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HomeMy WebLinkAbout03-29-12PETITI/O~V FOR GRANT OF LETTERS REGISTER OF WILLS OF _ ('~i ~,p p IA4 ~ COUNTY, PEIv'NSYLVANIA Petitioner(sj 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 Litters in the appropriate Porn: Decedent's Information ~, , Name: _ p ~1 SSA TAA1~. V~~S • .~~-e~k a/k/a: a/k/a: a/k/a: Date of Death• ,~ ANA ~ ;~ a ~ ~ ~ Decedent was domiciled at death in ~ County, principal residence at o~ (o ~..e ~ ,he , ALA„ ~ ~„ Street address, Post Office and Zip Code Decedent died at ~ C.~ U ~p ~~ Street address, Post Office and Zip Code Estimate of value of decedent's property at death (stare) with his/her last ' County City, Township or Borough ~ County State Ifdoneiciled in Petrnsylvania ............................ All personal property $ ~ ~~ If not domiciled in Pennsy!vania ........................ Personal property in Pennsylvania $ Ijnot domiciled in Pennsy!vania ........................ Personal property in County $ Valtee of real estate in Pennsy!vania .............................. ............... $ ............ TOTAL ESTIMATED VALUE.... S 1 .-- / ~ Real estate in Pennsylvania situated at: ,~~~~ ~ A~ (Attach additional sheets, ijnecessary.) Street address, Post Office up 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 Will of the Decedent, dated thereto dated County and Codicil(s) State relevant circumstances (eg. renunciation, death ojexecrrtor, 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(8), 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. a., d. b. n., d.b.n.c.t.a., pendente life, durunte absentia, durante minoritute 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 Will and was survived by the following spouse (if any) and heirs (attach crctditionul sheets, i/ neeessu>7~): Name Relationshi Address ~1 D ~ 3o c,~~ s ~ ~-->> SR ~~ ~ File No: .-~ ~ - ~ ~ - (j ~> 1 ~ (Assigned by Register) Social Security No: '/,~ r~ ~'~ ~ ~ ~~ Age at death: ~~"' ~~~ ~~~6 F~r,» aw-nz ,•~~. ~nitiiznll Page 1 of 2 Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA COUNTY OF } } SS: } Official Use On]y Petitioner(s) Printed Name Petitioner(s) Printed Address ~ N ~ e ~~ .. ~~ s ~~.' ll esc~A ~ 1 The Petitioner(s) above-named swear(s) or affirm(s) the statements i e foregoing tition are true and correct to the best ofthe knowledge and belief of Petitioner(s) and that, as Personal Representative(s) of the Deced t th etiti (s) ill well and truly administer the estate acc rdpin o law. Sworn to or affirmed and subscribed before Date / ~ .Z me this d of p~b2-- Date By' - ~ Date Fur the Reis r Date BOND Required:~YES ~NO FEES: Letters ...................... $ ( )Short Certificate(s)..... . ( )Renunciation(s)........ . ( )Codicil(s) ............ . ( )Affidavit(s)........... . Bond ........................ Commission ................. . Other Automation Fee .............. . JCS Fee ..................... TOTAL ..................... $ To the Register of Wii[s: 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 a/k/a: File No: 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 instrument(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 For,,, nw-nz rw. ~niriiznli Page 2 of 2 uinc Qnc over .e/~„ LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee for this certificate, $6.00 _ P 1815 9 8 5 ©-___- ///~~~ Certif_ication Number TYpe/Pdm In Permanent 1 BI 7-'his is to certify ihu? the' inli)rmation hcrt:~ g)ti'eu is a)rrectly co~ied~from :u~ or~i~inal Certificath ~)f [?Bath duly filed N ith sic a~; f.oral Registrar. The original certificate mill `)c °+>rwarded to the S€ate Vital cords Office f r pcr)luu)ent filing. j!1 a.2~ JAN 2 0 2012 __. _.-- -- - Q~-----1' --~ - I_i)cal }~eg)strar Date I,sued COMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF HEALTH . VfTAI RECORDS 1. Decedent's Legal Name (Rrst, Middle, Last, Suffix) --- _ v. v~rz ra State Rle Number; 2. Sex 3. Sodal Serarrity Humber 4. Data of Death /Day/Yr) (SpNI Mo) Melissa Jana shank Fema 1 l 6 9- 4 4- 5 6 5 5 (M° January 13, 2012 Sa. AgtrLast Birthday (Yrs) Sb. Under 1 Veer Sc. Under 1 Da 6. Dale of Birth (MO/Day/Year) (SpNi Month) 7a. BMthplace (CKy aa.r~~dd $fate a F i C ore gn ountry) S g Months Day: Hpurs Minptes June 2, 1 9 5 3 Cam H i 1 1 P A 8a. Residence (Stet or Foreign Country) eb. Resieence (Street ane Number -Include Apt No.) 8c Dld Decedent Uvebinaa Towinsh{ ? u^ry) Cum e r a n Penn si t p s . yen a 226 Reno Street Ayes, decedenuiyee In ae_ Realdenee (cor,nty) twp Cumber 1 a nd ae. Ra:ldence (tip c°ee) ENO, tlecedcm INCe wtthin RmK. p~`~ e w Cumb'_ r 1 a n d 9 ~/~r° . Ever in US Armed Forces? 10. Madtsl Status at Tlme of Death ~ Married Widowed 11 SuryiVirtg Spouse's Nam Q Yes ~ ff K e ( w e, give name Prior t0 first marri No ~ Unknown Q Divorced ~ Never Married Q Unknown fie) 12. Father's Name (Firs[, Middle, Last, suffix) ' ]3. Mother s Name Prtor fo Flrs[ Marriage (Rrst, Middle, Lazt) Byron Lloyd Jane Lewis 14a. Informant's Name 14b. RNationship [o Decedent 14c. informant's Mail{ng Address (Street and Number, City, State, Zip Code) Brid et A M _ era Dau hter 6304 Wiscasset Rd_,Bethesda,MD208'16 s ff Death Occurred In a HosPKal: ~(~In ittlent l""'•....•.a:••.•Me.•...••ea•~.... on y one ... P ff Death Omarred Som ••. •• ••••••.•.•••••....•••••...•••• •• ••. ewh OHh~ ..•••••.•'••..-..."...•"'•• , . ............... crc r Than a Hos Kai: P ~HOSgce FaUl 1~ ..•••••..._•.••. Eme en Room/Out anent Dead on AMVaI Nursi Home/Loo -Term [are Facility Other (S KY apt Oecede^t's Home lSb F dlit N ) . a y ame (ff not institution, give street and number) 15c. cKy or Town, size, and Zip code J~ cwt, ~ ~~ 140 MaadowbrooK Court New Cumberlartd PA 17070 , yo,k 16e. Method of Dlsposltlon Burls Cremation 166. Dale of DlsposiUOn 16c. Place of DlsposKlon (Name of cemetery, crematory, or other pace) O Remwalrrpmstafe p Dpnaaion .$n _ 20 , 20'I 2 BFH Crematory ~her (Specl(y on 16d. Lo®ti of DisposKlon (City or Town, State, and 21p) 1Z nature d Funeral Service Ucansee or Person in Char e nt g erment S7b. Ucrose Number Grantyille, PA 17028 ~ FO '712342-L 1'1c. Name and Complete Address of Funeral FscilKy tone & Murra Fun -• ~ t 3$. Decedent's Eduq[lon -Check the pox that best describes the 19. Decedent of Hispanic Origin -Check Me O. Decedent's Rsce 1 Chedr ONE OR MORE races to inei highest degree a level of school completed at the tim t h f d h ® e w e o at eat . box thM base describes whether fhe decedent the deceeent considered hlmseff or hersNf to be O 8th grade or less . Is Spanish/His Q No diploma, 9th -12th grade Pani4Latino. Check the ^NO' ~ WhKC 0 Korean bo ff eeced t I en s rtot SpaMah/Hispanic/Latino. 0 Black or Afrimn AmeHtan 0 Viemamese Q High school graduate or GED oomplctee No, not Spanish/Hlspsni4LaHn o 0 gmeriran Inelan or Alaska Na[iv 0 Other Asian Q Soma college credK, but no degree ~ Vas, Mexican, Mexican American, Chlwno 0 / Ian Indian e 0 $~ Associate degree (e g AA A$) N i . . , at ve Hawa}ian ~ Q Ves, Puerto Rican Q Bachelor's degree (e.g. BA, AB, B$) Q Chinese ~ Guamanian or Chamorro Cuban ~ Yes ' 0 RliPino O Samoan 0 Master's degree (e.g. MA, M5, MEn MEd, MSW, MBA 6. ) Q Ves, other Spanish/Hlspani4Latino [] Japanese ~ Other Pacff r Islander DoLYOrate (e.g. PAD, EdD) or Professional degree (Specify) ~ Other (Specify) e. MD DDS DVM LLB JD 21 DaCadeM's Single Ratt Self-OCSlgnation -Check ONLY ONE to Indicate whM the decedent considerM himself or herself to be. 22a $[ White Decedent's U l O . sua caa ~ Japanese ~ Samoan Paton - Indfote type of work Black or Afrion American 0 Korean ~ Other Pacific Islander dOAe ~~^B ^iost °( working IMe. DO NOT USE RETIRED. 0 American Indian or Alaska Native 0 Vietnamese 0 pon'[ Know/Not Sure = ny e s t i g a t o r O Asian Indian p Ocher Asian p Refusee ~ Chinese ~ Native Hawaiian 22b. one of Business/Industry ~ Ocher (SpcUfy) ~ FlIIPI^° 0 Guamanian or Chamorro P i n ice r t o n S e c u r i t y TEMS S3a _ 29 MVST aE COMPLETED 23a. Date Pronoun Dea Mo/Day r) 23 b. Signature Person Pronouncing Deal (On when appl b) 23 aV PERSON WNO I+RONOUNCES OR u r= crose Number Janus CERTFIES DEATH ry 13, 2012 23d. Date Signed (MO/Day/Vr) 24. Time of Death PronOUnoed 4:25 PM 2S. Was Medical Examiner or Coroner Contacted? ~ yes ~ N o CAUSE OF DEATH Approximate 26. PaK 1. Eller the dl 1 f ts-diseases, injuries, or compllcatlons-that directly caused the death. DO NOT enter terminal events such as cardiac arrest 1 re piratory arrest, or ventricular flbr111atlon without showing the etlol merval: ogy. DO NOT ABBREVIATE. Emer only one ovx Il on a se. Add additional lines ff necessary 'e Onscf to Death IMMEDIATE CAUSE ~ a Probable Atherosclerotic Cardiovascular Dis ease , years (Rnal disease or condition Due to (or sequence of): resuKing in death) as a CO^ b. SegvenHally list conditions, Duc LD (or sequence of); If any, leading to the ®use sz • con Rated on line a. Enter the ~ UNDERLYING GUSE Duc to (or as a consequence ofJ: (eisease or Injury the( G InK1a[ee the Buena resulting d. - In deMh) LAST, Dve [o (or as a consequence of): 26. PaK 11. Enter other slanificant condKi trio •tl - ~ t h but not resulting in the underiying reuse given In Part 1 27 W ~' . as an autopsy PerfOrnied7 Yes No 2B. Were av[opry findings avaNable to complete the O f d use o eath? 29. ff Female: 30. Did Tobacco Use Contribute to Death? 0 Yes ~ No ~ Not Pregnant within 31 Manner ast f D h ~ p . year o eat Q Pregnant a[ time of Beath Q Yes ~ Probably ~ Nsturel Q Homicide No O Not Pregnant, but pr Ys Q Unknown O Ac Jeent egnant within 42 da of deatr ln Q 5vlcirk Q Cov~d nOt bed~~nrtined ~ Not pregnant, but pregnant 43 days to 1 year before death 32. Data of Injury (MO/DSy/Vr) (Spell Month) ~ Unknown if pregnant wthin the past year 33. Time of Injury 34. Place of Injury (e.g. home; mns[rvr_Ylon site; farm; school) 35. WcaHOn of In)u (St d ry reet an Number, City, State, Zip Code) 36. Injury at Work 37. If Transportation Injury, Specify: 3g. Describe How Injury Occurred: Yes ~ rs OPeretor 0 Pedestrian Passe 0 No )~ Ber Q Other (Specify) 39a. Certffier (Check only one): CaKlfying physician - To the best of my knowledge, death occurree due to the uuse(s) and manner stated ~ Pronouncing 8: Certifying ph sican - T th b y o e est of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated ]~ Medical Exnmirror/COr On the bssls o6exami rtion /or invests {on, in my Opinion, Beath occurred e[ the time d t ~f~ l , a e, and place, and due to the cause(s) and manner rtated Signature of certifier. ( ~t/ mss, J ~'P' Title of certifier: Deputy Coroner ' 3 h (Kem 26) Ucense Number: 9b. Name, Address and Zip Code of Person Completing Cause of Claude W Stablay I1, RN 1 18 Pleasant Acres Rd, York, PA ~ 7402 39c Oxe signed (f,.t^/Day/Yr) 4 0. Registrar s DlstrlR Num er 41. Registrar s 5 January 13, 2012 Gate Mo Dsy r / - ~ / / 42. Reg~ 4 ~~ 3. Amendments z O /ao i . 7R ~ ~~ X78 sA- s~ ITEM # > > '~` ate'/SBc)RG ®ff , ~FiOULD READ ~ --7~Nt~ ~~ /9Sg ,~B -~~,~Ai~..,i ~ /O~'~ ~~ D{spositlon Permit No. O {!~ -~ / V T V H305-143 REV 07/2011 RENUNCIATION REGISTER OF WILLS ~«~-, ~~ G~Mi COUNTY, PENNSYLVANIA ~~ Estate of Deceased ~.~ v .v,'k : ~G-. I' ~ S S ~ `~ , in my capacity/relationship as (Print Nam >a ~ of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to -, ._ / <~~~-~~ v (Date) ~~rreer Haaress/ . ~ p,/ (City, State, Executed in Register's Office Sworn to or affirmed and subscribed before me this day of Deputy for Register of 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 renunc~' t~io~~n~or the purposes stateld within on this -.-s~~, day Of __~~L?.~ /~ C l ~~~~11r ~~ ~b.l ~ n ~ -~n `f-~~ ~ ~ ~,~ Ndtary Public My Commission Expires: (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration ofNotary's Commission.) Form RW-06 rev. !0.13.06 COMMONWEALTH OF ~NNSYLVANIA I Heather M. Thom, Neota P Lowergllen Twp., Cumberland County r My Commission Expires Ap~l g. 2012 tulember, Pennsylvania Association of Notaries