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HomeMy WebLinkAbout07-06-12~ nesei PETITION FOR GRANT OF LETTERS REGISTER OF WILLS OF CUIy1BERLAI~'D COUNTY, PENN~LVANIA~t ti Petitioner(s) named below, who is/are 18 years of age or older, apply(ies) for Letters a cified low din .., su ort thereof avers the follow in and res ectfull re uest s the ant of Letters in the a ~ ' `~e forrfi~~ ~.. _ 1 ~; , ~.., cn - cri .x. ~- Decedent's Information © r._ I' C; Name: Ronald J. Sheppard File 1~To: Z~-~,Z 7`~2, ~ ~__ ` ' ~~ . a/k/a: (Assigned bV~~egister).,._ ==- a/k/a; ~ ~'~ a/k/a: Social Security No: Date of Death: June 3, 2012 Age at death:62 Decedent was domiciled at death in Cumberland County, Pennsylvania (Stage) with hislher last principal residence at 80 Oak Flat Road Newville West Pennsboro Cumberland Street address, Post Office and Zip Code City, Township or Borough County Decedent died at 80 Oak Flat Road, Newville, West Pennsboro Twp Cumberland PA 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 $ ~ S . ~ ~,) ~~ If not domiciled in Pennsylvania ...................... . .Personal property in Pennsylvania $ If not domiciled in Pennsylvania . . ......... . ............ Personal property in County $ Value of real estate in Pennsylvania ... . . .................. . .... D © e~ c'~ G~ ~,"~- S TO ALE TIMATED VALUE.... $~ C ~' ~ ~ ~ Real estate in Pennsylvania situated at: L7 ~ ~ ~'~-- ~ 1~ t~ 1~~?G~~ ~ ~ 1"~'~' ~~ Q ~_ (Attach additional sheets, if necessary.) Street address, Post Office and Zip Code City, Township or Borough County A. Petition for Probate and Grant of Letters Testamentary Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated thereto dated and Codicil(s) State relevant circumstances (e.g. renunci¢tion, death of executor, etc.) Except as follows: after the execution ofthe instrument(s) offered for probate Decedent did not marry, was not divorced, was not a partyto a pending divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(8), and did not have a child born or adopted; and Decedent was neither the victim of a killin8 nor ever adjudicated an incapacitated person. 0 NO EXCEPTIONS Q EXCEPTIONS B. Petition for Grant of Letters of Administration (If applicable) _. e.t.a., d.b.n., d. b.n.c.t.a., pendente life, durance absentia, durante minoritate If Administration, c. t: a. or c~b.n.c.t;a., enter date of Will in Section A above and complete list of heirs. Except as follows: Decedent was not a party to a pending divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(8) and was neither the victimsn of a killing nor ever adjudicated an incapacitated person. _I Q N E 'CEPTIONS Q ENCEPTIONS I'~`~~ ~. L~ (~ IL ~21MC~--r 1 !~ C_ v ~~O ~ C~ r\C] C c~ r~~f i~I~ c. ~\ Sh C +~--f~G.I' C GL .~. C' S . O (,~ ~ T 2 r\ /~5 c~ r-b ( u C.J n -~ ~ vin ~ %~ Ci. Pe~toner(s)~a$eraproperse~hhas/h~veasgertamedtha Decedent left noWil~and~assurvivedbythefollowingspou (~fany~andheus(atta~ additional sheets, if necessary): ~° ~ ~,~~ ~ ~~ ~ ,n S~~ ~,lfc., wl C~ Name Relatlonshi Address Ryan Sheppard Son 80 Oak Flat Road, Newville PA 17241 anielle Palmer Daughter 395 Edward J. Roy Drive, Apt. 204 Manchester, NH 03104 2 t-s ~ ~ v Y~ ~~~ vvV~r1 ~ t ~i c~ rx G.~wc t~.~ ~~ \. Pa e 1 of 2~~ Form RW-02 rev. IOill/2011 g Oath of Personal Representati~~e COMMON«'EALTH OF PENNSYLVANIA COUNTY OF CL~~IBERLA:~'D se r.. ~~• -v r- ~. Petitioner(s) Printed Name Petitioner(s) Printed Address ~7 " t t-~~: r°"~ : 'an She and G_ _:. ~ 80 Oak Flat Road, Newville, PA 17241 anielle Palmer C.~ ' ~ . 1 ...:, 395 Edward J. Roy Drive, Apt, 204, ?Manchester ?~ZI 031 r_. - -r ~_ --r :. ~~ . <~ The Petitioner(s) above-named swear(s) or affiml(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 Petiti[oner(s) will well and truly administer the estate according to law. Sworn to or affirmed and subscribed befo~r~e~ 1~ - ~t,~.~ Date ~7-v~~~- me thi ~~cf'ay of , ~'~~'~--- .~ =ham,/~~? Date ~y? - (~( -,~ Cl%~ By:~ Date ~~ r the Register Date BOND Required: Q '4'E,S ~ NO FEES: .y E Ct Let~rs ...................... $ ~© ( )Short Certificate(s)...... !~ d ( ~ )Renunciation(s).. , . , .. , , h .OLD ( )Codicil(s) ........ . .. . . ( )Affidavit(s)..... , .... , . Bond ........................ Commission ................. . Other ...,... Automation Fee . .............. , JCS Fee . .................... v4~ TOTAL ..................... $ To the Register of Wills: Please enter my appearance by my signature below: Attorney Signature: Printed Name: ~. ~ 4 Supreme Court ID Number: ~f(n3`~ Firm Name: ~~"e ~-~^ ~ ` ~ ` ~ Address: 'j S . --~ G--r o/~ 51'~ Cam'\~s -~. -~'~ 1'7cr3 Phone: 7 ~ ~ ` Z i(3 - S~~ 3 ~ Fax: '7 ~ 2 3 -- t-~ Email: ~ ~ ~ i ~ v' DECREE OF THE REGISTER Estate of Ronald J. Sheppard File No: ~ ~ ` ~~ ' ~~" a/k/a: AND NOW, J ll ~ ~ ~ ~C1 / ~ , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREEDJ%I t Letters of Administration are hereby granted to ~~/ ~ Y/ ~' ~'~Gi' /l ti C:i9r c' r_ ra `l7er- the instrument(s) dated described in the Petition be admitted to probate and filed of record the last Register of Wills Form RW-02 rev. 10/11/2011 in the above estat;, and (if applicable) that } SS: } (and Codicil(s)) of Decedent. G~~~ PagJ~~, 2 I ,,.~~~ u', ,-,~1, . ,b ~,7/~)~ -4~+`'~ ~~~~ >~?t~{e: t_ . ;` .'t?'t„~ .rt~~~y .fit ~rt?~Z JUL -6 PM ~ •S~ i'('~' tat' tai) t u ];PCB C. ~(, ~ (.., ~ ~ 8 4 8 814 4 ~5~.~ ~~k~~-~ ~ut~ 5 - ZO~2 - -- II V Type/Print In COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF HEALTH VITAL RECORDS Permanent CERTIFICATE OF DEATH Black Ink x/33-261 State File Number: ~_ 0 $O_ a 1. Decedent's Legal Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number 4. Date of Death (MO/Day/Yr) (Spell Mo) Ronald J She and June 3, 2012 Sa. Age-Last BlrthdaY (Yrs) Sb. Under 1 Vear Sc. Under 1 Da 6. Date of Birth (MO/D ay/Near) (Spell Month) 7a. Birthplace (Cityy nd State or Foreig Country) MonChs Days Hours Minutes New YOrK C1t NY 62 October 27 1949 76. Birthplace (cp~nty) - Sa. Residence (52ate or Foreign Country) Sb- Residence (Street and Number -Include Apt No.) 8c. Did Oecede nt Live in a TownshipT PA Qg Ves, decedent uYed in West Pennsboro Ywp. ( Bd. Resitle n c e c n „nty) 80 Oak Flat Rd_ ~ ~ ,. ,, y ~ ~ C~++i u-~cr1. c"371d. Se. Residence (Zip Code) 0 No, decedent lived within limits of city/born. 9. Ever In US Armed Forces? SO. Marital Status at Time of Death ~ Married J~ Widowed 11. Surviving Spouse's Name (If wife, give name prior to first marriage) Ves Q No Q Unknown Q Divorced ~ Never Married Q Unknow 12. Father's Name (First, Middle, Last, Suffix) 13. Mother's Name Prior [o First Marriage (First, Middle, Last) Edgar Sheppard Anna Hancock 14a. Informant's Name 14b. Relationship to Decedent 14c. Informant's Mailing Address (Street and Number, City, State, 21p Code) o Danielle K. Pa]sner Dau hter 395 Edward J. Ro Dr_ Ma.lzchestar, NH 03104 G . '. .. ..."""'°""".......... ..... ........ lsa. P ace.o Deat... c. eck ony one .............. . .. . ' ..... ..... ..... . .. . . .. . _ .........................."'........................ ...' . .. . . vP++tt If Death Occurred in a Hospital: LJ Inpatient ~ : - a - . . ..... .. . ° -....... ..... .'..... °'.... ..... . . . .. ....... w if Death Occurred Some here Other Than Hos pital~ ~ Hospice Facility Decedent's Home ° Q Emergency Room/Outpatient Q Dead on Arrival . ~ Nursing Home/Long-Term Care Facility Q Other (Specify) ~d 15 b. Facility Name (If not institution, give street and number; iSC. City or Town, State, and Zip Code 15d. County of Death 80 Oak Flat Road Newville, PA 17241 Cumberland 16a. McChod of Disposition ~ Burial ® Cremation 16b. Date of Disposition 16c. Place of Dis pos(tion (Name of cemetery, crematory, pr other place) m ~ Removal from State 0 Donation p other (speafy) 6 6 201 2 Evans Cr~-nation Services 16d. Location of Disposition (City or Town, State, and Zip) 1>a. Signature o Fu eral Service License arge of Interment 176. License Number LI~1a, PA _ FD 012633 L E 17c. Narr(e and Complete Address o ral Fac ity EtNing Brothers ~urierajl Home, =nc_ 630 S. Hanover St_ Carlisle, PA 17013 18. Decedent's Education -Check the box that best describes the 19. Decedent of Hispanic Origin -Check the 20. Decedent's Race -Check ONE OR MORE r s to Indicate what f- highest degree or level of school completed at the time of death. box that best describes whether the decedent the decedent considered himself or herself to be. 0 8th grade or less is Spanish/Hispanic/Latino. Check the "NO" ~%(/hite 0 Korean ~ No diploma, 9th - 12th grade box if decedent is not Spanish/Hispanic/Latino. ~ Black or African American ~ Vietnamese ~ High school graduate or GED completed F]~ ,not Spanish/Hispanic/Latino Q American Indian or Alaska NatiYe 0 Other Asian Q Some college credit, but no degree ~ Ves, Mexican, Mexican American, Chicano ~ Asian Indian 0 Native Hawaiian Associate degree (e.g. AA, AS) ~ Yes, Puerto Rican Q Chinese ~ Gu nian or Cha mono Bachelor's degree (e.g. BA, AB, BS) ~ Ves, Cuban Q Filipino ~ Samoan ~ Master's degree (e.g. MA, MS, MEng, MEd, MSW, MBA) ~ Yes, other Spa nlsh/Hispanic/Latino 0 Japanese ~ Other Pacific Islander 0 Doctorate (e.g. PhD, EdO) or Professional degree (Specify) ~ Other (Specify) . MD, DDS, DVM, LLB, JD 21. Dec~ent's Single Race Self-Designation -Check ONLY ONE to indicate what the decedent considered himself or herself to be. 22a. Decedent's Usual Occupation -Indicate type of work White Q Japanese ~ Samoan done during most of working life. DO NOT USE RETIRED. ~ Bla<k or African American ~ Korean ~ Other Pacific Islander $L1S 1neSS Mai-la er Q American Intlian or Alaska Native ~ Vietnamese Q Don't Know/Not Sure g 0 Asian Indian ~ Other Asian ~ Refused 226. Kind of Business/Industry 0 Chinese ~ Native Hawaiian Q Other (Specify) ~ Fllip lno ~ Guamanian or Cha mono SCh001 D15tr1Ct ITEMS 23a - 23d MUST BE COMPLETED 23 a. Date Pronounced Dead (MO Day/Yr) 23 b. Signature of Person Pronouncing Death (Only when applicable) 23c. License Number BY PERSON WHO PRONOUNCES OR CERTIFIES DEATH June 3 , 2012 23d. Date Signed (Mp/Day/Yr) 24. Time of Death A rOX _ 1 1 ~~ A. M. 25. Was Medical Examiner or Coroner Contacted? Yes ~ No CAUSE OF DEATH Approximate 26. PaK I. Enter the chain of events- diseases, injuries, o mplica[ions--that directly caused the death- DO NOT enter terminal events such a ardlac arrest Interval: respiratory arrest, or Ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ilne. Add additional lines If necessary Onset to OeaCh IMMEDIATE CAUSE > Va1VU1ar Heart DiS ease (Final disease o ndition Due to (o as a consequence of): resulting in death) b. Sequentially list c nditions, Due to (or as a consequence of): If any, leading to the c e listed on line a. Enter the V NDERLYING CAUSE Due to (or as a consequence of): (disease or injury that Initiated the events resulting d. In death) LAST. Due to (or as a consequence of): S 26. Part 11. Enter ocher si¢nificant conditions contribufin¢ fo death but not resulting in the underlying cause given in Part I 27. Was an autopsy p rf rmedl O Ves No ~ m Chronic Obstructive Pulmanary Disease 28. Were autopsy fin in s available to complete the cause of death? Q Yes Q No a 29. If Female: 30. Dld Tobacco Use Contribute to Death? 3 her of Death o ~ Not pregnant within past year ~ Yes 0 Probably py Natural ~ Homlcide- ' Pregnant at time of death ~ No ~ Unknown ~` Accident Q Pending Investigation ~ Not pregnant, but pregnant within 42 days of death ~ Suicide Q Could not be determined ti 0 Not pregnant, but pregnant 43 days to 1 year before death 32. Date of Injury (MO/Day/Yr) (Spell Month) Q Vnknown it pregnant within the past year 33. Time of Injury 34. Place of Injury (e.g. home; constru c[lon site; far ,school) 35. Location of Injury (Street and Number, City, State, Zip Code) 36. Injury at Work 37. If Transportation Injury, Specify: 38. Describe Now Injury Occurred: ~ Ves Q DriYer/Operator O Pedestrian ~ No Q Passenger Q Other (Specify) 39a. Ce rtlfier (Check only one): Q Certifying physician - To the best of my knowledge, death occu rre a to the c se(s) and m r sated me, date, and place, and due to the cause(s) and manner stated Pronouncing 13< Certifying physicia - To the best f my knowle ,death occurred at the d o anne Medical Examiner/Coroner - nation investigation, in my opini n, death occurred at the time, date, and place, and due to the cause(s) and m r stated Signature of certifier: Title of certifier: Acting Coroner Ucense Number: 396. Name, Address and Zip Code of Person Completing Cause of Death (Item 26) 63 7.5 BaSe110 rE'_ Road , Suite ~~ 1 39c. Date Signed (MO/Day/Yr) Matthew S. Stoner, Acting Coroner Mechanicsbur PA 17050 June 5, 2012 40. Registrar's District Number 41. Registrar's tore ~~ 42. Registrar File Date (MO Day/Yr) a~-ago ~ ~! e~ - 43. Amendments ~~ ~~/ ~ H105-143 D(sposition Permit No. CO REV 07/2011 IIIUS-905 RIiV.f H/Ill This is to certify that this is a true copy of the record which is on file in the Pennsylvania Department of Health, in accordance with the Vital Statistics Law of 1953, as amended. WARNING: It is illegal to duplicate this copy by photostat or photograph. 6328283 No. ~a(,,,(,~,~, orr~.~-k~`-u`~ Marina O'Reilly Matthew State Registrar ~~C L1 ~ ~"'~~ Date ~~/ /~ H105-t4a REV n/2oos COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS !!J TvPE/PamTIN CERTIFICATE OF DEATH PERMANENT BLACK INK (See instructions and examples on reverse) STATE FILE tJUMBER 0 i Sax 2 3. Botlal Securhy Number 4. Date of Death (Month, day, year) 1. Name of Decedent (First, middle, last, suffix) . Au st 22 2 11 ~ 1 A. She and Female e (Last Blnhdap Under 1 a UMer 1 tla 6. Date of Bl A 5 dh Month, tla , ear) 7. BIM lace (Ci and slate or torsi n punt Ba. Place of Death Check onl m g . Months Days Hours Minutes Hospital'. Other. 12/2/ 1948 New York City x ~ ^ mpeuent ^ ER / outpauem ^ Doa ^ Naramg Home ®Read¢nte ^ Diner spedry. 62 vrs. give sheet and number) 9. Was Decedent of Mispanc Origin? ~ N° ^ Yes 10. Race'. Ameriran Indian, BI¢Ck, While. etc. Facility Name (II not Ins[iW[ion fid Sb. County of Death Rc. CM. Boro, Twp. of Death , . (It yes, spadN Cuban, lSpeciryl 80 Oak Flat Road Mexico^, P°¢"° Rita^' ¢'t.l White Cumberland est Pennsboro m If il i id ) ~ ve ma en na e w e, g 12. Was Decedent ever In the 13. Decedents Education (Specify ony highest grade completed) 14. Marital 3mW5'. MameeP N ~er Married, 16. Surviving Spouse ( nt's Usual Occu elion Klnd of work done tlurin most of workin life. Do not state retired Divorced Sec Widowed 11 D d . ece e KiM of Work Kintl of Businessf Industry , U.S. Annetl Forces? Elementary i Secondary (D-12) College (1-4 or 5+) Ronald J . She rd 2 Married ppa Accountant State of PA ^ Yaz C~ No t6.D¢tedem'a Maiung Addresa (stre¢L tiry sown, stale, zip tptl¢I Detedems PA it eD~ea dent West Pennsboro rT~~,,,~ Decedent Lived In `wl-' ~ Tw'P ®Ves 17c 80 Oak Flat Rd. , . Actual Residence tla. State Clm)berland Towneniv? nd.^NO.Det¢demLNetlwnnm PA 17241 Newville, nb.counN atmalomitapr city/B¢m ' 19. Mainers Name (First. middle, maiden surname) s Name (First, mitld~e, last, suffix) 18. Father Muriel (Not Available) Not Available) 20a. Informant's Name (Type / PrinQ 20b. Inlormanl's Mailing Atltlress (Street, cM I town, state, zip coda) 80 Oak Flat Rd., N6xaviller PA 17241 Ronald J. Sheppard .R 21 e. Melhotl of Dlsposiilon eaemmatbn ^ Dwation 21 b. Date of Disposeion (MOnm, bay, yeaQ 21 c. Place of Disposidan (Name at cemetery, cr matpry or Dinar prey) 21 tl. Leeatlvn (city/town, slate. zip code) ^ Bpnal ^ R¢mgval bom stale . was cremeupn pr Don upn amnarl:m • 8 23/201 1 [ ^ Leola x PA Evans Cremation Services ^ Diner, r by Medical Examiner/Coroner. No Ves 22a. Signature of Fun al Se a Llcensea (or pars , ~ 226. Lcense Number 22c. Name and Atltlress of Facility Brothers Funeral Herne, Inc., Carlisle, PA 17013 2633 L F}ain D ~ c le ms 3a~c only when cenidying 23a. To the best awledge hoc r Com ¢ q F 01 tlat the time, date and place slate .(Signature and title) 23b. License Number 23c. Dale Signed (MOnm, day, year) p nol available al time el seam to l'~ physician ls n -) !'J ) I ~ V certify rouse of death. ( y to Medical Examiner /Coroner far a Beason Other than Cremation or DonanonY r Was Case ate 26 Items 24-26 must be completed by persm 24. Time of . 25. Dale Pronouxed Dead (Month. ay, year) ~ / ^ Yes I,I No wno pronounces death. r ' U M. s ~ ~ 4 ' b t t d alh 28. Dld Tobacco Use Contribute to DeatnP , Approx mate interval: Pad II. Enter other a-9 T t dl t l l d examp ) ons en CAUSE OF DEATH (See Inslruet DO NOT enter terminal events such as cardiac arrest. Onset to Deam but nd resulting in the uMerlying cause given in Pan I. ^Ves ^ Probably lications ~ Ihat directly caused the death m i i - p es, or co M nts-diseases, nlur Item 2]. Pan I'. Enter the h l Ll . ^ No ^ Unknow e on each line sl on y aspiratory arrest, or ventricular tlbrillalion without showing me etiology. . one caus 1 29. I( Female _ rM IMMEDIATE CAUSE Final dseaze or ~ conamm~ resuldnq in ~eam) ~ ~ ~.M ~ ~ Y (L (,~ a ^ Nm pregnam wimin past year Due lp (or s a con quence of('. ^ Pregnant al4me of death Sequ Bally Iisl contlnitns. H any, b lead-n to S listed on line a. s I uence o I' ^ Not pregnant, but pregnant wimin 42 days of death . Due tt (vr as a cone Enlar the UNDERLYING CAUSE q (disease or Injury Thal initialed Ina ^ Not pregnant, but pregnant a3 days ro t year events resulting In death) LAST. Due to (or as a consequence till. before death ear ith me ast it t ^ d. in p y pregnan w Unknown r 30a. Wes an Autopsy 3W. Were autopsy Findings 31. Mann each 32a. Date or Injury (Month, day, year) 32b. Describe How injury Occurred 32c. Place of Injury'. Home. Fenn. Elmei, Factory, OH'rz Building, etc. (SpecdyJ - Pedvnned? Available Prior b Gompletan alural ^ Homicide of Cause N Death? // ^ Accident ^ Pentli ng Investigation 32d. Time of Inlury 32e. Inlury at Work? 32t If Transportation Injury (Speciyf 32g. Location of Inlury (Street, city I town, state) ^ ,~ ^ Ves I~ No ^ Yes ^ No Pebestrian ^ Yes ^ No ^ Dnverl Operator ^ Passenger ^ Suicide ^ Ceuld Not be Detenninetl M. ^ Other- Spen/y Certifier (check only one) 33a -. 33b. 'nature and le o{LerWan j~ ( / ( ~ J J ~ ~! rr,, Y1 I 1 ,, ~ ~) ^ ~,'~~111~~ (B-L fJ `' . • Cartdying physitian(Physician certityinq cause of deem when anomer physician has pronounced Beam and completed item 23) ~ o ~ ,X (. I. ~ Y~zL I / N L, f To the bas\oi my knowledge, death oceurted dua to lheceuae(s)and manner as steied_________________________________ n Ph sician bath death and certi to cause of death pronouncing tying 1 l h t l i ( ¢ 33c. License NU (~ L (y 33d. Dale Sl rrtd (MOn[,tlay. year) ~ e s c a ng p y y • g en ty Pronouncin tlwrt Ts the best of my knowledge, deals occurred at thetime,date, and place, end due to the eause(s)end manner as stalad__________________^ -„ _ O/ (, ~' ~ ~ Vy~ "[ _( 1 I Z ll • Medital Examiner/Coroner On the basis of examinMlon end / or invealigetlon, in my opinion, deem occurred et the time, date, end place, end due to the cause(s) aM manner as ateted_ 34. Name and Atltlress of Person Who Completed Cause of Death (Item 2] Type I Pnnl t..,,a CF71~olyn cIQSScr, m~ ~~ ~` ~ 35. Register' g Wre and Di Idcl 36 Dale Fled (Month, day, year) , //~1 ^ ~Dll ~~1_ -' ~~ ~ / J 1, , „ //q~„~~ } Y~ r ~.: Dlsposnion Permit Na. U ~ ~~~~y .. ~~. f••~ C.r? C_J 7 ~ ) ~. ~ JJ ' / © ` ~ _t ~ TI ~ o ~` ~~ ~; ~ ~ ~ , ~.,, ~-~> } ...> RENUNCIATION ~'~~ ~ `r ' ~' r)t': G ~ - REGISTER OF WII.LS ~~; , =~ ~, C'nmhPrland COUNTY, PENNSYLVANIA ~' ~' _ cn ~ ~ Zi-12~7~~ N Estate of R~nalc~ T ~hPnnarcl ,Deceased I Rvk ChPnnarr~ , in my capacity/relationship as (Print Name) can of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to 1 t~ ~-~ (Date) Executed in Register's Office Sworn to or affirmed and subscribed before me this day of TGJ1~ ^' r.l ~ N z~~~o ¢,n~~ 000 . ~~ ..-~ V N ~ J ~ Deputy for Register of Wills ~ ~ a 4 W Wi~~a E Q Q o Up U Z ~. •. a • ~ ~ ~ [fJl° Form RW-06 rev. 10.13.06 .~~` r (Signs re) P (l Rnx ~R(14~ (Street Address) naklanrl, ('A 94fin4 (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 stated with}~y on this 'k~^" day Notary Public ! '~ ~` \ i My Commission Expires: ~,~20 '20 ~ 3 (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission.)