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PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF 1 J ~ `(~' ~ t"~~ 23 ~~ ~° ~b
~~ ,,.~ '~ (~ n COUNTY, PENNSYLVANIA
Petitioner(s) named below, who is; are 13 years of age or older, apply(ies) for Letters as spec' ~~1HtV ~v rri~!
support thereof aver(s) the following and respectfully request(s) the grant of Letters in the appropr
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Decedent's Information
Name: /{.Q l{u,rv 7b
a/k/a:
a/k/a:
a/k/a:
Date of Death: _ Fir b / y 2v I Z
Decedent was domiciled at death in , 1l County,
principal residence at 7'~ ~oD~sa ~~„~ ~+~,,,i0 ~, I
File No• -~ ~ - ~ ~ _ ;
(Assigned by Register)
Social Security No: ~ ~j S 2 tr a z s 7
Age at death: __ ~g
~ F r~sfi P.o NV S ~'
his/her last
Street address, Post Office `rt~Zip Code t City, Township or Borough County
Decedent died at ~a ~ »/ro.~ Ct~„a j..1, t} P,a„ wa-cbaeLre .,d
Street address, Polt Office and Zrp Code City, Township or Boro~ngh ~ ~-o County State
Estimate of value of decedent's property at death: ~~r~ Y~~s ~
If domiciled in Petrnsylvania ............................ All personal property
If not dotniciled in Petrnsy!vania ........................ Personal property in Pennsylvania
Ijnot domiciled in Petrtrsyh~ania ........................ Personal property in County
Value of real estate in Pennsylvania ........................................................ .
TOTAL ESTIMATED VALUE... .
$ 7000
$ __
$ 7v yo
Real estate in Pennsylvania situated at:
(Attach additional sheers, ijnecessary.) Street address, Post Office and Zip Code Ctty, Township or Borough County
[~ A. Petition for Probate and Grant of Letters Testamentary nn
Petiponer(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated _ /+{!g / O / y~ ~ and Codicil(s)
thereto dated
State relevant circumstances (eg. renunciation, death ofexecrrtor, 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 in 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.a., d.b.rt.c•.t.u., pendente life, durunte absentia, durante minw•itute
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(g) and was neither the victim of a killing nor ever adjudicated an incapacitated person.
^NO EXCEPTIONS ^ EXCEPTIONS
Petitioner(s), after a proper search ltas/have ascertained that Decedent lefr no Will and was survived by the following spouse (if any) and heirs (attach
additionul sheets, if'necessury):
Name Relationshi Address
t k ~. ) o S'~ ifJ o /t1 RUwt~ 9 ~ /~( l ~ r `~o~ ~
A R/,r ltil r D 3- O a kl d s (3..a .~ ~~~
f 70~ L
t ~ a i~
F~,~,,,aw-nz ,-~~.tnitliznl/ Page 1 oft
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA }
i } ss:
COLNTYOF ~~iY~~bCrl~1'1C~ }
LL . ~~ts+~
i?~ i'~~~~ 23 F'~~ 3~
Petitioner(s) Printed Name r
Petitioner(s) Pri t
I T
Gt(C i)~~i ' r• 1 b {~ ,j~~
~' p lY(/t~l lV N.~' `! t )~ 1..0~~ sr8'~O frlt'Y' ~A -L~
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 Decedent the Petitioner(s) will well and truly administer the estate according to law.
Sworn to r.affirmed a bs ri fore Date 3 - / < - 2 0 l Z
me thi ~ay of 2 Date
By. Date
F ,lister Date
BOND Required: ^ YES ~NO
FEES:
Letters ...................... $ / l<~
( ` )Short Certificate(s)...... ~ (;(;
( V )Renunciation(s)......... ;F-j , L`.
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commission ................. .
Other
t,l ~ t l~ ...... I ~ (i .
........
---~----
Automation Fee ............... ,~- ~;( ~
JCS Fee . .................... -~ .,, cs L
TOTAL ..................... $
To the Register of Wills:
Please enter my appearance by my signature below:
Attorney Signature:
Printed Name:
Supreme Court
ID Number:
Firm Name:
Address:
Phone:
Fax:
Email:
DECREE OF THE REGISTER
Estate of ~..~~ G ~ ~L1 ~' ~ `~ ~~ File No: ~ ~ - I ~ - (,, ;~~1 °;
a/k/a:
AND NOW, `~.-~ ~ ~ C,~~ ;~ ~ _, in consideration of the foregoing Petition,
satisfactory proof having been presented before me, IT IS DECREED that Letters ( ,~ -~- j y^ n j~
are hereby granted to (~) I ( k,(1 ~~a K (~ ~ \~~ ~~
in the above estate and (if applicable) that
the instrument(s) dated I
described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent.
r.
Regtster of Wills
Form RW-D? rev. (0/!1/1011 Page; 2 Of Z
Estate of
I,
~"
in my capacity/relationship as
~ (Print Name)
'; g ~I ~ e 1'" of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
~~ ~ ~/2.
(Date)
(Signatu e) /
(StreetA dress)
~ ~~~~ ~
(City, Stale. Zip)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this _~ y
of "~~~(
-~
~.
eputy for Register o Wills
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 Seaf of Notary or other official qualified to
administer oaths. Show date ofexpiration ofNotary's Commission.)
C) t,.~,
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RENUNCIATION
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REGISTER OF WILLS ~~n ~ -• ~ ~:
COUNTY, PENNSYLVANIA --
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~ ~ ,Deceased
Form RW-06 rev. 10.13.06
LOCAL T {~.'S CERTIFICATION OF DEATH
WARNIN~,Ipttl~gga;l ~~~glpplicate this copy by photosi:at or phcrtagraph
F~c~ fore this certificate, $(i.li0
___ P 18330206____
Certification Numher
Type/Print In
Permanent
Black Ink
hr~ is to ~( rt.it t ~ tt)
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O~~Hi~rs ~~~~7 ;v, .,~~` ~A; Rccurd~ [ifficL~ tin (~: ~~rr(.u-lent t~ilnjg.
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COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH ~ VITAL RECORDS
LFRTIFILATE OF DEATH
rlty Numb<r 4. Date of Death (MO/Day/Vr) (Spell Mo)
5ecu
2. Sax 3. Soc1a1
1. Decedent's gal Na a (Flrsx, MidtllR, Last, uHlx)
/
r
p
1f - ~ / / ~~~ /l/ / Ob/
6 a. Age-Last Birthday (Yrs) Sb. Under 1 VRar .Under 1 Da 6. Oate of Birth (MO/Day/YRar) (Spell Month) 7a. 01rth lace (C ty StatR or ForR n C u
9 ~y Montha Oays Hours Minutes ~./f
/ /~ s~ ^~
~
/ _
/- /l /`C /C ~ I~ ~/
v\ 7b. Birthplace (County) p
8a. Resl a (State or F reign Country) Bb. Residence ($treff and Number -Include Apt No.) Bc. Dld Decedent Live In a Townshlpi
/
n
~B q ~a
/~ / ~
~ ~ Yes, dec<d<nt Ilved In CwD~
8tl. Resltle
(t ~ ty) ~
` ~,/ -
/
Be. Residence (21p Code) ~ SSA rs-t city/born.
No, decedent Ilved wlthln limits of l'~/~ ~
9. Ever In 5 ed Fortes? 10. Mar ital Status at Tlme oT Death Q Marrlad WltlowR 11. Surviving Spouse's Name (If wife, glue name prior to /lrst marriage)
Q Yes No Q Unknown Q Di vorced Q Never MarAetl Q Unknown
12. Father's N Itat, Middle, Last, Suffix) 13. Mother's Nama Prior First Marriage (First, Middle, Last) _
•
/
14a. Inf r _ R 14b. RRIRtlonshlp to Decedent 14c. Informant's Mallln Address (Street and Number Clty, 5<ate, Zlp Code) ~ ~B
~~a//m
~ O~
d
'
~( Fl
Th
H
~
S ce
ent
a Home
oaplce Faclll<y
an a
ospttal:
~( Inpa nt 11 D<ath Occurred SomewharR Other
41:
I1 Death Occurred In • H
Q Emer envy Room/Outpatient Dead on Arrival ~ Nursln Homa/LOn -Term Care Faclllty Other (SDeclfy)
a lSb. Faclllty Nama (If not Inst utlon, glue street and mbar; SSC. CI r Town, State, and Zlp Code 15d. Cour~tt of Deat
~
y, -c.P~ Gv
ame of cemetery, crematory, or other place)
lt on (N
16a. Method of Dlsposltlon Bu Cremation 16b. Dat of Dlzpo n 1 . Place Dlspos
T
..E$ J
/
Q Removal from State Ognatlon C~j //'G/I /~ //'t° /r
Oth<r (Specify) ~~
State, and 21p)
16d. Location of Dlsposltlon (City or Town er
b
17a Ignatu or Person In arge of I 7b. LI a Num
e
Z tl
Gr
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}
4"~ a
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17 a and Complete Address of Funeral Fac Ilty
'
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18. Datedenf's Education -Check the box that best dascrib<s the 19. Decedent of Hlspanlc rigln -Check th 20. Dace 's RRCe -Check ONE OR MORE r s to Ind what
highest degree or IRVeI of school completed at the time o/ death. box that b<st describes whether tM decedent the detedant consltleratl hlmsRlf or Mrself to be.
8th grade or less Is Spanish/Hlspanlc/Latino. Check the "NO" Q White Q Korean
o diploma, 9th - 12th grade box If decedent Is not Spanish/Hlspanlc/Latino. Q Black or African American Q Vletnameze
Q Hlgh school graduatR or GED completed No, not Spanish/Hlspanlc/Latino Q Amerlun Indian or Alaska Native Q Other Asian
Q Some collRge cradle, but no degree Ves, Mexican, Maxlcan Amarlcan, Chicano Q Asian Indian Q Native Hawallan
Q Associate tlegree (e.g. AA, AS) Q Ves, Puerto Rican Q Chinese Q Guamanian or Chamorro
Q Bachelor's degree (e.g. BA, AB, BS) Q Yes, Cuban Q Flllplno Q Samoan
Master's degree (e.g. MA, MS, MEng, MEd, MSW, MBA) Q Ves, other Spanish/Hlspanlc/Leilne Q Japanese Q Other Pacltlc Islander
Q Doctorate (e.g. PhD, Ed D) or Professional degree (Specify) Q Other (Specify)
. MD DDS DVM LLB 1D
21. Decedent's Single Race Self-Dealgnatlon -Check ONLY ONE to Indlute what the decedent consideretl himself or herself to be. 22a. Oecetlent's Usual Occupation -Indicate type of work
~~Whlte Q Ja Panase Q Samoan done during most of working IHe. DO NOT USE RETIRED.
Q Black or African American Q Korean Q Other Paclflc Islander
Q Amarlcan Indian or Alaska Native Q Vietnamese Q Don't Know/Not Sure s~ / C C/e
Q Asian Indian Q Other Asian Q Refused 22b. Kind of Business/Industry
Q Chinese Q Native Hawallan Q Other (Specify)
~
Q lZ ~ /
Q Flllplno Q Guamanian or Chamorro S
C
R MS 2ge - 25 MUST BE MPLETED 23a. DaN Pr n DR Mo Day 23 . SlgnaturR o Person Pronouncing Death Only w en app Ica le 23c. License Number
un
e
r
BY PERSON WHO PRONOUNC[S OR O/'~ ,
~ ~~ ~~„~ ~ ~`.)
CERTIRIlS DgATN OL
2 d. a ~ 51 n ~Day/Yr) 24. Time of Death !!))
/Jl~ 25. Was Medical x miner or Coroner Conbcted7 Q Ves No
USE OF DEATH Approximate
26. Part 1. Enter the chain of events--tllseases, Injuries, or eomplleations-that directly caused the death. DO NOT enter terminal events such as cardiac arrest Interval:
e i
respiratory arrest, or ventricular flbrlllatlon without showing th tlology. DO NOT ABBREVIATE. Enter only causes on a Ilne. Add additional Ilnes If necessary Onset to Death
o
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e e
J
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j
IMMEDIATE CAUSE ---------------> a. i~Q/`/C~f ~ ~ ~' I ~ ~ yJC (
(Final disease or condition Due fo (or as a consequence of):
resulting In death) ~
~
T
-
~ ~
`'
~
~
~ `J
-
/
b
///
a consequence of):
Due to (or as a
Sequentially Ilse conditions,
If any, leading to the c
listed on Ifne a. Enter the -
UNDERLYINO CAUSE Due io (or as a consequence of):
(dl3eaae or Injury that
F
,? InlHated the events resultin8 d. -
In tleath) LAST. Due to (qr as a consequence of):
26. Part 11. Enter other I nlfl any n I 1 n 1 I but not resulting In the underlying cause given In Psrt I 27. Was an autopsy peAormed7
S Yes No
f 28. Were autopsy findings available
[o complete the cause of death?
Q Ves No
29. If Femalr. 30. Dld Tobacco Use Contribute to Death? r of Death
31. Mann
t Pregnant wlthln Paat Year Q Ves Q Probably
N
~Unknown a
a~94at cal Q HomlcldR
Q Accltlent Q Pentling Investlgaxlon
~' Q Pregnant at time of tleath
Q Not pregnant, but pregnant within 42 tlays of death o ~
Q Q Sulcltle Q Could not be determinetl
Q Not pregnant
but pregnant 43 tlays to 1 year before death 32. Date of Injury (MO/Day/Yr) (Spell Month)
,
Q Unknown If pregnant wlthln the past year 33. Time of Injury
34. Place of Injury (e.g. home; construction site; farm; school) 35. Location o1lnJury (Street antl Number, Clty, State, 21p Code)
36. Injury st Work 37. If Transportation Injury, Specify: 3B. Describe How Injury Occurred:
Q Ves Q Driver/Operator Q Pedestrian
Q No Q Passenger Q Other (Specify)
39a. CertfRer (check only one):
ertlfying physlclan - To the best of my knowlatlge, tleath occurred tlue to the cause(s) and manner stated
Q Pronouncing 8 Certifying physlclan - To the beat o/ my knowledge, tleath occurred at the time, tlate, and place, and tlue to the cause(s) antl manner slated
Q Metllcal Examiner/Coroner - On basis of ex minatlon, and/or Investlgatlon, In my opinion, death occurred at the time, date, antl place, and due to the cause(s) and manner stated
1
Signature of certifier: Iflar: Llcens< Num
39b. Name, Address and Zlp Code of Person ComplaHng Guse of Death (Item 26) 39c. Oate ~Jg(led (MO/ ay/Vr)
~ Z~
- L 4 /Yr s / }r
CG ~
40. Registrar's District Number R<glstr r s Slgna u ~, L/ i/ ~/
' r)
42 aglstr~Fl a Date sy
/
~•tst~
/
W~
43. Amendments
7
Dlsposltlon Permit No. V ( ~!W 1 ~ H105-143
REV 07/2011
~~~~t t~ ~n~ c~ e~~~mer~~
1, HELEN KURLYO, a resident of Upper Allen Township, Cumberland
County, Pennsylvania, being of sound and disposing mind and memory,
do hereby make, publish and declare this as and for my Last Wi11 and
Testament, hereby revoking any and all Wills by me at any time hereto-
fore made.
ITEM I. T direct that all my just debts and funeral expenses
be paid as soon after my decease as may be found convenient.
ITEM II. All the rest, residue and remainder of my estate,
real or personal, which I may own or have the power to dispose of at
the time of my death, I give, devise and bequeath, in equal shares,
unto my son, Nickolay Kurylo, 409 Walnut Street, Millerstown,
Pennsylvania 17062, and my daughter, Maria Mihailoff, 744 Barrymore
Lane, Bethlehem, Pennsylvania 18017. if either of my said children
shall predecease me, his or her share shall go to his or her surviving
issue, if any, in equal shares, otherwise to my surviving child.
ITEM III. In the event that I become terminally i11, I wish to
die peacefully and humanly without the benefit of life support systems.
ITEM IV. I hereby nominate, constitute and appoint my son,
Nickolay Kurylo and my daughter, Maria Mihailoff, Co-Executors of this
my Last Will and Testament, with full power in their discretion to do
any and all things necessary for the complete administration of my
estate, with full power to sell at public or private sale and without
order of court, any real or personal property belonging to my estate,
and to compound, compromise or otherwise to settle or adjust any and
all claims, charges, debts and demands whatsoever against or in favor
of my estate as fully as T could do if living.
TN WITNESS WHEREOF, I have hereunto set my hand and seal to
this, my Last Will and Testament, this 10th day of August, A.D., 1988.
~ (SEAL)
Signed, sealed, published and declared Z~
by the above-named Helen Kurylo, as and
for her Last Will and Testament in the
presence of us, who, at her request, in
her presence and in the presence of each t? ~:
other, we believing her to be of sound ~~ `~~
and disposing mind and memory, have here- nT
unto subscribed our names as witnesses ~~r`
ri m "~
this 10th day of August, A.D., 1988. -~~~~ tNa
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s
~ COMMONWEALTH OF PENNSYLVANIA )
SS:
COUNTY OF DAUPHIN )
WE, HELEN KURYLO, Harry G. Banzhoff and Jo Anne R. Foltz
the Testatrix and the witnesses, respectively, whose names are signed
to the foregoing instrument, being first duly sworn, do hereby declare
to be the undersigned authority that the Testatrix signed and executed
the instrument as her Last Will and that she had signed willingly and
that she executed it as her free and voluntary act for the purposes
therein expressed, and that each of the witnesses, in the presence and
hearing of the Testatrix signed the Will as witness and that to the
best of their knowledge the Testatrix was at that time eighteen years
of age or older, of sound mind and under no constraint or undue
influence.
TESTATRIX:
WITNESSES:
Subscribed, sworn to and acknowledged
before me, by HELEN KURYLO, the Testatrix,
and subscribed and sworn to before me by
Harry G. Banzhoff a nd Jo Anne R. Foltz
the witnesses, this 10th day of August,
A.D., 1988.
;/• / ~ n
~ Notary Public
LAURI L LEPfKER, tdOTARY PtlBtt~i
My Cori Expirrea Septerr~ber30,1991
Harrcg, PA Deuphkt Cowry