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PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF 4~ ~r_~ (~- .-- ~-~ ~) ,_ =~~ 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
.~r w.._.. ~ -
Name: _ ~L~*!' -~ ~~ ~ ~,~ ~ .~~ ~,.~:. File l~ o: ...~ s) ' ..... ~ ~ ~ ~ ~°~
a/k/a: (Assigned by Regis
Date of Death: x~":`,r`~ ,~ ~ .y Age at death: =~~~
Decedent was domiciled at death in ~~./~`° "'z.° ~, .. , - ~ - ~., County, ~'~€ ,~/.~!.. ', '_ ~ ' . / ~" rsrare/ with his/her last
,~ .
principal residence at ~ - 'x~ : ~ ~-~ .:. . ~_ ~ ~ , . t ~,~:,~ # .. , .;,~- ~ . -~ =t- : ~ ,,. ~ ~ ,~.~~' ~~ (T,_ ~r:~_:~
Street address, Post Office sad lap Code City, Township or Boroag6 County
Decedent died at ;~,/,,, is ,, F )I . , , ,f~- ~.- ~ '. .~
Street address, Post Office and Zip Code City, Township or Borough County State
Estimate of value of decedent's property at death:
If domiciled in Pennsylvania ............................All personal property $ ;'. ~' ''
If not domiciled in Pennsylvania ........................Personal property in Pennsylvania $
Ijnot domiciled in Pennsylvania ........................ Personal Property in County $
Value of real estate in Pennsylvania ......................................................... $ ? r.. ;:~' _ . ~
TOTAL ESTIMATED VALUE:.... $ ' . ' ~--r;. t '' 0.00
i,~a .. ~r,.-
/
Real estate in Pennsylvania situated at: ± ~^ ,. ~r . ~ t=; u -~`= # ; rt =: e~. ~ ~-. - : ° - ~.
(AUach additional sheets, if necessary.) Street address, Post Office sad Zip Code City, Township or Borough County
^ A. Petition for Probate and Grant of Letters Testamentary
Petitioner(s) aver) he/she/th~y is/are the Executor(s) Darned in the last Will of the Decedent, d~ ,red ~,~f.';+'"° ,~: _3:.> ~ and Codicil(s)
thereto sated Ttff.STr ~l "Yeda1J~12s~1 'nt c-~~ ~- 9- / 2 ~f
State relevant cirenmstaacea (Gg. renanciation, death orexecator, eta)
Except as follows: after the execution of the instrument(s) offered for probate Decedent did not marry, way not divorced, was not a parry 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 bam or
adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person.
NO EXCEPTIONS o EXCEPTIONS
^ B. Petition for Grant of Letters of Administration (If applicable) .;~ ~'_ /' 1 ~ '~ r
c.t.a., d.b.n., d.b.n.c.t.a., pendente rite, durante absentia, durante minoritate
If Administration, Gta. or db.n.c.t:a., enter date of Will in Section A above and complete list of heirs.hn3
Except as follows: Decedent was not a party to a pending divorce proceeding wherein the grounds for divorce had
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 leR no Will and was survived by the following spo~~~
additional sheets, if necessary): -~ n
'_~ O ii
Name Retationslti Address ~
Form RW-Ol rev. 10/11/2011
ish~s defined~„-t
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and~irs (a~at~l} T
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Page 1 of 2
Form RW-01 rev. 10/11/2011 Page 2 of 2
~ .
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF
Petitioner(s) Printed Name
.. ~ ..
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Official Use Only (~
Printed
', . J~~~ E
f C
`'1f S ~~ 1 ~ ..
The Petitioner(s) above-named swear(s) or affirm(s) the statements in the foregoing Petition are true and co:trect 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 d truly administer the estate according to law.
Sworn to or affirmed and subscribed before ~,~~ ~ Date
me this 9~_ day of /~~~ ~y ~- y - ~'' /z
By: '_`~""'__'-' _ e~ Bate
'~-- Date
Fo he Register Dale
BOND Regnired: Q YES ®NO
FEES:
Letters ...................... $
( )Short Certificate(s)...... }'~
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commission ................. .
Other
9 /L yam-...... .
........
Automation Fee .............. .
JCS Fee . ........... .
. .
TOTAL ..................... $ -~---8~}~
3~~
To the Register of Wills:
Pleaae enter my appearance by my signature below:
Attorney Signature:
ll
S ,,.
Snpreme~onrt
~:,
ID Number: - :.1 _,
~..
Firm Name: ... ~ ~ ~ ~:.. , ; - + ` '1:" .- : ~- .,
Address: -+ '
Phone: ~ ~ ; -~ ~ - _~ •~`
Fax: °- `? ;.. _ t"f (n-
Email: - " t'- r : tT . -~s~l 3;~yyr' ~ •. )--r
f' ~ /F!
Form RW-Ol rev. 70/77/2017 Page 2 of 2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF
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se
Petitioner(s) Printed Name Petitioner(s) Printed Address I
The Petitioner(s) above-named swear(s) or affirm(s) the statements in the foregoing Petition are
of Petitioner(s) and that, as Personal Representative(s) of the Decedent, the Petitioner(s) wi
Sworn to or affirmed and subscribed before
me this day of
By:
For the Register
BOND Required: AYES ~NO
FEES:
Letters ...................... $
( )Short Certificate(s)..... .
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commission ................ .
Other
Automation ee ...............
JCS Fee . ...................
TOTA ..................... $~
Estate
a/k/a:
File No:~~ I ~ ~ ~ ~ -iD
AND NOW / Vn(~1 ~ ~ Y~ , to consideration of the foregoin Petition,
satisfactory pr a ing been presented before tne, IT IS DECRE D th t Letters ~ ~ ~-
~Qyl,~ L~l~l 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 Codi ' s)) of Decedent.
Register of Wil s
Form RW-03 rev. !0/1I/10!! Page 2 of 2
Date
Date
Date
Date
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
e and correct to the best of the knowledge and belief
and truly administer the estate according to law.
Nl(1i,4nG Rc~I ro/r +~
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARN :~
~n~~~~~il~e~~oQ~Gplicate this copy by photostat or photograph.
Fee for this certificate, $6.00
~~ ~ ~ A~~ , b ~~~ 9. ' ~ This is to certify that the information here given is
correctly copied from an original Certificate of Death
duly filed with me as Local Registrar. The original
~~(~}( (~~ certificate will be forwarded to the State Vital
~p~'S COURT Records Office for permanent filing.
P 1 R ~ R R .~ n ~ cuMR~R!. ~vn c~~. ~ ~~~
Certification Number
ryPe/Print In
Permanent
Austin C.
" ~ ASR ~ 2
Local Registrar Dato Issued
__
COMMONWEALTH OF PENNSYLVANIA . DEPARTMENT OF HEALTH ~ VITAL itECORDS
CERTIFICATE OF DEATH
1) 2. Sex 3. Social Security IVUmberState File N4_ Date of Death (Mp/Day/Vr) (spell Mo)
tgherty Male 192 14
s u d 1 D y 6. Date pf Birth rMm]n..,H_._, ~~__,...____, t_ 5570 April 9 , 2012
j~ ga. Residence (state or Forei V C L O b e rL C
gn Country) 86. Residence (Street and Number- Include Apt No.f
Penns lvania
Sd. Residence (cp~nty) 218 Bailey Street
Cumberland He. Residence(ZlpCOde) 17070
9ss.-~~sE1Ver in U Armed Forces] 10. Marital Status at Time of Death [~ Married Q W
i .W talc- t]fNO Q Unknown Q Divorced Q Never Married Q Unknown
1924 7b. Birthplace (Cr
gc. Did Decedent uYe in a gown:htp]
Q Yes, decedent IiVed in _
No, decedent INed within limits of
--- ~--~--~-~~-• •r •~ .+=wuem a4c. Informant's N
~ r ene B. Dou hart Wife 2e8 Baffle
3 If DeaTh Occurred In a HosPltal: vr ~~~-~~~~~~~~~~~-~-""""-"""-""'""""1if De -~~~ ~ ace o aat _ o _y one ...
Emer tJ Inpatient ath Occurred Somewhere Other Than a
genry Room/OUtpatlent Q Dead on Arrival Nursing Home/Long-Term Care Facl
156. Facility Name (If not institution, give street and number; •lSC. City or Town, State, and Zip Code
~ 218 Baffle Street New Cumberland P
16a. Method of Dlspasltion Burial Q Cremation 16b. Date of Dlspositlon 16c. PI c of Die
Q Removal from State Q Donatl
>'er
io fir
on ~ ----~-~ .~--•~~~_ ... _~~..~.ery, crematory, or other place)
other(spenfy) April 12, 2012 Rolling Green Cemetery
16d. Loeatlon of Dlspositlon (City or Town, State, and Zip) 1]a. Signet of F ral Servic Licensee or Person In Char
Hills He of Interment 1]b. License Number
~ Camp PA 17011 FS 012
E 1]c. Name and Complete Address of Funeral Facility 849 L
s
Parthemore FH & CS Inc. P.
r~ 1H. Decedent's Ed
i O. Box 43 New Cumber)
ucat
on -Check the box that best describes the
t- highest degree or level of school com
leted
t th 19. Decedent of Hlspanlc Origin -Check the
p
a
e time of death.
Q 8th grade or less box that best describes whether the decedent
Q No diploma, 9th - 12th grade is Spanish/Hispa nlc/Latino. Check the "NO"
Q High school graduate or GED completetl box if decetlenT is not 5
not 5 Panlsh/Hispanic/Latino.
®" No
ani
h/Hl
Q Some college credit, but no degree ,
p
s
spanlc/Latino
Q Yes
Mexlca n
M
i
Q Associate degree
(e.g. Aq, AS)
' ,
,
ex
can American, Chicano
Q Yes
Pue KO Ri
Bachelor
s degree (e.g. BA, AB, BS)
' ,
can
Q Yes
Cuban
Master
s degree (e.g. MA, MS, MEng, MEd, MSW, MBA)
Q D ,
Q Ves, other Spanish/Hlspanlc/Latin
octorate (e.g. PhD, EdD) or Professional degree o
a. MD DDS DVM LLB JD (Specify)
21. Decedent's Single Raro self-Designation -Check ONLY ONE To indicate what the decedent considered himself or
Q W
t
a
o Q J oP enese
Q BI ck r African American Q K Q lam
Q American Indian or Alaska Native Q Vietnamese Q Other Paclflc Islander
Q D
'
Q Allan Indian Q Other Allan on
T Know/Not Sure
Q Refusetl
Q Chinese Q NatiVa Hawaiian
Q Fili
ino ~ Other (Specify)
p
Q Guamanian or Chamorro
BY PESRSON WH PRONOVNCES ORE 23a~at^ronounr~ D~d Mo ay 23 . Signature o Person Prc
max. ~ J LT ,~•y~-- I <.. r~ pt D ! n i ~~ ---Lt ~~s~x~.~, ~ ~ ~~ I ,~/ ~'~-17 ~C
(~ 25 W M dl I E 1 C tatted? ( f Q yes
I CAUSE OF DEATH - ~N
26. part I. Enter the chain of t -diseases, Injuries, or complications-that dlrettly caused the death. DO NOT enter terminal' events such as cardiac arrest, APProrvimate
respiratory arrest, or Ventricular flbrlllat without showing the etiology. DO~ AB~VIATE. Enter onl Inte al:
/ ~ y cause on line. Add additional Tines If necessary ' Onset to Death
IMMEDIATE CAUSE ----_ ______~ a I ^~
(Final tlisease or condition /T o (or `r+
resulting in death) B / y r ~ ~l~ as a tonseq~~~ ~~~/
Seq uentlally list conditions, Due to ( 3
if any, leading to the cause U nee of)
listed on Tine a. Enter the e L ~ f~ ~~•t/~(~.~~ ~ ~(•/~G fir( r~.~- ~~
UNDERLYING CAVSE Due to (ors ~LL~~-+. ( [- 1
(disease or Injury that as a comsequencewf):
Initiated the events resultin8 d.
In death) LAST.
T - ....e w for as a consequence of):
26. Part 11. Enter other sl¢nifl t ditl t tb ti t d th but not resultln In the under) In '
Yn \~ ~ g Y B cause given In Part 1 2]. Was ~-
~~J m ~ ~ ~ ~ ~~ ~~~ n autoPSY Perform0
)J a IYes
U ~ ~-~ 28. Were a topsy ftndings awl
to c plate the c of de
29. If Female: ` ~~ L
30. Did To oQ Yes ease
Q Not pregnant within past year bacco Use Contribute to Death] 3~1. Ms_~~ r of Death r
Q Pregnant at time of death Q Yes Q Pro ~$'Naturcl Homicide
~ Q Not pregnant, but pregnant within 42 days of deatf Q No ^ Q Accident Q Pendin Inyesti lion
~- Q Not pregnant, but pregnant 43 days to 1 year before deatF 32. Date of In Q Suicide Q Could not be determined
Q Unknown if pregnant within the past year Jury (MO/Day/V r) (Spell Month) Q
33. Time of InJury
34. Place of Injury (e.g. home; construction sits; farm; school) 35. Loeatlon of In u
C> J ry (Street antl Number, C ity, State, Zip Code)
36. Injury at Work 37. If Transportation InJury, Specify: 3H. Describe How InJury Occurred-:
Q Yes Q Driver/Operator Q petlestnan
- Q No Q Passenger Q Other (Specify)
39a. ~.a~Mer^Check only one): '
~r Ce Kifyl g physician - To the best of my knowledge, tlaattl occurred due to the c sa(s) and m stated
ip Pronouncing TBa Certio Inge hyslclan - To the best of my knowledge, death occurred ai the time, date, and place, and tlue to the cause(s) antl manner stated
Metlicai Ex inar/C the basis of axe inatlon, Intl/or Inyes[igatlon, In m
y opinion, death ;red at [he time, date, and place, and due to the cause( )and
Signature of certifier Title of certifier: ! u (~/j, /~i/~t j!e
396. N a, Ad ss s p Code pf p rso m leting Cau Death m 26) - License Numbed - { C
lJtrf/ ~•~ .. - ) ~ r~ / 39c. D to Slgnetl (MO
40. Registrar s District Number 41. Registrar's ~iJ P ~ !/
_ // 42. Registrar FI a Date Mo Day r
43. Amendments ~' 7a 7 S!/ is
_ /eJ o/L
twp.
decedent considered himself or bent f to be. to Indicate what
White Q Korean
Black or African AmeACan Q Vietnamese
American Indian or Alaska Native Q Other Asian
Allan Indian Q Native Hawaiian
Chinese Q Guamanian or Chamorro
Filipino Q Samoan
Japane:ie Q Other Paclflc Islander
Other (SpecHy)
to be. 22a. Decedent's usual OccupaHOn - Indlrate type of wort
done during most of working IHe. DO NOT VSE RETIRED.
Administrator
22b. Kind of Business/Industry
Dlspositlon Permit No. ~~( e~0 ~ L y H105-143
- - - - --- -.. _ _ REV 0]/2011
_. - _ -