HomeMy WebLinkAbout07-11-12PETI ION FOR GRANT OF LETTERS ~ __
~,., ~-~,
REGISTER OF WILLS OF COUNTY, PENNSYI~IA ~ ~ r~~
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Petitioner(s) named below, who is/are 18 years of age or older, apply(ies) for Letters as sp iI`below.,..and in_~
support thereof aver(s) the following and respectfully request(s) the grant of Letters in the appropri~orm: ~".~=
Decedent's Information nc~' ~ ~ " _.T_;
U ~. ~ C~
Name: l.~.tJ~(~~ ~ 1 t~ '"~~'~~~_ File No: /U - ~ ~~ . '~ ~ ' = ~'~
cn
a/k/a: (Assigned by Re aster) L~
a/k/a:
a/k/a: Social Security No: _~~-(~ ~-~~~~
Date of Death: 7 A e at death: '~~
Decedent was domiciled at death in C u~ty, ~~ ~ ~ (State with his/her IastC~~
principal residence at ~ ~ ~
Street address, Post Office and Zip Code City, Township or Borough County
Decedent died at ~ ~ I
~' (1 r ~~~
Street address, Post Office and ip Code City, Township or orough County ate
Estimate of value of decedent's property at death: ~„/
If domiciled in Pennsylvania ............................ All personal property $ /'~l `~-
If trot domiciled in Pennsy!vania ........................ Personal property in Pennsylvania $
If trot domiciled in Pennsylvania ........................ Personal property in County $
Value of real estate in Pennsylvania ......................................................... $ , "
TOTAL ESTINIATED VALUE.... $ (~' ``+l'
T-
Real estate in Pennsylvania situated at:
(Attnch ndditionn! sheets, i(necessory.) 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 and Codicil(s)
thereto dated
State relevant circmnstances (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, 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. u., pendente life, durance absentia, durance minoritute
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.
~'O 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 (attuc•h
additiarul sheets, iJ'necessary):
Name Retationshi Address
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F»,-»,>zw-nz r~~. /nilliznll Page 1 of 2 \
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Oath of Personal Representative
CON[MONWEALTH OF PENNSYLVANIA
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COUNTY OF
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Petitioner(s) Printed Name "..
Petitioner(s) Printed Address ,.,
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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 Personal Representative(s) ofthe Decedent, the Petition (s) will well and truly administer the estate according to law.
Sworn to or affrmed a subsi;ribed before ~- f: -''r Date // jZ
me this / ~ay of!~'" ,C ..~' ~ , : ~C-t ~,' Date
$y. , 9 ; ~ ! '~('_ , Date
fie Register _ Date
BOND Required: QY~.S ~NO
FEES:
r
Lett rs .................... ,,
.. $ _., t t t. ~_
( ~;) Short Certificate(s).... .. L ' i_'
( ~ )Renunciation(s)....... .. z'
(~ )Codicil(s) ........... . .
( )Affidavit(s).......... . .
Bond ...................... ..
Commission ................ . .
Other ...... ..
Automation Fee ............... _ ~jl j ~'
JCS Fee. .. t~ i?
TOTAL ..................... $ _ ;-_ i` ~~
To the Register of Wi!!s:
Please 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
7h~_~
Estate of ~ ~~ /~~ CJ ' ~~ ~~" ~ ~ File No: ~~ ~ ~/1 -" r
a/k/a:
AND NOW, ;~GC- ~ ~ j / / ~ ~~~ 'n consid ration of the fi~regoing Petition,
satisfactory proof having been presented before me, IT IS DECREED that Letters LI ~ 1, ~ 5 ~~
are hereby granted to „6~G~~F~ Z.~S-~ '~~
in the a ove estate and (if applicable) that
the instrument(s) dated
described in the Petition be admitted to probate and filed of record a the last Will (nd Codicil(s)) of Decedent.
~ ,, .. _ .,
Register of Wills
ur~`,'' ~
Fo,,~, nw-o? rev. roiuizn~~ F~e
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I.. ~., GI`s '; ~:;
E'Ct" (~i)I Ill`. C'.Clii]t'~'[l., `'~E..l1i) .
~D12 JUL I { All 9~ 4~
~ .~ ~ ~ '~` ~ ~~ ° ~~ CUMBERU~ND C~.I PA '
L~vc. ~ ~c~i-~,l,~vrr~X' JUL 4 2 012
(_ Cf'Il~1(_aIlU13 till~l!~tCl _.
Type/Print In COMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF HEALTH ~ VITAL RECORDS
Permanent I"C~T~r.^ w
O
~' _ ~ ~ State File Number:
1. Decedent's Legal Name (First, Middle, Last
Suffix)
,
2. Sex 3. Social Security Number 4. Date of Death (MO/Day/Vr) (Spell Mo)
' - Female 180-66-8503 July 1, 2012
6a. Age-Last Birthday (Yrs) Sb. Under 1 Year Sc. Under 1 Day 6. Date of Birth (MO/Day/Near) (Spell Month) 7a. Birthplace (Clay and State or Fore(
C
gn
ountry)
31 Mpnths pays Hours Minutes Dec_ 26, 1980 Car11s1e PA
Zb. Birthplace (County)
Sa. Residence (State or Foreign Country) eb. Residence (Street and Number -Include ApY No.) 8c. Did Decedent Live in a Township?
353 Crossroad School Rd _ fives
decedent h
d i
W P
,
..e
n
nnsbo o twp.
8d. Residence (County)
Cumberland He. Residence (Zip Code) 41 Q No, decedent lived within limits of
ciCy/boro.
9. Ever in US Armed Forces? 10. Marital Status at Time of Death g] Married ~ Widowed 11. Surviving Spouse's Name (If wife
give name prior to first m
i
~ V
[
,
arr
es
age)
~ No ~ Unknown ~ Divorced ~ Never Married Q Unknown Jasall= Greene
'
12. Father
s Name SFirst, Middle, Last, Suffix) 13. Mother's Name Prior fo First Marriage (First, Middle
Last)
Lar
W
lhid
,
ry
1
e Patricia Anderson
14a. Informant's Name 14b
R
l
ti
h
'
.
e
a
ons
i to Decedent
Jessie Greene husband 14c. Informant
s Mailing Address (Street and Number, Cit State, Z' de]
353
`
~p
~
0
Crossroad School Rd_, IV
ewvl
l
e, PA 1724
C
s ......................................................... -......................................... 15a. Place of Deat (Chet on y one)
IF Death Occurred in a Hos tai: In - ""'-•-~~~~~~-- - ----------- --- --......
......
pi patient If Death O
d
--- -
---------
o _
ccurre
Somewhere Other Than a Hos Gal:
'
pi Q Hospi a Facility
pecedent s Home
Q Emerge ncY Room/Outpatient 0 Dead on Arrival
N
i
Q
urs
ng Home/Long-Term Care Facility Q Other (Specify)
15 b. Facility Name (If n titution, give [reef and number; 15 ~. City or Town, State
and Zip Code
°<
,
15d. Gounty f Death
M.S. Hershe
Medical Center Hershey
Pa. 17033 D
h
,
aup
in
16a. Method of Disposition g] Burial ~ Cremation 166. Date of Disposition 16c. Place of Disposition (Name of cemetery, c matory
o other place)
p Re
l f
s
,
mova
rom
tate p Donati°^ July 6 , 2012 Westminster Memor
ial-rGard
- -
ens
Other (Specify) _ -
v 16d. Location of Disposition (City or Town, State, and Zip) 1?a. Signat of F n cal Service in Cha
f I
rge o
nterment 1Z6. License Number
Carlisle, PA 17013
138504
0 17c. N and Complete Address of Fune al Facility
Ho~~'man-Roth F
l H
unera
ome & Crematory, 219 North Hanover Street, Carlisle, PA 17013
m
•- 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 races to indicate what
hi
hest de
ree
r l
l
f
h
l
g
g
o
eve
o
sc
oo
completed at the time of death. box that best describes whether the decedent the decedent considered himself or herself to be
~ 8th
d
l
.
gra
e or
ess is Spanish/Hispanic/Latino. Check the "NO" ~ White 0 Korean
~ No di
l
9th
p
oma,
- 12th grade box if decedent is not Spanish/Hispanic/Latino. ~ Black or African American ~ Vietnamese
Q Hi
h
h
l
d
g
sc
oo
gra
uate or GED completed ~ No, not Spanish/Hispanic/Latino Q American Indian or Alaska Native 0 Other Asian
~ So
ll
d
b
me co
ege cre
it,
ut no degree ~ Yes, Mexican, Mexican American, Chicano ~ Asian Indian Q Native Hawaiian
Q Asso
i
t
d
c
a
e
egree (e.g. AA, AS) Q Yes, Puerto Rican
0 Chinese Guamanian or Ch
'
O
a mono
Bachelor
s degree (e.g. BA, AB, BS) Yes, C2 ban ~ Filipino
Samoan
Master's de
ree (
MA
M
g
e.g.
,
S, MEng, MEd, MSW, MBA) Q Ves, o her Spanish/Hispanic/Latino ~ Japanese ~ Other Pa clflc Islande
r
Doctorate (e.g. PhD, EdD) or Professional degree (S
ecif
) ~
p
y
Other (Specify)
. MD, DDS, DVM, LLB, Jp
21. Decedent's Single Race Self-Destgna<lon -Check ONLY ONE to indicate what tM1e decedent considered himself or herself [o be
22a
Decedent's U
l O
.
-
sua
ccu pati°n -Indicate type of work
(~ White Q Japanese 0 Samoan d
d
one
uring most of working life. DO NOT USE RETIRED.
Q Black or African American Q Korean Q Other Pacific Islander
Q American Indian or Alaska Native ~ Vietnamese 0 Don't Know/Not Sure Administrative Assistant
Q Asian Indian ~ Other Asian ~ Refused 22b. Kind of Business/Ind ust
ry
~ Chinese
~ Native Hawaiian Q Other (Specify)
Q FIIi
i
Manufacturi
P
ng
no 0 Guamanian or Chamorro
ITEMS 23a - 23d MUST BE COMPLETED 23a. Dale Pronounced Dead (MO/pay/Yr) 236. Signature of Person Pronouncing death (Only when a
licabl
) 23
Li
BV P
pp
e
c.
cense Number
ERSON WHO PRONOUNCES OR
CERTIFIES DEATH (/
23d. Date Signed (MO/Day/Yr) 24. Time of D ath
~/~
~ y t-) 25. Was Medical Examiner or Coroner Contacted? ~ Ves ~ No
CAUSE OF DEATH
AppC Oximate
26. PaK 1. Enter the chain of events--diseases, injuries, or complications--that directly caused the dea<h. DO NOT enter terminal events such as cardiac arrest 1 rv
l
a
:
respiratory arrest, or ventricular fibrillation with o
u
t showing the etiolog
y. DO NOT ABBREVIATE. E
nter only
one cause on a line. Add additional lines if necessa
Onset to Death
ry
(
~
r
.t
w
IMMEDIATE CAUSE > Q-~y Q: f~ ~i~ {y~ ~iM~ ~ ~,p `O /~-M
fF at disease o condition pue io (or as a consequence of): -
esul ing in death)
b.
Sequentially list conditions, Due <o (or as a consequence of):
if any, leading t° the cause
listed on line a. Enter the
UNDERLYING CAUSE Due to o as a con
( r sequence °f):
(disease or Injury that
Initiated the events resulting d. -
m death) LAST- Due to (or as a consequence f
o )
Z6. Part I1. Enter other slenifica nt cond't'o ontr'butine to death but not resulting in the underlying cause given in Part I 27
W
s
g .
a
an a topsy performed?
~ Ves ~No
m 28. Were autopsy findings avalla ble
to complete the cause of death?
a
a ~ Yes ~ No
29. If Female: 30
Di
o .
d Tobacco Use Contribute to Death? 31``M``a nner of peath
Not pregnant within past year V
es ~ Probably ~Natu cal ~ Homicide
~ Pregnant at time of death
~ No 0 Unknown Accident
P
m ~
ending Investigation
Q No[ pregnant, but pregnant within 42 days of death
S
i
r. u
cide Q Could not be determined
Q Not pregnant, but pregnant 43 days to 1 year before death 32. pate of In Mo/Da /Vr 5 ~
Jury ( Y ) ( Pell Month)
~ Unknown if pregnant within the past year
33. Time of Injury
34. Place of Injury (e.g. home; construction site; farm; school) 35. Location of Injury (Street and Number, City. State, Zip Code)
36. Injury at Work 37. If Transportation Injury, Specify: 38. Describe How InJury Occurred:
Q Ves Q Driver/Operator Q Pedestrian
No Q Passenger Q Other (Specify)
39a. Certifier (Check only one):
Q Certifying physician - T° the best of my knowledge, death occurred due xo the cause(s) and manner stated
Pronouncing & Certifying physician - To the best of my knowledge, death occurred at the time, date, and place, and due to the c se(s) and manner stated
M
di
l E
i
e
ca
xam
ner/CO ~ /~(( th ba f examination, and/or investigation, in my opinion, death
rred at the time, date, and place, and due to th
e c
au
se(s) and manner stated
r
~
~ `
em
`
~
Signature of certifier:
/ t
~ Title of certifie r:_ M ~ License Number: ,"` \ ~V
396. Na e, Address and Zip Code of Person Completing Car~~oTjJe}gdyt~~ Med ica I Center, Hershey, Pa.17033 39c. Date Signed (MO/Day/Vr)
'
40. Registrar
s District umber 41. Registrar 5~[ure ~^
42. Registrar ile pate (MO/Day Vr)
~
43. Amendments 1
=~ rtrll ~S %I ~• 1~/~ ~ ~c,kld r~'~tc? : ~e'5.~~' ~zY'r' c° it ~'
/~ ~ ~ /[ ~n f~ H105-143
Disposition Permit No. ( J tJ f REV D~/2f)1 t
i.
Sa: 9
~~ t'~.1
RENUNCIATION ~'~ ` ;
--
-- -
REGISTER OF WILLS ~c ' ~ :Yr
COUNTY, PENNSYLVANIA
y ~' ^
`~
~~- ~ - ~ ~ Q ~~~ ~
cn o
Estate of ~-~u~~-/~ Vvl LNiG~~ - ~~'i•c-:tJ~
Deceased
I, (~T,a .~.a c"' it ~~L_/y ilk
in my capacity/relationship as
(Prrnr Name)
~~' ~~ ~ >~ r r` of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
~-zc ~; ~F. ~I. ~~r~~ ~~ti
`~ / / f <-
(Date)
Executed in Register's Office
Sworn to or affirmed a_nd subscribed
before, e th~s t/t day
of '~ ~ ~ 1 '
_ ,
i
,~ ~-- -,~
e uty for Register of Wi11s
~-~ ~, l - /
,-~ ~ ~/
(Signature)
• jiJ'
(Street Address)
~~~~~ir~`c~~. ~~ ~~~ ~l
(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
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RENUNCIATION L-
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-.. -,-
REGISTER OF WILLS ~ ~ ~ `~,
COUNTY, PENNSYLVANIA c."
~' f `~ - L 1 J.5!~
Estate of -" .~ ~ .Q c-,~ LIJiL ~j'i D ~ - ~~ ,Q~~-~.~.~ ,Deceased
I' - G ~~~ ~ ~ ~`L ~`L'/p , in my capacity/relationshi as
Prrnt Name) h
~~ ~~ ~`£° of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
J~ss~ ~ ~2~~ .~
~/~/i ~
(Dat
Executed in Register's Office
Sworn to or affirmed and subscribed
before e this ~ ~ ~' day
of f~ C C. ii ~)
~~ /$ ~--//- .. /may/ /~ 1
e ty for Register of «'ilis
~~
(Signature)
/l9 Z.s' It/~L~1lvi ~So~7~~~,~I ~.~
(Street Address)
Nc ~ (~rG Lc ~i~t ! 7z ~
(City, Stale, 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