan done during most of working Ilfe. DO NOT USE RETIRED. ~ Black or African American Q Korean Q Other Pacific Islander Q Am<rlCan Indian or Alaska Natiye Q Vletna mesa Realtor 0 Don't Know/Not Sure ~ Asian Intllan ~ Other Asian ~ Refused 22 b. Kind of Business/Industry 0 Chinese ~ Natiye Hawaiian Q Other (Specify) ~ Filipino 0 Guamanian or Chamorro Re81 EBt HtE: ITEMS 23a - 23d MUST BE COMPLETED 23a. Date Pronounced Dead Mo Day 236. Signature o Person Pronouncing Death (Only w en applicable) 23c. License Number BV PERSON WHO PRONOUNCES OR CERTIFIES DEATH Fe.bruury '20 "LUl'L 23d. Date Signed (MO/Day/Vr) 24. Time of Death CL.,YY\ 25. Was Medical Examiner or Coroner Contacted? Ves Q No CAUSE OF DEATH Approximate 26. Part I. Enter the Chain of events--diseases, Injuries, or compli cations--that directly caused the death. DO NOT enter terminal events such as cartliac wrest Interval: - respiratory arrest, or ventricular flbrlllatlon without showing the etiplogy. DO NOT ABBREVIATE. Enter only one cause on a Ilne. Add additional lines if necessary Onset to Death IMMEDIATE CAUSE -- > a. Prvbiahlr_ Nt . Z (Final disease o nditlon Due to (o as a consequence of): resulting In death) b. Corrxinrv Ar ~'G~ T~1Se!'i«- Sequentlally Ilst condiYlons, Du~to (or as a consequence ofJ: if any, leading to the cause listed on line a. Enter the V NDERLVING CAUSE Due to (or as a consequence of): (disease or injurythat F initiated the events resulting d. ~ in death) LAST. Due to (o as a consequence of): 26. Part 11. Enter other nific n Iti n ri t d h but not result(ng In the underlying cause given In Part I 27. Was an autopsy performed? O Ves ~ No 28. Were autopsy findings ayallabl¢ o co t plate the cause of deathT o Y<s Q No 29. If Female: 30. Did Tobacco Use Contribute to DeathT 31. Manner of Death c ~ Not pregnant within past year 0 Ves ~ Probably ~ Natural 0 Homicide ' 0 Pregnant at Um< of death 0 No ~ Unknown ~ Accident 0 Pending Investigation ~ ~ No[ pregnant, but pregnant within 42 days of death ~ Suicide ~ Coultl not be determined t- ~ Not pregnant, but pregnant 43 days to 1 year before death 32. Date of In Mo/Da Jury ( y/Vr) (Spell Month) ~ Vnknown If pregnant within the past year 33. Time of injury 34. Plac¢ of Injury (e.g. home; construction site; farm; school) 35. Location of Injury (Street and Number, City, State, Zip Code) 36. Injury at Work 37. If TransportaCign Injury, Specify: 38. Describe How Injury Occurred: Q Ves ~ Driver/Operator Q Pedestrian 0 No 0 Passenger ~ Other (Specify) 39a. Certifier (Check only on<): ~ Certifying physician - To the best of my knowledge, death o red due to the c se(s) and m stated ~ Pronouncing Ba Certifying physician - To the best of my knowledge, death occurred at the time, date, and plac<, and due to the cause(s) and manner stated Medical Examiner/Coroner - On th sis of examination, an or Investigation, in my opinion, death occurred at the tim<, date, and place, and due to the cause(s) an er¢d Signature of certifier: ~ Title of certifier: U License Numbe 39b_. jJ ae m~ ddress an Zip C de of P< .G~ p~ng Causo of / ` h (Ite~)~~ ~ ~ ~ I ST S 39c. Date new (~ o/D rl ' v ice f C.ia- Q/4 ~ , O l ~ Q[ 40. Registrar's District Number 41. Registrars 5~ 42. Regis[r r Flle Dat< (MO Day r ~ ~-a i ~ ~~~/ v/.z 43. Amentlments Disposition Permit No.OLat7O (J~'1 Z H 105-143 REV 07/2011 J