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PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF Cumberland 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: John H. Jenks Jr. File No: ~~ ~ - ~ ~_~ -- ~~ j °~ -~~~,
a/k/a: (Assigned by Register)
a/k/a: Social Security No:
Date of Death: March 20, 2012 Age at death: 72
Decedent was domiciled at death in Cumberland County, pennsvlvania (State) with his/her last
principal residence at 6 Pocono Dr., Mechanicsbure PA 17055 Upper Allen Township _ Cumberland
Street address, Post Office and Zip Code City, Township or Borough County
Decedent died at Lifc Care Hospital Mechanicsburg PA 17055 Cumberl•m_d PA
Street address, Post Office and Zip Code City, Township or Borough County State
Estimate of value of decedent's property at death:
/f domiciled in Pennsp[vmiia ........................... All personal property $~S tom. ~ :i
If i:ot domiciled in Pennsylvania ........................ Personal property in Pennsylvania $
--
/ not domiciled iia Pennsylvania . ....................... Personal property in County $
--
I~a ue of real estate in Pennsylvm:ia ......................................................... S __
TOTAL ESTIMATED VALUE.... $ ,? , o C> 0.00
Real estate in Pennsylvania situated at:
(Attach additional sheets, ifnecessarv.)
Street address, Post Office 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/are the Executor(s) named in the last Will of the Decedent, dated
thereto dated
and Codicil(s)
~~
~9
r
State relevant circumstances (e.g. renunciation, death of executor, etc.)
Except as follows: after the execution of the instrument(s) offered for probate Decedent did not marry, was not divorced, ~ ~ a party t`~~ypendi ~~_~
divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. 3323 ~7 '~
§ (g), and d i~Ck~ave a c born,t>r --
adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. ~ -;`;`' ~ ~°'^~ ;~,;°~
~- f\3 i
ONO EXCEPTIONS O EXCEPTIONS ~ ' 1
~ 1 _ -
B. Petition for Grant of Letters of Administration (If applicable) C;~ ~ ~ ~ ,~
c. t. a., d.b.~i., d. b. n.c.ta., pendente life, durante a6se~:uria, durant~7ninoritµt~ ~~
~ -~ _~
If Administration, c. t. a. ord. b. n. c. t. a., enter date of Will in Section A above and complete li'i~ of heirs. cn `-'~
c:: ,
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' NO EXCEPTIONS O 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 sheete•, if necessary):
Name Relationshi Address
Virginia Jenks Wife 6 Pocono Dr., Mechanicsburg, PA 17055
Foi~mR6V-02 rer.l0i11i20/1
Page I of 2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
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COUNTY OF Cumberland
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Petitioner(s) Printed Name Petitioner(s) Printed Address _
Vir inia Jenks 6 Pocono Drive Mechanicsbur PA 17055 r,
The Petitioner(s) above-named 5tvear(sj or affirm(s) the statements in the foregoing Petition are true and correct to the best ofthe knowledge and belief
of Petitioner(s) and that, as Personal Representative(s) of the Dece~t, she Petition ~{~) will well and truly administer the estate according to law.
~,.- ~
Sworn to or affirmed and subscribed before '~ ,71 ~n_'~~ Daa:e~ -'~ ~ 1~
me tip ~ day of f~. ~ ~ ~-. ~ r, Date !
BY %' ~ ~ ,t k 1~ 1 ~_ ~ . ~-~~ ~ ~ Date
Fnr the Register Date
BOND Required: 0 YES ~NO To the Register of Wills:
FEES: Please enter my appearance by my signature below:
Letters ...................... $ ~(,~~~~~..,
( `~ )Short Certificate(s)...... _yt(J .(_~~;
( ' ~ )Renunciation(s)......... j,~7 . (`,(~~
( }Codicil(s) ............ .
( )Affidavit(s)........... .
Qond ........................
Commission ................. .
Other .......
Automation Fee . .............. ~- ~~ L'
~~> ' ~~ =,
JCS Fcc . .................... ~ ~_.
TOTAL ..................... $ `~ - ~' b.OO
Attorney Signature}
`~ f ~~ --
Printed Name:/ Dusan Bratic
Supreme Court
ID Number: 19249
Firm Name: Bratic & Portko LLC
Address: 10] South iJS Route 15
~illsburg PA 17019 __
Phone: 717-432-9706
Fax: 717-432-9220
Email: hratic nrtk~ and rnm __
DECREE OF THE REGISTER
Estate of John H. Jenks Jr. File No: ~ i ~ ~ 1 „~ C.~ _~~~~ ~='~
a/k/a: -
AND NOW, ~ ~ ~ ~~ .,~~ j ~~.1-- , in consideration of the foregoing Petition,
satisfactory proof having~~presented before me, IT IS DECREED that Letters ~~(_I ('~,, j ; i } - ~ ~~~ ,_ i~~f ~„
are hereby granted to ,~ C~ C t ~ L
in the a ove estate and (if applicable) that
the instrumei7t(s) dated
described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent.
Register of Wills ,/
t ' ~'~t, ,~ C' ~ ~=~ ~ /
Form RGV-02 rev. L2i11/2011 .-~- ~ ~ {_ i ~., ,_. /age 2 Of 2
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LC)~~. REGISTRAR'S ~;~R~"IFI~"~TI~".~N CC~~ C~:"~~
~1V~;f~Nl~4G. It is illegal to duplicts?y~',>r~~ ~ _:~,:;~ ~Ir tl?°ratr:4:~t d°Ifi ~•Ft'Laksg;~:,,~•~_-:
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COMMONWEALTH OF PENN
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S
LVANIA • DEPARTMENT OF HEALTH
VITAL RECORDS
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1. Oecedenf's Legal Name IFlrst, Mddle, Ust, SuKxl Z. 6!x 3 Social Security Number51 N4. Oxe or Death IMp/Day/Yr) (Spell Mo)
ohn H. enks r Male 161-34-4437 March 20 2012
9a. aye-Last BirtMaY (Yrs) Sb. Under Near Sc. Under 1 Da 6. Date of girth (MO/Day/Year) ISpell Month) )a. Birthplace (Oty and State or Foreign Country)
Months Days Hours Minutes
72 Decsnber 24 1939 )b girtnplat<IcoNntYl Dau bin
Ba. Resdence (state or Foreign Country) gb. Residence (Street aM Number- Include Apt No.) 8c. DID Decedent we in a TOwnsnlpZ
PA 6 Pxono Drive [AY'e5, e<«eent lly<e in 11r'[E1er Allen
Btl. Residence (County),
CllEfiberlaElC1 Be. Resdence (lip Cpee) 1 ^NO, decedent lNetl wgnin limits of city
9 Everin US Armed Forces? 10. Martial Status at Time of Death ~f Married ^Widowee 11. SUrvMng Spouu's Namellf wl(e, give name prior to Rrst mamiagel
Yes ^NO ^Unkrwwn ^gvorted ^Never Married ^Unknown Virginia A. GuEEmo ~J
12. Fatheis Name IFIrsU Middle, Last Suflb) 13. Momer's Name Prior to First Marriage (First. Mitltlll, Lastl
John H. Jenks Sr. 2helma Dare
lba. In/orman['S Name 14b. Relationship [o Decedent 14c. Informant's Mailing Aedreas (Street and Number, Clty, state, Zip [otle~ -~-7
ffi Vi inia Jenks Wife 6 Pocono Dr. Mechanicsburg, PA 17055
a ..... ............ ...................................._ISa..Pace..:......'.~....._°c ..°A.Y..one ..............................
lioeatna~~.reai~aiio:pizl:
[]"iooSnent
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D<amDttprreasomewn<.<DmerTnanaHpSpgac Cy
iioso~~=racnlry
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De~edenFs
liome
^ EmergerRy Room/OUtpatlen[ ^ Dead on Arrival ^ Nursing HOme/LOng~Tlrm Cate Faculty Other (Specify)
~
156. Fxlliry Name I lr not Inrtltution, glue street and number; 15c. City or Town, State, rid 21p Code 16d. County of Death
LIfe Care Hos itals Mechanicsb PA 17055 Cumberland
r ]6a. Methotl of Olsposltion ^ 8urlal ^ Cremation 16b. Date of Disposi[lon 16c. Place of Disposition (Name of cemetery
crematory
or other
ixel
^ RemOVal from 6!>te DOna[lon ,
,
p
Dm<r(sp«Iryl 3/24/2012 ollin Green Memorial Park
Z 16d. Location of Dlippsitlon ICIry or Town, State, and Zipl 1)a. 5lgnature of Funeral Service licensee or Person In Charge o/Interment 1)b. lkense Number
Camp Hill, PA 17011 F'E 013239 L
E 1)c. Name arM Complete Adtlrea of Funeral Fadlity
IB. DxedentS Education - Check tbe boa that bell deuNbes [he 19. Decedent o/Hispanic Orlgln ~ Check the 10. Decedent's Pace-[neck ONE OR MOflE races to Indicate what
Highest dope<or level of sclwpl completed at th!time pf tleath. boxthat best describeswbetner the deceeenl the decedent considered himself or herself to be.
^ B[h grade or less is Spanish/Nlspanic/Latino. Check me'NO' ~ WhIIe ^ Korean
^NO diploma,9th-IZth grade b
ox
ll d<cedenl is not Spanish/Hispanic/Latino. ^Blackorgfrican American ^Vetnamese
ry
~~
^ High school graduate or GED Completed t~..O, Hat Spanish/Hispanic/latino ^American Indian or Alaska Native ^ Other ASian
Some college credit, but no degree ^ Yes, Mexican, Mexkan American, Chicano ^ Asian Indian ^ Native Hawaiian
^ Associate degree (erg, M, AS) ^ Yes, Puerto Rican ^ Chmese ^ Guamanian or Chamor.o
'
^ Bachelor
s degree (e.g. BA, AB, BSl ^ Yes, Cuban ^Flllpino ^ Samoan
^ M t 5 degree le.g. Mq, M5, MEng, MEd, MSW, MBA) ^ Yes, other Spanish/Hispanic/Latino ^lapanese ^ Other Paclflc Islander
^ Dottorate (<.g. PnD, Etl01 or Prolesslonal eegree ISceciryl ^ Other ISpecityl
MD DDS DVM lLB 1D
Zl. Decedent's Single Race Sel(~Designation -Check ONLY ONE to intllca[e what the decedent Considered himself or M1ersel(tp be 11a. Decedent's Usual Occupation ~ Intlicat! type of work
^(White ^lapanese ^Samoan done during most of working ll/e. 00 NOi USE RETIRED.
^ Black or AM
A
ri
can
me
can ^ Norean ^ Other PaclRC Islander
^ Amerkan Intllan or Alaska Native ^ Vietnamese ^ Don't Nnow/Nat Sure Shipping/Receiving
Z ^ Asian Intllan ^ Other Asian ^ Refused 118. Hind of Business/Intlustry
^ Chinese ^ Native Hawaiian ^ Other (Speclfyl
^ Flllpino ^ Guamanian a Cnamorrp Canputers
ITEMS 33a -23d MUST gF COMPlETEO Zia. Date Pronounced Dead (Mp/Dry/Yr) Z3b. 5lgnature of Person Pronouncing Death (Only when applicable 13c
license Number
.
BY PERSON WNO PRONWNCES OR
CERTIFIES DEATH U: // ~ ~~' 1657 ~L.
Z3d. Date Sig ed IMO/Day/Yr) Z4. Time o Dea
t
(~
^
a+
~~G'V-1 ZS. Was Medical Examiner or Coroner COntacletl) Yei ^ Np
CAUSE OF DEATH
Approximate
16. Part I. Enter the chain of events-diseases, injuries, pr complicahons-[hat elrettly causetl the dean. 00 NOT enter terminal events such as cartllac arrest Interval
.
respiratory arrest. or ventrlalar HpNllatlon without showing me etldogY. DO NOT ABBREVIATE. En[lr only on cause on aline. Adtl addltlonal lines if necessary Onset to Deam
e
11 J _
IMMEDIATE UUSE '--"-'"----"--' a._ (~I1YYl){7ni)~IYI C)n CI Y'v ~'yt SI I yf
_q~7 ~.
IFkal eisea5<p. tpnakio^ <tow~jprn o Se~< <00:
c
resulting in tleath) n ~ ~
b. IA ~rrsH,val p.~
Sequentially lh[conditipns. pue [o (pr ac nsequence op: -~~-~
i/ anY. leading to the cause ^ 1.~/~ /.~ n l1 n1 „ /1 1
Ilstetl on line a. Fn[erthe c ~lr~~)a.DI~)fN ll~Z~ L1 rLll [7~V1 IL~I ?r ~^~~'P[1f~ ~yS
UNDERLYING UUSF Due to for as a consequence oFl'.
(dgeau or inlvry that
c imnat<d m<ey<n[5 rea~eing a.
in deaml LAST. De< m Ipr as a tons<gD<n« on:
S 16. Part 11. En
ter Oth<r 1
Itl [ Mlt L butt
[ d th but no[ resulting in the underlying cause given In Part I 1J. Waz an autopsy pertormetli
-
1
Were autopsy lintlin
U, 1B
s available
Y
.
g
pmplete me cause of dean)
c
^ Yes No
If Female
u 29
.
. 30. Did Tobacco Use Contribute to Death) 31. Manner of Death
o ^ Not pregnant within past year ^ Yes ^ Probably'Natural ^ Homicide
^ Pregnant at time o/death
N
14'
^
o
Unknown d Accident ^ Pending Investigation
~ ^NOtpregnant
but Pregnantwithln4Z tla
soldeath /"
,
y
^ Sultlde ^ Could Hat be determined
^ Not
b
pregnant,
ut pregnant 43 days to 1 year before death 33. Date of In(ury IMO/Day/Yrl (Spell Month)
^ Unknown ll pregnant wimin the Past Year
33. Time of Inlury
34. Place of Injury (e.g. home; construcdon site: farm; scnooll 35. LocaUOn of Injury (Street and Number, C'rty, State, EID Code
36 Injury at Work 3). If Transportation Injury, Speciy: 3g Describe Haw Injury Occurred.
^ Y ^ DrNer/Operator ^ PedesMan
^ No ^ passenger ^ Other lSpecily)
39a. CertiRer (ChecN only ones:
^ Certifying phYSiclan ~ TO me best oI my knowletlge, dean occurred due to the causes and manner statetl
f$Pronounting B CenRying pnysklan ~ To the best of my knowledge, death acurred at Ine time, date, antl place, antl due to the cause(s) and manner statetl
^ Medical Examiner/Coroner - On he basis DE examinaUDn, aM/or investigation, :n my opinion, death occurred at the time, date, and place, and due to the <ause(sl antl
ma
ne
n
r stated
t
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~
Y
Signature of certifler:_~~ NNe of certifier. Licens<NUmber~ ~~~J Z -rG
5
L Pe
39 Name, Ad e s and Zlp Cm~r pn Completing Cause of Deam Rtem 2 39c Dale Signed IMa/Day/Yr)
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9An/ CS~u !7 [b ~ 7gc• ~
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a0. Registrar's Dls[nct Number 41. Registrar' Signature /-) 41. R gis[rar Flle Date (MO Day r~
43. Amentlments
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RE~L'r~'I_~TIOti
REGISTER OF ~~"ILLS
COUNTY, PENNSYLVANIA
Gr r, :~~, ~ ;;~~_
CUM~f~I ~;~~ ~,i~. ~A
Estate of
(Print Name)
Deceased
in my capacity/relationship as
of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
,~
~~~{
~1~ ~I ~~,
(Date_~-
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this _ ~~ ~ day
~.
~~ ~_
,, . ,
t i~ ~ ~ ~
Deputy for Register of Wills
(Signature)
(Street Address)
(City, State. Zi )
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 _ day
of
~_
Notary Public
My Commission Expires:
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's Commission.)
Form RW-06 rev. 10.13.06
~~ '~~.,t (,1r:
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RE ~ L"'v C L~ ~L~~PJ ~ C~7 , ~A
REGISTER OF ~Z"ILLS
~~'l~Y~'I~~ ',r'I : l~ C~ COUNTY, PE~~tiSYLVANIa
Estate of It ~I^, y"~ 4-~
I,
Ci'1
Deceased
'~ ~ (PrlntName) , in my capacity/relationship as
~ of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
~ -~ '
Gate) ~ i ~ `-~'~-~- Y
t
r ~~ - J
(Sign lure)
Ll~~,c~ ~Y;~ r'i/ Sir ~- l%'~ ~~_ l
(S[reer Address)
,~ ~ ~S~ ~~
(City, State. Zrp)
Executed in Register's Offrce
Sworn to or affirmed and subscribed
before me this day
of
Deputy for Register of Wills
Executed out of Re; ister'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 _ 9Z. day
of ./l~r1~ .m ~~,~ ~ ~
Notary Public
My Commission Expire
(Signature and Seal of Notary or
administer oaths. Show date of e
Notarial Seal
Da~~d M. Gilmore; Notary Public
1=airview Twp., York County
I~ ~~I~t Expires July 9, 2014
R~f~1~RI~PA'h~,dA4~,;66fipCiatlon of Not
Form RW-06 rev. ; 0.13.06
~~„ ~„ -,
~~',., Yf i :^
1..'J
ctIM~SE~iI.,SN~ c~ . ~a
~ REGISTER OF ~~~ILLS
~ t'~`~~' ~C:V ~(J~.i'~ ~ COLTS"TY, PEivNS~'I_VANIA
Estate of
J ~"-.
Deceased
1, C "i~r ~ ~~~~~~~~ ~~ ~~ ~- ~ -~r~K~S
in my capacity/relationship as
(Pr nt Name)
~ + 1 of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
~ ~ I-~t
(Dare)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this day
of
Deputy for Register of Wills
~----,,
~~
(Signature)
~~( ~~C Eel ~ (,~ ~1"\ -; ~ "t '~" ~ _
(Street Address)
(city, state. zip)
Executed out of Register's Offic.•e
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 _~/~ day
WMMC?NWEi1~9 OF~PENNSYLVANIA
'~lot8rial Seal
Notary Public i5avia M. Giimore, NOt~ry t~ubiic
Fairview Twp., York County
My Commission Expi s: My commission _ExpirQS auiy 9, zoia
M~thb~. Peiri{isvlv~r~le- ~ss~atlon of Notaries
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration ofNctary's Commission.)
Form RW-06 rev. 10.13.06