HomeMy WebLinkAbout03-22-12PETITION FOR G (RANT F LETTERS
REGISTER OF WILLS OF ~ V ~~'~ \ 2 -'L.~ 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 1:he appropriate form:
Decedent's Information ~ ~I i ~ ~ _ ~ ~~
Name: e- Lit ?~ ~ ~ NCLS SCsy`~- File No: (~
a/k/a: (Assigned by Register)
a/k/a:
a/k/a: Social Security No:
Date of Death: 1 l 4~ 2v r Z Age at death: ~
Decedent was domiciled at death in County, (scare) with his/her last
principal residence at ~3 Z c~u' ~'F~( ye=s' ~ G"/l~~~r' e~.~~.IgLC-~ rLl~7~L -~~
Street address, Post Office and Zip Code City, To~nship or Borough ~ County
Decedent died at ~ 3 Z Sam C C`f Cuti j ~~t ~ C ~1L.U S~C~~ ~/1?3 ~~-iU~ t~~-
Street address, Post Office and Zip Code City, Tow ship or Borough -~ County Sta~
Estimate of value of decedent's property at death:
If domiciled in Pennsy!vania ............................ All personal property $ 3 aO ~
If not domiciled in Pennsy!vania ........................ Personal property in Pennsylvania $
If not domiciled in Pennsy!vania ........................ Personal property in County $
Value of real estate in Pennsylvania ......................................................... $ °5
,~ ! TOTAL ESTCI~MATED VALUE.... $_~' G /IdYU p
Real estate in Pennsylvania situated at: Z 6 S~ N~ 2 ~(Y Srae~ Ff \ f.l~t( ~~ 2~i~-~y/C~. .~'~1/ ~'(j~
(Attach additional sheets, ijnecessary.) Street address, Post Office and Zip Code City~Township or Borough County
~ 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 Will of the Decedent, dated _ and Codicil(s)
thereto dated
State relevant circumstances (eg. renunciation, death of executor, e,tc.) ~ ~~
O ^' ~ ,~'i
Except as follows: after the execution of the instrument(s) offered for probate Decedent did not marry, was not divorce not a pa a pet~t~
divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(g), an stave a~itld bo~-p~
adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. - r~ N r ~- _~-=
NO EXCEPTIONS ^ EXCEPTIONS - ._.
.-'1 ii
B. Petition for Grant of Letters of Administration (If applicable) ~ ~ -r~t
c.t.u., d.b.n., d.b.n.e.t.a., pendente life, durante~setttia, dura a minor
If Administration, c.t.a. or d.b.n.c.Ga., enter date of Will in Section A above and complete list of heirs
Except as follows: Decedent was not a parry to a pending divorce proceeding wherein the grounds fiir 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 ~ 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):
Name Relationshi Address
0 R.. f /vim ~ L. ~Q ~.L+ ~I~'.V ~ (` ~ ~ Z l ` ~.71J ~~ 1~ tel. ~ `N~~1...~ S ~~ ~A'` l
.O ~ .~~
Form RW-02 rev. f0/!1/20!! Page 1 of 2 '`
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA }
`~ } SS:
COliNTY OF ~.V/~1~~7LL,~rl, (~l~~
Official Use Only
Petitioner(s) Printed Name Petitioner(s) Printed Address
~~,~,~~. ed ~~ ~3z , W ~.~ ST~.~ T C~L--sLL ~~ ~~~
The Petitioner(s) above-named swear(s) or affirm(s) the statements in the foregoing Petition are true and corrE:ct 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 to or af~f}rmed and subscribed before ~o~= ,~~ ~,,,, ,f~ ~~~ Lt Date~~l e,~~
met 's~~"day of Y ,~~/~- Date fft''.""~
BY~ '~ , ~1.~- _~ Date ~' ~?
Far the Register ate ~:
Z,. ;,:
m N - - C:~.
BOND Required: ~ YES ~ NO To the Register of Wi![s: ~ si -~--
/'• - .:
FEES: Please enter my app ranee by m sign ow: ^~
.._,;.y. _ ,,
Letters ...................... $-~~ Attorney Sig ture: .,~- ~ ;' ~'
(5 )Short Certificate(s)...... ~U _ ~ ~~ _
( )Renunciation(s).........
( )Codicil(s) .............
( )Affidavit(s)........... .
Bond ........................ Printed Name ~ ~ ~ • ~/~
Commission ................. Supreme Cou t _
Other ........ ID Number: ~11 ~[-~~ S
...... Firm Name: Gt-4~W ~{~' (CJL-~ a"(^' (~, yYQs7l~ W
........ Address: ~ ( ~I 1 C~ N 1 S ~ ~ `~ -'
........ t ~ Q d
........ Phone: r ~ O _
Automation Fee ............... ~ Fax: ~ ,
JCS Fee . .................... ~• 5 Email: ~, --
TOTAL ..................... $ .
DECREE OF THE REGISTER
Estate of ~ File No: ~- ~ ~ ~~
a/k/a:
AND NOW, 1, pf ./ , ~, in con i ration of a foregoing Petition,
satisfactory proof ha ing been presented before me, IT IS DECREED that Letters {,~~ ,n~r~ ~ p ~_
are hereby granted to
in the above estate and (if applicable) that
the instrument(s) dated
described in the Petition be admitted to probate and filed gf~t'~ord as the list Will (and C;o gills)) of Deceder}t.
1 1 • U~ ~//
Register of ill`~~ ~ ~QI ~~n` ^^, ~ J
Form RW-02 rev. 10/l1/2011 /y J/ ~~ Page 2 of 2
LOC ~~~~~~ ~~~ R'S CERTIFICATION OF DEATH
WAR ~J#N6r { .,.,: , ' iN+e~ t) bfduplicate~ this copy by photostat or photograph.
REG~.~ ~~ ~~~~- ~;i)~i~ r ,~
Fee for this certificaie, $6.00
P 1813.224
w012 ~R 22 Pali t~: 33
CLERK OF .:
aRP~Js coin
This is to certify that the information here given is
cgrrectly copied from an original Certificate of Death
duly filed with. me as Local Registrar. The original
certificate will be forwarded to the State Vital
Records Office for permanent filing.
/` c. ~~ ~z
Local ;egistra Date Issued
Certification Number
TV P./Print In
Permanent
Black Ink
~//
C /~XJ
V _
COMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF HEALTH ~ VITAL RECORDS
CERTIFICATE OF DEATH State Flia Number:
Decedent's LaEN Nama (First, la, Last, Suffix) Sax 3. Soelal Security NurnWr 4. ab of Death (M /Day/Yr) (Spell Mo)
1
.
LcN A oNC~~ Scarcr sBnwL I -22 - lrvg w ~ ~ o
or Foral{n Count )
1 :ca (City and a
Sa. AEa-Last Birthday (Yn) Sb. Under 1 Vaar Sc. Under 1 Da 6..Data of Birth (MO/Day ) (Spell Month) 7a. Birth
~
,=
~
~/1 Months OWS Houra Minutes ~
~~ ~
J 7b. BlKhpl.u (COUnLy)
Ba. IdanCe (Sbte or ForalEn Country) 8b. Residence (StraK an mbar -Include Apt No.) Be. Dld Decedent Llya In a Township?
~wj~l~s,~/~.~JIAI~+.~ ~ Vas, decadent (IVad In _ twP.
.~~5
-
8d. Rasidanu (County) ~
~
-
L ~7~C ~~ ~~
A•i2~'C SL
l-
b
Q"~./yQ '
city/
orn.
Ha. Rafidana (ZIP Coda) L]NSe. dautlant Ilwd within limits of
9. Ever In V9 A~ ~'~ rtes? SO. Mar ital Sbtus at Time o Death MaMad I owe 11. SurvNini Spou»'s Nama H wife, Elw name prior to flrrt marrlaq)
Q Yes [~Fo ~ Unknown ~ Dl vordd 0 Nwer Marrlad ~ V nknow
12. Father's Nama (Flrat, Middle, Vat, Suffix) 13. other's Nama Prlo to Flrrt Marrlaq (First, Middle, Last)
-..s w ~.~ ~.i ~..
14a. In}ormant'a Nama 14b. Ralatl hip to Dacedant 14c. In/or ant's Malll Address (StraK and Number, Clly, Sbt 21p Code)
one e,
-.~nn G ~.r~-a•a 3¢ . ass.- c ~ PA - > >
0
S
„C'i,
a ..... .............. ..--.-............... a. ace eat ac on one ............ -................................-.
........... .......... ............--... .............. ..........................................................Y....... ............ ~-~• .................-.--.......
H Death Occurred In a HospRal: ~ Inpatient It Death Occurred Somewhere Other Than a HospRal: ~ Hospice Facility 0/uec-adept's Homa
S Emar Room/OUt slant Deed on ArrlVal Nursin Homa/LOn -Term Can Facility O[har (SpacHy)
n
yy (1 not Ins~~tlon, We rtreK and number;
15 b. Faell ~
~ u W~.c~-` r. 14 City or Town, SbN, u~ 21p Coda 15d. County of Death
as~L~ YA . - o~ ~C~KBet¢.s~wcv
.
- 16a. Method of Disposition urlal CremKlon 6c. Place o1 Disposition (Nama of umabry, crematory, or Thar place)
166. Data of Dispositl n 1
~
, 0 Ramowl from Sbb O Donation 2
0~ . ~ ~Q\ 2
!'~ _ M
~
Other Gfy) a.>1S
~~~} ` S
v
~7~~
16d. Location of Disposition (City or Town, State, and 21p) 17a. atura o nsa or Parson In Chary;a M Interment 17b. Llunse Number
1 Nama and Com Ke rata of u 1 Facility
E}. SQL S..f~. '30`~ tJ. lJt' T. zc.~-~"EE.~N T'A- • ~I
~' 18. dent's Eduction -Check the box LhK bert daferib s tM 9. Daudant of Hispanic Or1Eln -Cheek th 20. Dacedant' Rau - Ch k ONE OR MORE taus to Indicate what
~ hiEhart daEraa or level of school compNbd at the time of death. box that bast describes whKhK the decedent the daudent considered himseH or hanaM to be.
p Bth Erade or less Is Spanish/Hispanic/Latlno. CMek tM "NO" Q W~l to ~ Korean
AmKlun ~ Vietnamese
lca
i
/L
H
6(
k
Af
I
S
i
h
Hi
span
no. [~
ac
or.
r
n
s not
pan
s
/
c
a
~ No diploma, 9th - 12th Erad• box I~~~Cadent
not 3panlsh/Hispanle/Latino O AmaAean Indian or Alaska NatWa 0 Other Asian
laNd ~No
m
t
GED
h
l
d
,
p
ua
a or
co
.~ H~{hm` e
oo
Era
but no da{tae ~ Yaf, Nlaxlean, Maxkan Amarlun, Chlono 0 Asian Indian O Native Hawaiian
~S toile{e credit
,
~ Affocieb dare! le.E. AA, AS) ~ Vas, Pwrte Rican ~ China» Q Guamanian or CFiamorro
~ Bachalor'a de[rae (a.E• BA, AB, BS) Q Yas, Cuban ~ FIIIPIno ~ Samoan
~ Masbr's daEraa (e.E- MA, M5, MEnE. MEd, MSW, MBA) 0 Yas. other Spanish/Hispanle/Latino _ O J.Panessl O Other Pacific Islander
~ Doetorab (a.i. PhD, Etl0) or Probsalonal daEraa (Specify) ~ Other (Specify)
. MD DDS DVM LLB 1D
21. Decedent's SlnEla Ran Self-DesiEnaHOn - CMek ONLY ON! to Indlub what Ma decedent considered him»If or her»M to be. :t2a. Oaudant's Usual Occupation - Indicate typo of work
~ W R! ~ Japana» Q Samoan done durlnE most of worklnE Ilfe. DO NOT USE RETIRED.
~ Korean Q Other Paelfle Islander
A
i
Cf
k
f
l
mer
can
ae
Or A
r
un
~
0 Amarlun Indian or Alaska NeHve ~ VlKnama» 0 Don't Know/Not Surf ~~g~-'~
Q Asian Indian Q OMer Asian ~ Rafu»d :[2b. Kind oT Bualness/Industry
Q China» ~ Natlw Hawaiian 0 Other (SPeelfy)
Q Filipino O Guamanian or Chamorro -~~-L..
ate Proneunu o Day SlEnature Persen ronoune nE D4K On y w en app ca 23c. can» Num er
a
sV P[FtSON WMO -RONOUNC[S OR
4aa l~ D1
cERnwes DEATH
23d. Dab SlEned (MO/Dey/Yr) 4 of Oaath
a
~ ./ a~7 25. Was Madlul Examiner or Coroner ContactedT ~ Yes
~
CAUSE OF DEATH
i Approximate
26. Part 1. EntK the chain of wants-dispsas, injuries, or eompllutlons-that directly eau»d the death. DO NOT enter brminal wants such as urdlac arrart, ) Interval:
O
t t
D
th
d
i
i
l Il
If
nse
o
ea
t
ona
nes
paces»ry
d
respiratory arrest, or ventricular fibrillation wwithou`t sh-owtlnE the KloloEY- DO NOT ABBREVIATE. Enter only one Ouse on a Tina. Add a
3 Z~~
~
~
~~IC r~Ct r.~
K Lli~
IMMEDIATE GVSE -----> /-(GI ~S PZ
(Final disea» or condition Oua to (or as a con»quanca on:
rosultlnE in death) )
b.
Sequantlally Ilst conditions, Dw Lo (or of a Con»quanu oT):
H any, IaadtnE to tM cause {
Iirted on Ilna •. Enbr the j
VNDERLYINB GVSE Due to (or as a consequence ot):
~ (di»a» or Injury Chat
~ Initiabd the wants rasultlnE d.
a
^
r <on
in death) LAST.. Oua to (or as a saquanu of): )
rrr
JJJ
26. PeK 11. Enter other but not rosultlnE In the underlylnE cause Elven in Part 1 27. Was an autopsy peAormed7
S Yas No
2B. Were autopsy flndlnES awllable
~' to wmplate [ha cause of death?
Yas No
•
29. If Fam~~a
[/Rot praEnant wllhin past war 30. Did Tobacee Use Centrlbuta to Deathi
~ Yas 0 Probably 31. Mannar o1 Death
~` Natural ~ Homicide
0 PreEnant at time of death 0 No ~~UnknoWn 0 Accident ~ PandlnE IrrvatHEatlon
~' 0 Not praEnant, but prainant within 42 days of death ~ Suicide 0 Could not ba determined
Q Not preEnent, but preEnant 43 days to 1 year before death 32. Date o} Injury (MO/Day/Yr) Spell Month)
Q Unknown if praEnant within the past year :l3. Time of Injury
34. Place of Injury (e.E. home; construction site; farm; school) 3S. Location of Injury (StreK and Number, Clty, State. Zip Code)
36. Injury at Work 37. If Transportatbn Injury, SpaeNy: 38. Describe How Injury Occurred:
Q Vas Q DrWer/OParator Q Pedestrian
Q No Q Passenpr ~ Other (Specify)
39a. C rtMter (Cheek only Dne):
rtHylnE physician - To the best of my knowladp, dgth otturrad due to the cause(s) and m r sbted
0 PronounelnE ~ CertlfylnE physician - To the bast of my knewladN, tlaath occurred a[ the time, dab, and plan, and due to the cause(s) and manner sbtad
0 Madlcal Examiner/COfener - esis of examination, and/or Invastiptlon, In my opinion, tlaath o
ttu
rrad at tM time, dal:a, and place, and due to theu
u»(a) and
m
a
n
n
er s
tat
ed
~
~
y
-
~
~
7
~r
_
y
SIEnKUra of urtlfia Title of certifier: / L ~ Lieanse Numbar._.. f r ~ ~~7 J~ F"
39b. Nama, ddresf and 21 rfon CompletlnE Cau» 0/ Da th (Ibm 16
~ 39c. Dab SlEned (MO/Day/Yr)
~pf+~~f 114.. \ 1\
~1$ CI -\ a~~Z
40. Rei s District Num er 41. r s turn 42. RaE ftrar FI a Dab Mo Day
/
43. mendments
~
- Y
~
~-1 2~„~ $ Q ~ H 105-143
Difpofitlon Parmlt No. 'l l7 REV 07/2011