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PETITI/]ON FO/R GR4NfT OpF LETTERS,)~~~ ~QY _~ ~~ 3: ~~
REGISTER OF WILLS OF (~ (,( fy 6riY~Gl yly COLRJTY,'PEDNSYLVAVIA
,~ rnv n~
Petitiot ^..nec na'ra. s'7o s sr l3 gars of ~ or c ~ ',. app(y(iesi ter Lz! ~ cit ed lo~.v, and in
~~'g , ~
suppor, [r _..~~t a~at(,I .he o~:u v,n_ nod resFectfc 1_ eecutstl,>I th ?rlnt of Let,ar; ii~~~~~m.~ `
Decedent's Information ~I ~,y
Name: /r .AOYtI ~.. c7C0I!
a'k'a:
a/k/a:
a/k/a; _
Date of Death: L~nr l I h . a01 a
Decedent was domic
principal residence at
(Store) with his/her last
Street address, Post Otfice and Zip Cade / City, Township ur' Borough ~^r County
Decedeutdiedat /D ~f ~,Se~t~.aS~~ srm /2"VSbur~i L,Um 6. P~
Street address, Post Ofnce and Zip Cade City, Townsl or Borou Count--~ y -~ta'te
Es[imate of value of decedent's property at death:
If domiciled in Pennsylvonia ............................ All personal property $ aSBO. pp
ljnot domiciled in Pennsylvania ........................ Personal property in Pennsylvania $
Ijerot domiciled in Pennsylvania ........................ Personal property in County $
Value ajrea! estare in Pennsylvania ...................... .................. $ D 00
TOTAL ESTIMATED VALIJE.... $
Real estate in Pennsylvania situated at l I ~ h J hU/Q,n a m )C
(Attach addnionnl sheets, i/'nec¢ssaryJ Street address, Past Orn<e and Zip Code
^ A. Petition for Probate and Grant of Letters Testamentary
Petitioner(s) aver(s) helshe/they is/are the Executor(s) named in the last W ill of the Decedent, dated
thereto dated
and Codicil(s)
State reI¢Yenf elreamSlanC¢8 (¢.g. renr,llrtrttlan, death aJ¢xecntor, erC.)
Except as follows: after the execution of the instrument(s) offered for probate Decedent did not many, was not divotred, 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 boot or
adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person.
^ NO EXCEPTIONS ^ EXCEPTIONS
~B. Petition for Grant o` Letters of Administration (If applicable)
c. t.u., d. b. n., d.b.n.at.u., pendente lire, durunte absentia, durance minoritate
If Administration, c.t.a. or d.b.n.c.t.a., enter date of Wi11 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.
9 NO EXCEPTIONS ^ EXCEPTIONS _
Petitioner(s), after a proper search haslhave ascertained that Deceder.: Icft no Will and was snrvivedby the following spouse (if any) and heirs (aauch
additional sheets, i(necessary):
Name Relationshi Address
an>rf ~. O~ob~r'fs rno~he/' !o ~t'aNfar) sf. Lemon yn~~ ~°a
~i ~~r~~• CO $/m4Y1 ~i5'~Q a ,~~2Jn ~ ~?o
h/r~m n ~r
File No: ~- ~ a - 5 yt
(Assigned by Register)
Social Security No: oZ0 9" ~~O _ ~ ~ 8
Age at death:
ar Boroagn conmy
~~~
d~
Fmm RW-OZ rev. !0//111011 PagC I Of 2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA }
~" ~j } SS:
COI.'NTY OF~ Vrmy~~~~ah~
L (f~~
Pae[ionea s; Pr:c'._4 Vmne Pari ~ _
~~ e C o er~ s /0 9 a S, ern "e 1~ 3
The Petitioner(s) above-named swoar(s) or affirm{s) the statements in the foregoing Petition are tme and correct to the best of the Imowledge and belief
oFPetitioner(s) and that, as Personal Representative(s) of the Dece nt, the Petitioner(s) wd . ell and truly admi ~ster the estate according to law.
Sworn to or affirmed an subscribed efore ~~ C ~~ Date Jr `~' ~
me this l ay of Date
By: Date
the Register Date
BOND Required: AYES ~O Ta the Register of Wills:
FEES' //////~~~``~'' Please enter my appearance by my signature below:
Letters .................... .. $
(4 )Sho rt Certificate(s)... ...
( I )Renunciation(s)...... ... --~5
( )Codicil(s) .......... .. .
( )Affidavit(s)......... .. .
Bond . .................... ...
Comm ission ............... .. .
Other ..... ...
Automation Fee ........ ....... ~
~~/
1CS Fee .............. T(T-
....... ~~~
~
TOTAL .............. ....... $
'~'.+~L,L
Attorney Signature:
Printed Name:
Supreme Court
ID Number:
Firm Name:
Address:
Phone:
Fax:
Email:
CREE OF THE REGISTER
Estate of
a/k/a:
AND NOW,
satisfactory proo
File No: d ~ ~~ ~i` ~ ~
_~, in con deration of the foregoing Petition,
,~
presented before me, IT IS DECREED that Letter.; rr,'~ i ~fi-~s ~_ O K
_ are hereby granted to ~~si~ ~ ~ ~r,~ ~'~
in the above estate and (if applicable) that
the instaunent(s) dated n he
described in the Petition be admitted to probate and filedgfrecord as the (asl~ Wy~l (and Codicil(s))
Form R4V-Ol rev. IO/(IR01! \ ~ ~' ~r v - `"- Page 2 Of 2.
Ir\!'Y .. e'~.
f~f ,, lr, ..: ~. -'~~;~ OF
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5.805 REV 1911 b
L0~1 REGISTRAR'S CERTIFICATION OF DEATH
(~`Gt It 7~(jre~l to duplicate this copy by photostat or photograph.
r,
ee for this certificate, $6.C~(t2~AY ~9 ~~trt 3r ~ 7
.~, 1~
CUMBERL+MID C0~ PA
P 18388800
Certification Number
This is to certify that the information here given is
correctly copied from an original Certificate of Death
duly filed with me as Local Registrar. The original
certiticate will be forwarded ro the Stale Vital
~JReeords Off~~ic.e,~~tbr permanent tiling.
~~~%~~%~- AAR 7/0 201
Local Registrar ~~~ Date Issued
pe/print In COMMON WEgLTN OG PENNSVLVANIq • OEpgRTMENT OF HEALTH V ITgL pECOR05
CERTIRCOTE AF OEATN
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BV PERSON WNO PRONOV NOES OR
CERTIPIEg OGTN
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35. Wes Mlelul EKeminer or <v.one, COn[acteal /%~
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1 CAUSE OF DEATH
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SlBnatur@orcertlrler: "Z Title of certlller:
/~~ eNUmber: rNy O{eyes qQ-L
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39b. Name, Atle[esa ane z1p Cotle bf Person completing Ceuae i h (item 3g)
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: s18
~/'a ~/ - rFle Dat. MO Day r
'S~~Y r/ =?o / L
3. gmantlmenti
ONpo,lVOn prime[ NO. O / e O I ~ ( H303-143
_ REV O>/2011
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''%l?i21iAY -9 Pt` 3~ 3"t
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RE\L~~tiCI:~TIO~~MBF I~iDC()TPA
LL RE ISTER OF ~ ILLS
~{ v r Nn~'OUNTY, PENNSYLVANIA
Estate of
I,
Deceased
in my capacity/relationship as
(Pant Name)
c~/.$ Tr:I Z of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
/Date)
Executed in Register's Ojfice
Sworn to or affirmed and subscribed
before me this day
of ,
Deputy for Register of Wills
~ ~~~. Q,.~.,,,..,.
(Signature) U
(S7reetAddress)
~~/ tE/f'/9NS`TDGd/d . ~, /mil/
(::iry, 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 renunci tion~r the
purposes stajed within on this day
Notary Public ~ ~ ,y~ r'"
My Commission Expires: r'/~C}/ Z~ ~-v`3
J
(Signature and Seal of Notary or other official qualified ro
administer aa[hs. Straw dare of expiration of Notary's Commission.)
Betty K Hoover, Notary'Puhlic
Lemoyne Borough, Cumberland Caunt
Form RW-O6 rev, 10.13.06