HomeMy WebLinkAbout04-13-12PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF <~ ~ ~M t3 ~ it t ~ ti ~
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: ~ 1Jq M Ca..~r,~ ~ +~
L~f_ I~ -_l~ ~,
File N
a/kta: o:
(Assigned by Register)
a/k/a:
a/k/a: Social Security No:.3 ~ G F? £ G,;`~ 7
Date of Death• J L / b / I/ Age at death• 3 ,'-
Decedent was domiciled at death in _ C~~~c- (~dQ County, ~'C.~.rs ~ ~~~,,; (scare) with his/her last
principal residence at / O L (.~/ f-4~ t rG~ d i' ~.,~ ~ ~ ; .t t e ~ v,,,, ~ ~,~,,,,Q
Street address, Post Office and Ztp Code City, Township or Borough County
Decedent died at s'o ~. r ~ `.: ~`-
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 $
If not domiciled in Pennsy!vania ....................... . Personal property in County $
Value of real estate in Pennsylvania ..................... .................................... $
TOTAL ESTIMATED VALUE.... $_~'Z
Real estate in Pennsylvania situated at:
(Attach additional sheets, ijnecessary.)
street address, Post Office and Zip 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
State relevant circumstances (eg. renunciation, death ojexecutor, etc.)
Except as follows: after the execution of the instrument(s) offered for probate Decedent did not marry, was not divorce
divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(g), aril
adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. J
NO EXCEPTIONS ^ EXCEPTIONS -\~
County
and Codicil(s)
~:
i ~ ...,~.Jr ! .-
i~ t a patt~'to a pendir
~have~hild horn oG=
X -
C7
-~ _
_..
[~--~8. Petition for Grant of Letters of Administration (If applicable) ~ -`' ~= To
c.t.u., d.b.n., d. b. n. c. t. a., pendente life, durante absentia, du~h'ite minorit
If Administration, c.t.a. or d.b.n.a~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.
'O EXCEPTIONS ^ EXCEPTIONS
Petitioner(s), after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (ifany) and heirs (attach
additional sheets, i/necessary):
Name Relationshi Addres
s
-
iv /4 / •/'p..
~. ~ v ei ~ ~i L
/ ..f'
~
~ /
y 6 V ~2 .la-
t ~ t /ii ~r~ ~ /' L .3 .~ fJ G~ l
/
-
-7
M L c"d
Cr~C r!r ~ ~
L
MGi~rW ee
I 2t L i.~/~,,,.l..._l~-P l~ Mr ~~~ Rio Z177~
/
L,~ c 4,,,t,, ~ C, .~ IJ ~C'r / L)~-` ~c~..,.,, f`s,. ~ /+~.,e. i44 f~i' Jvl.,/f Z~77~
~ ~ ~ C~~~,n ~ 4 •~.,, ~.,~ Z ~ /~. ~~ ~'C 'Sup !'u rk ~~e. f~a (}irlu~e, ~ ~ 123 ~
Forn: RW-01 ,-ev. tnilliznll
Page I of 2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF
}
} SS:
}
r'
~ icia] sc Only
i ~ ~.
.._
,, r; ~ J i/~ ~.,
n. rni:.
Petitioner(s) Printed dame Petitioner(s) ~,~ ~ 'ess~~,~ ~,
1
Vr,-c ~Uve~~~(,~ Z~1 6'J. ~~er>w, ~ur IY '"~~~;;;'
'~' ~9~ore ~~ 21
The Petitioners} 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 Petit}e~ner )will ell and truly administer the estate accord ng to l w.
Sworn to or ~ffirmed and//subscribed before (f ~ Date 5 Z `~ l L
me thi day_ f 9~L C~ ,o~L;~ Date
y: Date
For the 2~~gist ~ Date
BOND Required: Q YES ~ NO
FEES:
-~
Letters ...................... $ :~ L . LL.
( (~ )Short Certificate(s)...... ~ t-( ~;
( -=~ )Renunciation(s)......... t `J • UO
( _.. )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commission ................. .
Other .......
Automation Fee . .............. ~ C'
JCS Fee ..................... - O
TOTAL ..................... $ . J 0
3i
Ta the Register of Wills:
Please enter my appearance by my signature below:
Attorney S
(~ ,/,
i~ ~~
Pr~ed Name: c~~•~-,.C~ /~ /~c.T ~ S
Supreme Court
ID Number: ,3 vJ 3 ~~
Firm Name: ~l ~% ~c~..P~~ ~ T
Address:
C~-~f /~~t ~'~ [~~Jl
Phone: 7l~ "7 ~`f j 3 7~'~
Fax: 7f7 7~'-f ! 3 ? ti
Email: ,r'~'~'~ ' ; ~, ~ ~ (z ~cw c c'I.,
DECREE OF THE REGISTER
Estate of (. 15Ci ~.1 L(a~~~~ ~~ )C File No: ~~ ~- ~ ~;f -~ ~~ (t•'~ ~~
a/k/a:
AND NOW, i ; ~' ~' ~ ~~11 ~ , in consideration of the foregoing Petition,
satisfactory proof having been presented before me, IT IS DECREED that Letters ~~ (`~ 41,1 t\1~1~ ~ ~ l ~~G~~~1
~~~ n(.j (, i } ~ ~< <` _ 1 ~-{ ~ are hereby granted to ~: _ r ~ C L[ a~,c;%G ~ C I~
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.
~,-
vG~C r~ -~' ~,~, ' k
Register of Wills ,~ '
Fori~r R4V-Q2 rev. 10/1 ]/?0I1 ~,~~i ~! Page 2 Of 2
HIOS.KOj REV nln I
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograpt~l.
Fee for this certificate, $6.0(~
_ ~' 1821.~.Q~_0____
Certification Numbe:
H106.141 REV 11f2006 ~' " F COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL pECORD3
TYPE / PRINT IN
PBLACK IINK CORONER'S CERTIFICATE OF DEATH
$33-160 (Ses In~tructlons and sxampls~ on rovsroe) ,~«~~ ~,,,••
_..__.______... ,. .._......,.F, A.,, .,,,~~.t
Lisa M Laverick 2. Sex 3. 9acpl $ecway Number -.
°'D"A0'De"^~"'°"'''°°I'•~'°~
s. Age (LestBi
dhdey) Under 1 ear Urdar 1 da 6. Date of BIM Month, 7. Bhlhplea eM epta or br Female
a wu ) B - -
Pl December 8 2011
kbntlw
Days
Hours
Minuwe e.
an d DeeU (Check one
35 Yrs. Ma 2
Bb. coon d Death
N Bc
Ci Tw
d Deets Hapltal: ghar:
5, 1976 Crown point, IN
^ InpellsM ^ ER / Outpetlent ^ DOA ^ Nurang Home Readena ^~,
.
p.
• ;
Bd. Fstlxy Name (H rrot hpddkn, gN, sheet erd number) 9. Was Decedent of H
ppenk Origin? ~] No ^ Yet 10. Race: Amedan hMen
Black
Wnb
t
Cumberland Carlisle ,
,
, e
c.
(If "`~°D':'S'D""'"' (so&.w,i
102 Weat High Street M.da
P
11. Deadenl's Ueal ' n Kintl of eak tlap du most d INe. Do not sane
Ki n,
asdo Rkan, slc.)
12. Wes Deatled ever b ere 13. DeCedenl'e Eduatbrl White
~
~
~ ~
t
~ 11
nd of Work Kind dB~dness / Indusby
I S iali ~ M'oed (Spea~ly) M'"bd• 75' SuroM"9 ~ouee (N wile, gWa meitlen name)
U.S. Armed Fwcee7 Ebmentary /Secondary (0
12~
~ W ~ad~
cd
bge (t1 w
s Cabl ~ ^Y.e No
• 18. Decedent's Mailing Adtlress (Street, ctly r rowm, slats, zip coda) Decedents •
102 West High Street Actual Reeitlenca 17a. 3pte pA Did Decedent
17p. ^ Ya, Deadenl Ihed M
~~
• ?
Twp
nb. caamy C>.unberland , 7d. ~1 Na, Deaaern Livetl wxlin
FaMer's Name (FlrsL mitldle, last. sufix) Actual lirrsb d _ ~~r~ i A ~ P City I Born
IB. MoM,ar't Name (First, mldde, maiden aumame)
20e. InlwmaM's Name (Type! PdM)
Walter Laverick 20b.IM°mpnreMwm°"°o-ea'(sh'°'•`tly"aw"•°etar"'~P°aae)
aflion 1460 Deverly DL'ive, Lakeland, FL 33801
2, e
Met(pd ar D'g
.
p
i Cremation ^ Donation 21 b. Date d Dlelxpltlon (MaMh, day, yarl 21c. Place of
)
21tl. Lacatbn fGN / Worn, s+ela. zip cotla)
^ Burial ^ Removal from State i ~ or Derptlott Hof fman-R-R th '~
we1A~7 or
e ^
H~~
&
]nQ
OMor ~ h Madka Eamhpr l caapri Yea ^ No DeC 13 2011 gal
~
~
22a. SI
ra Sa L' (w ) b. Uarpe Number 22c. Name erd Addpae d FeMIiN Carl isle
- Hoffman-Roth Funeral Home and Cremator
y
Complete 23ea any when adM/ing 23a. To the best d my owbtlge, deem occurred a me Mme, date and place sptetl. (Sgnalure erd pb)
physician rid avatlade et time d deaM to 2 Lkena Number
23c. Date
oedN ease d death. slppd (Month, deY. rear)
~ llama 2426 rMlst be canphbtl M person 24. Time of DeaM 25. Data Pronounced Daetl (MMm, day, year)
26. Waa Ceee Referred to Medal Examiner / Coroner for a Reewn Otlpr men Cremetbn w Donaton?
wMpronouncwseeam 2 ~ 0 M. D ember 9 2011 Y
ea ^No
CAUSE OF DEATH (Sea Imtructlona and axampNa) r Aplxoximab mlavel: Pad II: EMSr oepr
Item 27. Pan is Enter Bp ffiein d event -dreaees, Intynes, or compkatlotp - met dredry ausetl Me deem. DO NOT enter bnMnal evenp such as ardac en
28. Did Tobeca Use CoMdbub t
t
D
lh?
es
o
a
, r
respiratory arrest. a venMCUler fibdlpdm wtltlod sMxing rip etiobgy. List onty one cease on each Poe. r Onset ro Deem but nd retuMing in Iha undadyMq aae given in Pad I. Yes
^ ^ PAY
MME0h1TE CAUSE (Fina daeasa w ~ ^ ~ ^ ~~
padti°n resdting indalhi
-~ a. Complications of Severe Hvponatremia
Chronic Substance Abus ~''I'F'"'~'
Due to (o as a conse
quence i
Pet cwldlbne, tl arty, b. ~ ^ Not pieplent wNan pea yam
b aua Paetl m line e. Due to r ^ Prspnem a tlms d dads
Enter UNSERLYBq CAUSE (or es a cmraequence op:
a Idaema or In that Iddatad the c, ^ Nw pregnard, da
Ore9neM xMin 42 days
99vveennbb r g In death) LASL r
d ~
Due 1° (w as a consequence of): r
d. ; ^ D ~. bN prepiuM 13 day, l0 1 yeef
30e. Wes en Adgpy 300. Were Autppry FInM9s 31. Mewter d Deem 32a. Dale d In ^ Unlmown N pregnant wMIFS Me Past Peer
N7 (Manor. tlay, year) 32b. Deewibe How Inury Ocaned
Perbmretl? Avadade Prior ro Completion
77~k,,ll
of Ceusa d Death? y{.l N•~ ^ Hankide 32c. Pba d Iry'ixy: Home. Faml. Sheet. Fecbry,
OIPa Buildry, sk. (3per/y)
Yes ^ No ~i Yas ^ No ^ Aaident ^ Pending Invealigatlon 32d. Time d InWN 32e. Injury al WoM7 321. P Trenaponalkn Injury (Spa rYyl 32g. laatlm d hryuN (Boast. dN /town
etete)
1'~'
,
^ 6ukida ^ Coukl Nd be Detennkied ^ Yee ^ No ^ DrNer /Operator ^ Passenger ^psdeehlan
M. lJtlpr wry:
33e. Certifier Idieck any ale)
~'roB PNYalcbn (Pnyeiden cerdlying cause d deeM when anodpr phyNdan hen prorpuncee 09em antl cartlplaed hem 23)
T 33b. S neturo antl mfier
S
o
I~knewl.ag.,d~Nap~.~wd~.romep~(.)~,dnMm„`a"d"d_""'
-------
^ -
• ~01101atoroS~ow/B>4nS PNYaroia (Poysidsn bats
----------------'---
Pronoundng gam antl arlNyhp b cape d desM)
T
a
h .Chief Deputy Coroner
o
le
at a
pY 1°wwMlge, e..Bt oaurtae a the INp, dale, and Platy, eM dw b tM
• Modal ExamhprlCaroar dal ae marslwaappd------------------ ^ 33c. license Number 33d. Deb '
S4pd (MOrim. deY, Year)
on np boa. or aagnaM rte r or invaatlgaron, ro my opinion, earn oalarM a the wna, eaea, one Ppa one da ro tb auaQy and mwtnw a aaalatL ~
3d. MtdAd~u d Ps~aq whp comae a Ib Feb guar 21 2 012
rn r
35. ~ r'sSignahnsend ~ Nu
- - ~ I
~ ~ I a~1 ~ I Q
'~'D°ba°dl"'0"~'•°°t•'~ r PrIM
atthew J Stoner, C~i~ef ~eputy Coroner
6375 Baseh
R
d
r
I
-2 ore
oa
, Suite #1
Mechanicsburg. Pa. ll05f1
This is uy t~ertif•~ ~}r.,t thr? infon~tiation I,en° /:tiL~~n i>,
correctly copied tr~.~rr_,(n original CertifiL:ate of f~~ath
duly filed ~Vitl1 rnt~ a, [_(.ual Re,gistrrr. 'I hr original
°ertificate Will I'?s• i?r~yarded to the .'state w'Ital
kecords Ot~fic;: fo( i1~~rnlarlent filing.
' ~ ~< <~, ~~t ~' ~ ,`> , - B 1 T 012
~"~ ' -
I_.ocal Rcr I,trur ~ ,~ t}att.• Issued
rte; -1-3
O ~ T t,:
_~ xY -
G... ~-'~ ~ %~ .
'~ x_ ~) L _.) ~' ~ ..1......
_ .7U it ;~' _ "-. ~:.r:,
7 ~ _ d-t=.
D ~ ' ~~ u7 -C''ri
.C'
Diepwidal Permit No.
' ___2~0~/ 55(p
^~(" ~'
ai2~t'~ I3 ~EN~ 24
RENUNCIATION
CLERK ~~`~
ORPHkN'S nCI,,Rr
REGISTER OF WILLS CUMR~p! t,,,n,,~~ nrl , RA
~~~'-~ ~c~.Q COUNTY, PENNSYLVANIA
Estate of ~i 1 q /~') (c.+s,•~'~ k ,Deceased
I, w'` ('~'~''' ~ °"'~'''~ k , in my capacity/relationship as
r (Print Name)
I ~ ~ ;, N ~~'"~ < <~ of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
® -acs-~ a
(Date)
Executed ii;~ Register's 3~fice
Sworn to or affirmed and subscribed
before me this day
of
Deputy for Register of Wills
~l •
(Signature)
(Street Address)
~d~-~Nr~, /=L 33~~
(etty, stare, ztp)
Executed ~ t[t of Register's Clff[Ce
Before the undersigned personally appeared the
party executing this renunciation and certified
that he or she executed the renunciation for the
purpos ed within on this o~"h day
of ~T~-h n ~yl a
N
ion Expires: P'1~~~ I I, az~ I~{
Form RW-06 rev. 10.13.06
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's Commission.)
~.•"""••. BIBI MOONAB
~~~~a~ p~B ~.
:° ; ~? Notary Public -State of Florida
•': »; "e My Comm. Expires May 11, 2014
=.";,eOFi ~:= Commission # DD 990805
~'"•"„~~~' Bonded through national Notary Assn.
.%
;I?
~~ 13 ~ I I' 24
,
RENUNCIATION CLERK ~;;
ORPHAti'S CJI!Rr
REGISTER OF WILLS
C ~.w {e.,. ~~ ~. COUNTY, PENNSYLVANIA
Estate of L; ,t 4 M ~ o vs,.'~ !~ ,Deceased
I, r~l ~4r., J o ~ • ~s.~ ~ ~i
in my capacity/relationship as
(Print Name)
M ol-k- ~~•v~1-r^•L~ of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
~n~ Ce•+.~ck
/ao/.a
(Date)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this day
of ,
Deputy for Register of Wills
~~ ~~ '
(Signature
(Street Address)
(City, State, Zip)
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 state within on this ~ C~ day
of f~j?GY~~ a,/~.17
Notary Public /~
My Commission Expires: ) /~ 6 aCi/ 7
(Signature and Seal of Notary or other officia~ Gt:ali5ed to
administer oaths. Show do?e of expiration of Notary's Commission.)
Form RW-06 rev. 10.13.06
f, .fir ~ _
tat; = ,~! ~ e
~. •J
'~'!? ~~°~' f 3 ~~f f l ~ 24
RENUNCIATION
CLERK nl-
ORPHAN'tc OLtR r
REGISTER OF WILLS CUP,~fi%G! F;r.~'T;jrn Pq
C ~M d tic C~~- D COUNTY, PENNSYLVANIA
Estate of ~~~14 M Cg ~~.~~~ k
,Deceased
I, ~4~~ ~ o ve.<< lc
in my capacity/relationship as
(Print Name)
rid t~
of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
~~~t. ~a~e.i;c.lt
as a
(Date)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this day
of ,
Deputy for Register of Wills
Form RW-06 rev. 10.13.06
Sara d uc
(Signature)
is 5 ~Yl eaa~Ozl~ lc~rl~ ~e
(Street Address)
~ o-vc~ 19~` r~- _rv~ [~ a ~ ~7~C
(city. State, Zip)
Executed out of Register's Office
Before the undersigned personally appeared the
party executing this renunciation and certified
that he or she executed the renunciati n for the
purposes stated within on this __~ day
of Qit L- ll./~ ~/ ~--
/~1
o ary Public
My Commission Expires:
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's Commission.)
SHANNON D. DOUGHTY
NOTARY PUBLIC
FREDERICK COUNTY
MARYLAND
MY COMMISSION EXPIRES FEB. 23, 2015