HomeMy WebLinkAbout07-09-12PETITION FOR GRANT OF LETTERS
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REGISTER OF WILLS OF°•
COUNTY, PENNSVANIA ,.~ ..a
OO G,. ~. ~r ~- <
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Petitioner(s) named below, who is/are I8 years of age or older, apply(ies) for Letters as ed below, an~rin=
support thereof aver(s) the following and respectfully request(s) the grant of Letters in the appro ~brm: ~p ~
Decedent's Information ..o ,_ ~ ~
Name: r i v~ n ~,~...) ~~ Y ~ I ~ File No: ~ .~ r ,, ~~ =~ = ~-,
a/k/a: (Assigned by I2ggrster) •• ~,~
a/k/a: y~~ ~
CY1
a/k/a: Social Security No: ~~' - (< Y - y'C ti ~7
Date of Death: ~),,,, ~, e ,~ y ~ o) Z Age at death: ? j
Decedent was domiciled at death in CuN, hc~)~ad County, ~!] (State) with his/her last
principal residence at j ~ y i~ c- ~< <• o ~, (" ~ . ~ / ~. ,~,, ~ ~ . s ~ ~_~, C,. J ~ ~: ~K ~(
Street address, Post Office and Zip Code City, Township or Borough County
Decedent died at 1 ~ ~ I (. ; ,, a ),^ ~ -~ o wn !~ .~
~--~cti ~ ,- ~ > ~~,- ti ~ ~ in ~ ~ f A
Street address, Post Office and Zip Code City, Township or orough County State
Estimate of value of decedent's property at death
If domiciled in Pennsylvania ............................All personal property $ y *,~
If trot domiciled in Pent:Sylvania ........................ Personal property in Pennsylvania $
If trot domiciled in Pennsyh~ania ........................ Personal property in County $
Value of real estate in Pennsy[vania ......................................................... $
TOTAL ESTIMATED VALUE.... $
Real estate in Pennsylvania situated at:
(Annch additional sheets, ijnecessaty.)
(y r 1.
Street address, Post Office and Zip Code City, Township or Borough
^ 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
County
and Codicil(s)
State relevant circumstances (e.g. renunciation, death of executor, etc.)
Except as follows: afrer the execution ofthe instrument(s) offered for probate Decedent did not marry, was not divorced, 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 born or
adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person.
^ NO EXCEPTIONS ^ EXCEPTIONS
~] B. Petition for Grant of Letters of Administration (If applicable)
c.t.a., d. b. n., d.b.n.c.t.a., pendente life, cturunte absentia, durante minoritate
If Administration, c.t.a. or d.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 victim of a killing nor ever adjudicated an incapacitated person.
®NO EXCEPTIONS ^ EXCEPTIONS
Petitioner(s), afrer a proper search has/have ascertained that Decedent lefr no Will and was survived by the following spouse (ifany) and heirs (attach
aclclitional sheets, i/necessary):
Name Relationshi Address
_S "~ e ~ r, c . /I'~ ~~c: i I t_ i 3 ~_-~ t~.;a_ j ( G t .-~ ~
1'1 iwr Y ~ I~C I I ') v-~ ~~ .- ~ 31 ~ ~:ec}1~,,, Kc
~=.r otic C
Fo,~n, nw-nz r~~. ~nitliznl>• Page 1 of 2 ~~~
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Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA }
} SS:
COUNTY OF }
Petitioner(s) Printed Name Petitioners;
- ..- ~ ! E -- - -
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The Petitioner(s) above-named swear(s) or affirm(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 Perso 1 Representative(s) of the Decedent, the Petitioners will well and truly administer the estate according to law.
Sworn to (firmed an bs~i-idib fore ~,.~~~~ ~i/ ~ Date / ;o ~ ~ 1 z.
me this C~'day of. ~ L~ ~ ~ Date
By: ( ~ ~ Date
Fo Re,;ister Date
BOND Required: Q YES ~NO
FEES:
~ CC,
Lette s ...................... $
( ~) Short Certificate(s)...... C' C5
( l) Renunciation(s)......... ~' C' b
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commission ................. .
Other ........
........
-~'IT = f1
Automation Fee . .............. i1 J 7 L~
JCS Fee . .................... ~ C'~
TOTAL ..................... $
To the Register of Wills:
Ptease enter my appearance by my signature below:
Attorney Signature:
Printed Name:
Supreme Court
ID Number:
Firm Name:
Address:
Phone:
Fax:
Email:
DECREE OF THE REGISTER
Estate of .LJI,I C//1 /~ G1 ~lC~~ ~~ ~, L File No: ,~, / - ~,T'~[t (r>
a/k/a:
AND NOW,r.J , in consideration of the foregoing Petition,
satisfactory proof having been presented before me, IT IS DECREED that Letters l.~ f ~~(~ ~!~ ~/ct J~ c'IZ_-
are hereby granted to ~~/Cl t~ ~~ ~r' ~ , l~t' /
in the above estate and (if applicable) that
the instrument(s) dated
described in the Petition be admitted to probate and filed of
Form RW-01 rev. 10/11/2011
the last Wil),(and Codicil(s)) of
of Wills
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Page 2 of 2
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cL}12 JUL
~~~
OF~PI~~i'S t~UliC
~ ~ - ~ ~ : , ,-~ ~ C1Jl~8ERlAND CA., ~` . ~ •
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- _ _ __
~~c'i-i.i l C't i'.Ifl 1 ~ _.
•pe/Print In COMMONWEALTH OF PENNSYLVANIA • OEPAgTMENi OF HEAIiH • VI
TAL gECORpS
f FRTICI!•ATC nC nF:nTu
1. Decetlent's legal Nam Middle, Las[, Suffix) 2. Sex 3. Social Security Number' a e rv4. Dale of Death (MO/Day/rrl (Spell Mo)
Brian Walker Dell Male June 29, 2012
6a. Age-Last Birthday (Yrs1 6b. Under 1 Year Sc. Under 3 Da 6. Date of 8'rrth (Mp/Day/year (Spell Month) ]a. Birthplace (City and State pr Foreign Country)
Monet: pays Hours Minute: Pittsb h
PA
,
37 Jul 2 1974 ]b. Birtnpma (cpenty) Al hen
8a. Residence (State or Foreign Country) 8b. Residence (Street and Number ~ Include Apt No.) 8<. Did Decedent Live in a Township?
PervLS lvania L$ve,
decedent gyee in I7pper Allen
,
Iwo
Re. Rezmen[e (cggntyl 2109 Beacon Circle
Cumberland ee Re:manta (zip Code) 17055 ^NO, de[eaent lived wunin limit, or [BVroorp.
9. Ever In US Armed Farces? ID. Marital Status at Time of Deatn ^ Marrietl ^ Widowetl 11. Surviving Spouse's Name (((wile, give name prior [p flri riage
Ima
^Yes WNp ^Unknown ^Divorced ~N er Married ^Unknown
]2. Father's Name IFlrst, Meddle, Last. Su Hlxl 13. Mother's Name Prior to First Marriage (Firs[, Middle
Last)
Stephen M. Dell ,
Judith Walker
lAa. Informant's Name lAb. Relationship to Decedent LAC. Informant's Malling Atldress Street and Number, Clty, State
Zip Cotle)
0
Judith W. Dell Mother ,
2109 9eacon Circle, Mechanicsbur , PA 17055
w .. ..
'
~~~~~~~ 15 PI of D m {Ch k lY
"'
¢
~ If Death Occurred
I
~ i P ens ....... ...
-I/D h0 dS h OM1 rTh H I. ,~..yy "' "'
p Vg HOSp ce Facl'ty ^Decedents Home
^ Emergency R om/Ou[pa Lem ^ peatl r vat ^ Nurs rig Home/Long-Term Care Faclty ^ Other (Specify)
~
16b Facility Name (lf not institution, give street and number; 16c. City or Town, State, and Zip Code 16tl. County of Dean
~ Carol Croxton Slane Hos ice Harrisbur PA 17110 Dau hin
~ 16a. Method of Dlsppsilion ^ Burial ~ Cremation lfib. Dale pt Disposition 16<. Place pl Disposition (Name o(temetery
crematory
or other
lace)
^ gemoval tram State ^ Donation ,
,
p
^omerlsp«dy)_ June 30 2012 Hollinger Crematory
Z 16d. Location pt pisposition (City or town, State, and Zip Sta. Si of F or Person in Charge of Interment 1]b. License Number
a Mt. Boll S tin s PA 17065 - FD - 014889
E 1]c Name andCOmplete Adtlress of Funeral Facility
Mal zzi Funeral Herne 8 Market laser Wa hanicsbur PA 17055
]e. pemaenrs Edp[arion -meek me bet mat best deurroe, the 19 De[eeent or w:pans[ o.igln ~ cneck me 20 Decedent: qa[e ~ meek oNE Dq MoRE rat., m mdmare wnat
nignest degree or level pf :moos com
letes err m
t
f d
m
p
e
ime o
ea
net mat beer ae,oibea wnetner the ae[edem the deceeem [pn:m¢ree nimmn or ne.,elr to be
^ em grade or le:: is Spanish/HI:p m[/Labno cneck me "NO" Q] venue ^ Korean
a
^NO diploma, 9th12lM1 gratle box it eecedem
rs not Spanish/Hispanic/Latino. ^elackpr Alncan American ^V I
^High school gratluate or GEO Completed onot Spanish/Nrspanl</latino ^Amencan Indian or Alaska Native ^Othe aASean
~
^ Same college credit, but no tlegree
Yes, Mexican, Mexican American, Chicano ^ gsian Indian ^ Native Hawaiian
to degree e.B. AA, p61 ^ Ye Puerto Rican ^ Chinese ^ Guamanian or Chamorro
'
Bachelor
s degree e.g. BA, q0, 851 ^ vas, C` ban ^ Fillplno ^ Samoan
^ Mastei s degree leg. MA, MS, MEng, MEm MSW, MBA( ^ Yez, o net Spanish/Hispanic/Latino ^lapanese ^ Other Pacific Islander
^ Doctorate (e.g. PhD, Edpl or Professional degree ISOe<ifyl ___ -_.... _- ^ Other S
(e. MD, DDS, AVM, LLB, ID Pacify _.
ZI. pe<edents Single Race Sell~pesigna n -Check ONLY ONE to indicate what the decedent considered Himself or hersell to be Z2a Decedents Usual Occupation ~ India a type of work
o
White
^lapanese ^Samoan done during most of working life. DO NOT USE gETIgED
.
^ Black or Alncan Amencan ^ Korean ^ Other Pacific Islander
^Amencan Indian or Alaska Native ^Vietnamese ^pon'I Know/Not Sure Food SeTV1Ce
^ Asian Indian ^ Other Asian ^ Refused Z2b. Kind of Business/Industry
^ Chinese ^ Native Hawaiian ^ Omer ISpecilyl
pFaipmp ^wamamanprcnamprrp Health Care Systems
ITEMS 23a ~ 23d MUST BE COMPLETED 23a. to Pronounced Dead (MO/Day/Yr) Z3 51 a ure of Person Pro u I Death (Only w en applicable) Z3c Li arise Nu
t
nc
BY PERSON WHO PRONOUNCES OR
~
j
/. r k ~ ~ e a ~ s,~S~a
CERTIFIES DEATH LK-.A.~
Z3 . pate Signed ( o/pay/Yrl 2d. seta of DeamD ~.~./~
l
~
1
C7
r
V
• t ZS. Wax Medical Exa qr Coroner tatted? ^ Ves ^
CAUSE OF DEATH A
i
ppmx
mare
16. Partl. Enlermechalnolev ts-diseases, Injuries, or<omplications-thatdirectlycaused the death. 00 NOTenrerterminal events such as cardiac arrest Interval:
aspiratory arrest, or ventricular fibrillation without s
howing [ne
ti
e
ology. DO NOT ABBREVIATE. Enter only one cause on a line. Add addl[ional lines it necessary Onset to Death
hI
/
~
l
IMMEDIATE CAUSE ----~~-~--> a. As C[rl ~l /IG C N ~4 hJ Z
r[/acs
V,
(Final disease or condltlpn Tor a{ a consequence oil.
resulting in dean) / Z y
b. _..~~01i~ ~ r2C C.~ M ~
riall
list conditi
n
y
g
T
s, pus plot asacpnsequence pf).
it any, leading to the cause
h
a
UNDERIYING
CAUSF
e Due to for asa consequence oft:
Idi
m
= ze ury
bared me eyenta respltmg e.
in dean,) Lan. Due to for as a consegpence pq.
S 16. Part IL Enter other si¢nificant contll ontr bu t d lh but not resulting in the underlying cause given in Pan l 2). Was an autopsy pertormed?
F ^Yes ^ No
28. Were autopsy fintlings available
to plate the cause of deathl
co
^ Yps ^ No
29 If Female- 30 Did Tobacco Use Contribute to Oeaml 31. Manner of Death
o ^ N pregnant within pas[Year
t ^Yes ^ Probably ®NaNral ~ Npmiride
^ Pe
gnanta me of death ®No ~ Unknown Accident ion
^ ^ Pending
l
nv
st
gat
^ Not Pregnant, but pre hen AZ der
gnant wit ys o(tleath o
t
e
e
^ Suicide ^ Could b d termined
^ Not pregnant, but pregnant 43 days to 1 year helore deam 32 Date of Injury (MO/Day/Yr) (Spell Month)
^ Unknown if pregnam within the past year e ry
33 Tim of lnju
34 Place of Injury (e.g. M1ome: construction site: farm. school) 35 Location of Injury S[ree[ and Numbs.. City, Slate, Zip Code)
36. Injury at Work 31 If iranspor[a[ion Injury, Specify 38. Describe How Imury 0[curred
^ Yes ^ Driver/Opere[oi ^ Pedes r
t
^ No ^ Passenger ^ Other
l6peciry)
39a. Certifier (Check only one)'.
® Certitying physician - To the best of my knowledge, death occurred due to Ina causal:) and manner stated
^ Pronouncing & Certifying physician - To the best of my knowledge, death occurred at Ina lime, date, and place, and due [o the cause(s) and manner stated
^ Medical Examiner/COIO abazis of yon, and/pr loves Lrga Lion, in mY opinion, tleath occurretl at the time, date, antl place, and due to the causes and manner stated
~
Signature of certi(ler. C
recta ptcertifler- A')I~ _ license Numbec._/"'~l V'-/t4 [/~~
39b Name, Address and Zip Code of Person Completing Cause of Death tercet 261 39c. Dale Signed IMO/Day/Yr)
Sv5/~,J A (mzon MO SOU UV~v'2giq l7a,v~ o-7zsNC ~ 7c>i .lax Z-`"l Zol
40. Registrar's Olstn[t Number 41. gegi~ r' (gnat 42. gegist err Flle Date IMO/Day/Yrl
43. Amendments
0729476 Hlps~tA3
Disposition Permit No- ftEV 0]/2011
RENUNCIATION
REGISTER OF WILLS
COUNTY, PENNSYLVANIA
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Estate of __ ,2/ ~ i t3ti ~ ,¢~ ~ ~ t~ l JC L ~ ,Deceased
I' - ~ ~ ~~tl ~~ ~``~ ' ~ L-1--- , in my capacity/relationship as
_ (Para Name)
~`~T~~ ~ of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
- ~ ~ ~7~ fit-} l~~ , ~ ~ L ~ ,
.J ~ l y fb ~ ~--
(Date)
Executed in Register's Office
Sworn to or affirme nd subscribed
before me thi c!~ day
of ~ - C/
puty for Register of Wills
(Signature)
-~
i ~- ~~17~J~LL ('`i ~GLI-
(Street A(ddress) , / C~
(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 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