HomeMy WebLinkAbout05-01-12PETITION //FOR //GRANT OF LETTERS
REGISTER OF WII.,LS OF (~ yrvf ~r~1a .,~ 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 ~~ ,,rr~~ /
Name: T„ ~ J3et~c File No• C~Ci~ - C~i ~~~
a/k/a:
a/k/a:
a/k/a:
Date of Death: ZZ y o
Decedent was domiciled at death in
principal rfe-sidence at t goo n.(.~ S.T
Gt.F~~T t rtLoNi411s~t~ddress, Post Office and Zip Code
(Assigned by Register)
Social Security No: Zab - D S- Z7~ Z-
Age at death: _ 9
County, ~,A (State) with his/her last
Ca».~, NfJ~ Gam.... `~~
City, Township or Boroagh
Decedent died at f '700 S.~" o ~ ~,'~ ~
Street address, Post Office aad Zip Code City, Towns 'p or Boroagh
Estimate of value of decedent's property at death:
Coanty
County State
If domiciled in Pennsylvania ............................All personal proP~'h' $ / ~ Qt OOQ . 0~
If not domiciled in Pennsylvania ........................Personal property in Pennsylvania $
If not domiciled in Pennsylvania ........................Personal property in County $
Value of real estate ix PennsYlvania ......................................................... $
TOTAL ESTIMATED VALUE.... $~ Qp~
Real estate in Pennsylvania situated at:
(Attach additional sheets, if necessary.)
Street address, Post Office and Zip Code City, Township or Boroagh County
l~ 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 ,(~ and Codicil(s)
thereto dated
s ~ ~ -~°6 ~`. d°~.c-~4P art.. ! ° Z+h 7
State relevant circumstances (e.g. renunciation, eath of executor, eta)
C7 __
Except as follows: after the execution of the instrument(s) offered for probate Decedent did not marry, was not divorcenot a p ~LL apen~}n ,~
divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(g), an ~ot have ~ild b6~~
adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. A ~ ~ -~,- ~~',: ~i
Sl NO EXCEPTIONS ^ EXCEPTIONS ~ ~ ~ '
^ B. Petition for Grant of Letters of Administration (If applicable) : ~ C~ ~n `' -
c.t.a., d.b.n., d.b.n.c.t.a., pendente lite, durante a -- tin, durante minazz'la{~:
--~ .~ ... .. r,-;
If Administration, c.t.a. or db.n.c.~a., enter date of Will in Section A above and completelist of heirs~ ~'~ G
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 has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs (attach
additional sheets, if necessary):
Name Relatianshi Address
Form RW-01 rev.1oi11izo~1 Page 1 of 2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA }
} SS:
COUNTY OF }
Official Use Only
Petitioner(s) Printed Name Petitioner(s) Printed Address
ysY ~ d~ ~~~ ~-? ~7
,` oK~~
,~
The Petitioner(s) above-named sweaz(s) or aff rm(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 y administer the state according to law.
Sworn to or affirmed and subscribed before -~- ~ ~ ~ ~ Gw[ ~~ate ~ - ~ 7 - /
me this ~7 r~ day of ~' iy ~ 'Date
$y; Date
or the Register Date
SOND Required: ^ YES ^ NO
~'~~5:
QG~~
Letters ...................... $
( '~ )Short Certificate(s)..... .
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commissio .... ...
Other _~ ~ .. , .. .
Automation Fee ...............
7CS Fee ..................... '
TOTAL ..................... $
To the Register of Wills:
Please eater my appearance by my signature below:
Attorney Signature:
/ l/ I/ 4.~C/[/ ~
Printed Name: "C~~-~1'.nn /Y~~~
Supreme Court ~ ~~ ~ y
ID Number:
Firm Name:
Address: `(
[ O
Phone: ~ [ '~ - (.l Z -g ~ g
Fax: -' 7l' 77
Email: 13 L ~ ~ ~i'~/ Gr- . Cori
17 r- -~ ;: _:~:~
~ R'' ~ ~ ~ ~
"7O n
-
-~ ~-- _-. r
_ .
_,:
v --i _
..: -
!-.._ ^~-i
~. --rz
Form Rw-oz rev. loiuiao~! Page 2 of 2
Oath of Personal Representative
CO'vl~tO~WEALTH OF PENNSYLVAVL-~ }
} SS:
C~;L'~TY OF ,
Official Usc Only
- - ~
Petition ~ P-;r.r~d >.daress
The Petitioner(s) above-named swear(s) or trm(s) the statements in the foregoing Petition are taste and correct to the best of the knowledge and belief
of Petitioner(s) and that, as Personal resentative(s) of the Decedent, the Petitioner(s) will well and truly administer the estate according to law.
Sworn to or affirmed a subscribed before Date
me this da Date
By:
Date
Fort Re,;ister Date
BOND Required: ^ YES ~ NO To the Register of Wi!!s:
FEES: Please enter my appearance by my sign re below:
Letters ...................... $ Attorney Signature:
( )Short Certificate(s)..... .
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Botid ........................ Pri d Name:
Commission .................. upreme Court
Other ........ ID Number:
•••••••• Firm Name:
•••••••• Address:
•••••••• Phone:
Automation Fee .............. Fax:
1CS Fee . .. ................. Email:
TOTA ..................... $
DECREE OF THE REGISTER
Estate of ~~ r I ~ ~~ C~` File No: r I ~ 1 ~ - ~ 5~~
a/k/a:
AND NOW, ~(, 1 ~~ 1 ~ , in consideratipn of the foregoing Petition,
satisfactory proof having been resented before me, IT IS D CREED_ that L rs -e~`IZ~IY~2.'~
are hereby granted to ~ ~C.Y
to the above estate and (if applicable) that
the instrument(s) dated ~ ~~
described m the Petttton be admitted to probate and filed o~ r~cord as the last Will (and Cody}1(s)) of Decedent
of Wills
Form RGV-02 rev. !0/!1/2011 , O !!?~~-~~~C 2 Of 2
LOC~"R~?G~~~F~~R'S CERTIFICATION OF DEATH
WARI~;;,(t is illegal ^tp duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00 `~I ~ ~ ~ ~ ~ ~ ~ ~ 3}~ ~ ' ~ ~ This is to certify that the infortnati(n~l here liven is
cc)rrectly copied from an original Certificate of Death
(~~~~( ~~ duly filed with me as Local Regist~~aJ-. 'I~he original
~RP~"~ ~O~RT certificate ~a ill be forwarded to the State Vita]
Kecords 0f1`~ice for permanent filing.
Cl1M~FRl /~~~~~, ~'',~ PA
P 18388967 ~~1~~ A~za o~2
Certification Number
Type/Print In
Permanent
~~
V
m
C
Local Kegistrar ~~?~ Date Issued
COMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF HEALTH ~ VITAL RECORDS
f"C~TS LS!`AT~ A
- - - -" - - - - State Fiie Number:
1. Decedent's Legal Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number 4
D
t
f D
h
.
a
e o
eat
(MO/Day/Vr) (Spell Mo)
John Back
Male 206-OS-2732 April 22, 20'12
Sa. Age-Las[ Birthday (Yrs) Sb. Under 1 Veer Sc. Under 1 Da 6. Date of Birth (Mp/Day/Near) (Spell Month) ]a. Birthplace (City and State or Foreign Count
)
ry
Months Days Hours Minutes Monessen
PA
,
9~ March 4, 1921 ]b
Birth
l
.
p
ace (cpunty) yyestmorEaland
8a. Residence (State Or Foreign Country) Sb. Residence (Street antl Number -Include Apt No.) 8c. Did Decedent Live In a Township?
®ve:
decedent used In Lower Allen Twp
PA 824 Lisburn R
d
A L 21
.
.
oa
,
6
8d. Residence (County) p wP~
Cumberland 8e. Residence (tip Code) "1 70'I ~ I~ No, decedent Ilved within limits of
city/bo
9. Ever In VS Armed Forces? 30. Marital Staf us at Time of Death Q Married ® Widgwed 11
Survivin
S
ous
N
If
f
.
g
p
e s
ame (
wi
e, give name prior to first marriage)
I~ Yes Q NO Q UnknO Q Divorced 1~ Never Married I~ Unkno
w
12. Father's Name (First, Midtlle, Last, Suffix)
13. Mother's Name Prior to First Marriage (First
Middle
Last)
,
,
Jack Back Rose Ribich
14a. InformaM's Name 14b
R
l
[I
hi
O
'
.
e
a
Ons
p to
ecetlent
Jo
B
k Bi
i 14c. Informant
s Melling Address (Street and Number, City, State, 2Ip Code)
an
ac
tont
Daughter 4547 Deer Path Road Harrisbur PA 17110
'~ ......... .. _ _ _ ~ ~ _ _ _ a. P ace o Deat
I~Dea[h Occurred In a 1-lospital: tr lipatl
nt
I
De
t
Oc
u
r
d
Y
e
•
f
1v
a
h
r
c
e
Somewhere Othe
Th n e Hospital ^ Hospice Facility C~ Decedent's Homes
Q Emergency Room/OUtpatlent Q D
d
•
ea
on Arrival Nursing Home/Long-Term Care Facll lty ether (Specify)
15 b
Facilit
N
m
If
I
~ .
y
a
e (
not
nstRUtlon, glue street antl number)
lSC. City or Town, State, and 2Ip Code lStl. County Of Death
Manor Care, Camp Hill Camp Hill, PA 170 ~ C
b
l
d
um
er
an
16a. Method Of Disposition ® Burial Q Cremation i6b. Date of Disposition 16c. Place of Disposition (Name Of
t
ceme
ery, crematory, or other place)
O Removal from state p Donation
04/23/202 Mon Valley Memorial Park
Ocher (Specify)
16d. Location of Olsposltfon (City or Town, State, antl Zip) 1]a. Sign u Fun Service Licensee or Person in Charge of Interment 3]b. License Number
Donora, PA ~ 5053 FS O'12 849 L
E
.9 1]c. Name and Com late Address Of Funeral Facility
Parthemore ~unaral Home 8
Cremation S
i
I
'
~ r
erv
ces,
nc., P. ox 431 ,
1303 Bridge Street New Cu mbarland, PA '17070
18
d
'
. Dece
ent
s Educstipn -Check the box that best describes the 19. Decedent of Hlspanlc Origin -Check the 20. Decedent's Race -Check ONE OR MORE
I- races to Indicate what
highest degree or level of school completed at the time of death. box [hat best describes whether the decedent the decedent con
id
d h
s
ere
imself or herself to be.
Q Bth grade or less Is Spanish/Hispanic/Latino. Check the "NO" ® White Q Korean
Q No diploma
9th - 12th
rade
,
g
box if decedent Is not Spanish/Hispanic/Latino. Q Black or African American Q Vietnamese
® Hl
g
h school graduate or GED completed
O
r
®No, not Spanish/Hlspanlc/Latino Q American Indian or Alaska Native Q Other Asian
Q S e college credit
but no degree
,
Q Yes, Mexican, Mexican American, Chicano Q Asian Indian Q Native Hawaiian
Q Associate degree (e.g. AA
AS)
,
Q Ycs, Pu<rto Rican
Q Bachelor's tlegree (e. g. BA, AB, BS) Q Chinese Q Guamanian or Chamorro
~ Yes
I
Cub
n
,
,
a
Q Filipino Q Samoan
Q Master's degree (e. g. MA, MS, MEng, MEd, MS W, MBA) Q Ves
other S
anish/His
i
/L
i
,
p
pan
c
at
no Q Japanese 1,~ Other Paciflc Islander
Doctorate (e. g. PhD, EdD) or Professional tlegree
(Specify) 0 Other (Specify)
. MD DDS DVM LLB JD
21. D<ceden['s Single Race Self-DesignatlOn -Check ONLY ONE to Indicate what the Decedent co nsideretl himself or herself t
b
22
'
o
e.
a. Decedent
s Usual Occupation -Indicate type of work
® White Q Japanese Q Samoan d
one during most of working Ilfe. DO NOT USE RETIRED.
Q Black Or African American Q Korean 0 Ocher Paciflc Islander
Q American Indian or Alaska Native Q Vietnamese 17 Don't Know/Not Sure Manager
Q Asian Indian Q Other Asian Q Refused
22b. Kind of Business/Intlustry
Q Chin<se Q Native Hawaiian Q Other (Specify)
Q Filipino I~ Guamanian or Chamorro
Steel Mfg.
ITEMS a - 23d MUST BE COMPLETED 23a. Date Prgnouncetl Dead (Mo Day/Yr) 23b. Signature of Person Pronouncing Death (Only when applicable) 23
By PERSON WNO PRONOUNCES OR
U
<.
cense Number
CERTIFIES DEATH 04/22/20 ~ 2
23tl. Date Signed (MO/Day/Yr) 24. Time of Death MD 421 980
3:1 5 pm 25. Was Medical Exe miner or Coroner Contacted? Q Ves ® No
CAUSE OF DEATH
26. P
Approximate
as 1. Enter the cha~vg^.5--diseases, Injuries, Or complications--that tllrectly caused the tleath. DO NOT enter terminal events such as ca rtli
e
ac arrest, Interval:
r piratory arrest, or ventricular flbrillatlon without showing the etiology. p0 NOT ABBREVIATE. Enter only one cause on a line. Atltl adtlitional lines If necessary. Onset to Death
•
•
IMMEDIATE CAUSE --------> a. SBpS15 • `ate-t.[G7
(Final tlisease or cond HlOn Due to (o as a consequence of):
reauRing in death)
b. urinary tract infection Li W,¢Q
t
.
(~
Sequentially list conditions, Due to (o as a conse
uence
f
q
):
o
If any, leading t0 the c
<
listed on Ilne a Enter the
UNDERLYING CAUSE Due t0 (o
~ as a consequence of):
(tlisease or Injury that
F Initiated the events resulting d.
I
!S
O n tleath) LAST. Due to (or as a consequence of
)
26. PaR 11. Enter other slenlflcant tontli[Ipns t Ib ti t d th but not resulting in the underlying cause given in Part I. 27
W
~ .
as a autopsy performed?
Q Ves ® No
28. Were autopsy findings available
t0 complete the cause of tleath?
29. If Female:
Q Y
I
E es
~ No
30. Ditl Tobacco Use Contribute to Death?
31. Manner of Death
Q Not pregnant within
est
ear
p
y
Q Ves Q Probably ® Natu rai
I~ Pregnant at Lime Of death
1~ Homicide
~' ®
f
Q Not pregnant, but
ys of death No Q Unknown 0 Accident 0 Pending Investigation
n 4
r- to l
Q Not pregnant, but Suicide Coultl not be determined
egnaM 43 tla
P
Ys year before death 32. Date Of Injury (MO/Day/Yr) (S
ell M
th
p
on
)
Unknown if
~ pregnant within She past year
33. nme of Injury
34. Place of Injury (e.g. home; construction site; farm; school) 35
Location
f I
S
.
o
njury (
treet antl Number, City, State, Zip Cotle)
36. Injury at Work 37. If Transportation Injury, Specify: 38. Describe How Injury Occurretl:
1~ Ves Q Driver/Operator Q Pedestrian
® No Q Passenger Q Other (SpeclTy)
39a. Certifier (Check only one):
® Certifying physician - TO the best Of my knowledge, death o red tlue to the cause(s) antl manner statetl.
17 Pron
i
8
ounc
ng
< Certifying physician - To the best of my knowledge, death occurred a[ the time, tlate, and place, antl due to the c e(s) and ma
Q Medical Examin
/C
er
nner statetl.
oroner - On the basis of examinetlor~~/or Investigation, In my opi nlOn, tleath occurred at the time, tlate, and place, and tlue to the cause(s) antl m her statetl
/
n
.
Signature of certifier:
IM ~
Title of certifi
r
:
e
ucense Number: MD 421 980
39b. Name, Address and Zip Code Of Person Completing Cause of Death (Item 26
) 39c. Date Signed ( /Day/Vr)
Dr. Namrata Haldipur, M. D., 3456 Trindle Road, Camp Hill, PA '170'11 L{ Z c.~ ~
4 1 Z
0. Registrar s District Numbe
r
41. Registrar's nature
~
r
42. Registrar F{le Dete (MO Day/Vr)
Z ~ ~
~'
/
'/
CaL
43. Amendments T ~ °~ ~/d ~ ~ L
n,......,.,..., oe....,. n,., ( ) /t~ /~ L~, '~Lf, H10S-143
i
..
la-s6~Y
LAST WILL AND TESTAMENT
OF
JOHN BECK
I, JOHN BECK, of the City of Monessen, County of West-
moreland and Commonwealth of Pennsylvania, being of sound
mind and memory, do hereby make, publish and declare this to
be my Last Will and Testament, in manner and form following,
hereby revoking any will or wills heretofore made by me.
FIRST: I direct that all my legal debts and funeral
expenses be fully paid and satisfied, as soon as conven-
iently may be, after my decease.
SECOND: I give, devise and bequeath all of my Estate,
real, personal and mixed and wheresoever situate to my
wife, MARY BECK, to be hers absolutely.
THIRD: If my wife, MARY BECK, should fail to survive
me, in that event, I give, devise and bequeath my entire
Estate to my daughter, JOAN D. BECK, to be her: absolutely.
FOURTH: I do hereby make, constitute and appoint my
wife, MARY BECK, to be my Executrix of this my Last Will
and Testament. If my wife, MARY BECK, should be unable to
serve in this capacity for any reason, then, iri that event,
I appoint my daughter, JOAN D. BECK, to serve in her stead.
My Executrix shall serve without Bond.
IN WITNESS WHEREOF, I, JOHN BECK, the Test;ator above
named, have hereunto s cribed my name and affixed my seal
the day of 1976.
~ L.~....~-;rte-t-= ~,t~..Y~'~ ~...... ( SEAL
dd ':;'~) ~~r,` ~'~3'a'~v11~ John Beck;
~_1'~i1.j~„'
~. - ~ ~~~
_ ,,_ _
~;-- _ ~-,
'.
w
r
LAST WILL AND TESTAMENT OF
JOHN BECK
PAGE TWO
SIGNED, SEALED, PUBLISHED AND DECLARED bye the above
named Testator, John Beck, as and for his Last; Will and
Testament in the presence of us, who have hereunto subscribE
our names at his request as witnesses thereunto, in the
presence of said Testator and of each other.
Id
~~ ~~~ ~~ r
r-=-
!COMMONWEALTH OF PENNSYLVANIA )
SS:
COUNTY OF WESTMORELAND )
I, JOHN BECK, Testator, whose name is signed to the attach d
or foregoing instrument, having been duly qualified according
to law, do hereby acknowledge that I signed and executed the
instrument as my Last Will; that I signed it willingly; and
that I signed it as my free and voluntary act for the purpose
therein expressed.
7
o n Beck
SWORN TO AND SUBSCRIBE
before me this
day of 1976.
,r,
~~ i
r
t p
P"a5:^. ,`: "9, 4",`eM~v'tFttrr,?,..i C~a.. F~a.
::'~~ ~s..-~~zsG,.. ~x,:,'sTes Suite il, 1475
I
COMMONWEALTH OF PENNSYLVANIA )
COUNTY OF WESTMORELAND ) SS:
WE , ~~K, L . ~~~~s~;~Jand p S ~~~~, the wit-
nesses whose names are signed to the attached or foregoing
instrument, being duly qualified according to law, do depose
and say that we were present and saw Testator sign and exe-
cute the instrument as his Last Will; that te~~tator signed
willingly and that testator executed it as hi:~ free and vol-
untary act for the purposes therein expressed; that each of
in the hearing and sight of the Testator, signed the will as
witnesses; and that to the best of our knowledge the Testa-
tor was at the time 18 or more years of age; of sound mind
and under no constraint or undue influence.
SWORN TO AND SUBSCRIBED
before me this a ~
day of 1976.
y ~ 1~~ ~,
S`
No~~~rc~.o ,~~t~'v~tis ,;
t+,ny Com~+`~sie:'. }xp•res 5upe ]]~ ]97~i
Ir s