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PETIT/I~ON FOR GRA1NT OF LETTERS
REGISTER OF WU.LS OF CUtnbe~Iavi d. COLJNT'Y, PENNSYLVANIA
Petitioner(s) named below, who is/aze 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 n
Name: AMRNQA ~bSE Btt~(rNF.p.
alkla:
a/k/a:
a/k/a:
Date of Death:
Decedent was domiciled at death in CumBEZt,A~D County,
principal residence at 110 FOJQ Seaswts
Street address, Post Office and Zip Code
Decedent died at
File No: ~' 1' ^'~ - 'J l
(Assigned by Register)
Social Security No:
Age at death:
(Stare) with his/her last
City, Township ar Borough
Street address, Post Office and Zip Code City, Township or
Estimate of value of decedent's property at death
Ijdomici/ed in Pennsylvania ............................ All personal property
Ijnot domiciled in P¢nnsy!vania ........................ Personal property in Pennsylvania
Ijnot domiciled in Pennsy[vania ........................ Personal property in County
l~alue ojreal estate in Pennsylvania ......................................:..................
TOTAL ESTIMATED VALUE... .
s %04 . ~X1
Reai estate in Pennsylvania situated at: A~ON~
(Anoch addi[iona! sheets, if necessary.) Street address, Posi Offire 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(aze the Executor(s) named in the last Wi11 of the Decedent, dated
thereto dated _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
and Codicil(s)
State relevant circumstances (eg. renanciodon, deatA of execator, elc.)
Except as follows: after the executionoftheinstrumem.(s)offeredforprobateDecedentdidnotmarry,wasnotdivorced,wasnotapattytoapending
divorce proceeding wherein [he 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.
Q NO EXCEPTIONS Q EXCEPTIONS
® B. Petition for Grant of Letters of Administration (If applicable)
c. t.a., d.b. n., d.b.n.c.t.a., pendente lire, durante absentia, duran[e minoritate
If Administration, c.t.a. or db.n.c.t.a., enter date of Will in Secrion 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 Q EXCEPTIONS "°~
Pefitioner(s),afterapropersearchhas/haveascertainedthatDecedentleftnoWillandwassurvivedbythefollo~ouse(if~)anditra~ troth
additions! sheets, if necessary): ?TJ ~ ~.a. ~~ ~ j
n ,.- --c P -~. is
Name Reiationshi Addr? ~~ !V t..:il-`,
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Form xw-oz reu. Joirtizotr Page 1 of 2
County
"~/k1PHlN tPf~.
County State
a
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA }
} SS:
COUNTY OF L'umBEiccs-n1 b }
Of&cial O
e Only
s
f?l,(Js ~
C
ii_I:~f: ._ ~tiii~
Petitioner(s) Printed Name Petitioner(s) Printed Address
f~, i~ anZ0.~z 31b 4't-1'+ S-t- e0 ~x J5 PA 093
Ciyh4BRRLAND C~. PA
The Petitioner(s) above-named swear(s) or affirm(s) the statements in the foregoing Petition ate true and cottect to the best of the lmowledge and belief
of Petitioner(s) and tbat, as Personal Representative(s) of the De//~~~nt, t}te Petitio t (s) will well and tmly administer the estate according to law.
Sworn to or affirmed and subscribed before ~l~h~ Date ' ~ 7' 2.
met 's ~' day of _ ,r~f~ Date
By: Date
For the Register Date
BOND Required: Q YES ~,r LV0
FEES: //
Letters ...................... $
( '~ )Short Certificate(s).... - _
( 1 )Renunciation(s)......... , ~ -
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commission ................. .
Other ~ ........
Automation Fee ............... Jca
JCS Fee . ....................
TOTAL ..................... $
To the Register of Witls:
Please enter my appearance b;y my signature below:
Attorney Signature:
Printed Name:
Supreme Court
ID Number:
Firm Name:
Address:
l7 5
~~ DECREE OF THE REGISTER ~/
Estate of 4~~ r!`t ~~t ~~ (~ ~ File No: ~" ~ ~~ , J r
a/kJa: a
AND NOW, d(~J ~ , in consideration of the foregoing Petition,
satisfactory proof h ing een presented before me, IT IS DECREED at Letters _
aze hereby granted to ~n', ~~ ~T~Qsze-.-
in the above estate and (if applicable) that
the instrument(s) dated ~1
described in the Petition be admitted to probate and filed o~'ygcordlas the`~rst Will (and Co 'cil(s)j of Decedent.
Fours xw-oz rer. toiiJizor~ Page 2 of Z
HI05-ROS IiEV (91111
LOCAL REGI6AHG'B~TIFICATION OF DEATH
WARNING: It is illeg~F~~dErpli~at~~4~ts copy by photostat or photograph.
Fee for this certificate, $6.00
P 18160878
Certification Number
Tgyp./PNm m
Onr
,~.~~7 ~~Y -~ ~~,Irr,.r/r,/~4, This is to certify that the information here given is
rdu"°E,P~ FPEry;~;=_ correctly copied from .+n original Certificate of Deatk
~~~ _ 'rr=, duly filed with me as Local Registrar. The origins
~~ _- ii certificate wit] he forwarded to the State Vita
a~~~~ ~nt Records Office for permanent filing_
~~a~ v ati~,rl' M R ~ 6 2011
,,,,,,,,,,1
Local Registrar Date Issued
COMMONWEALTH OF PENNSYLVgNIq • DEPgRTMENT OF FIE/LLTH VITgl0.FCORD3
CERTIFICATE OF DEATH
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Dlspnsplpn PermR NP. U GP 7 U ~ / / REV '193
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RE~titiCI ~TIO~i
'~~i2~;~Y-2 FH f~ 44
CLERK OF
ORPHAN'S CGURT
Ct1P~1RFRl AND {;0 RA
L RESISTER OF w"ILLS
~umJer• IQ~ c~. COLNTY, PENNSYLVANLa
Estate of rl m ~ ND~ ~ - ~ ~ tG H ~' ,Deceased
I, C ~ I FFr~R.D A. L 1 D D 1 c.k , ~R • _, in my capacity/relationship as
(Pant Name)
FATHER of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
f1NitA CaNZA~EZ-
(Date)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this day
of
Deputy for Register of Wi(Is
Form RW-06 rev. !0.13.06
(Signature)
l.y~t /.xlLC~fk'sL GyPDY~"aQO~
(Sweet Address)
,~~w ,~3Gool7GteLA !°fl. l7a68'
(City, State. Z~pJ
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 Z7 day
of n~ ~C7tZ
otary Public
My Commission Easpires: ~~ - / _ I Z
(Signature and Seal of Notary oc other oRmial qualitied to
adminiQpp~®tiV~'At?Rf00FtRBNN $ommission.)
NOT IAL
BRFiNDA L. WATSON, Notary Public
N~wBloomtfeld Borough, Party County
M Commiwlon E' Irae Nov. 1, 2012