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HomeMy WebLinkAbout07-17-12Reset PETITION FOR GRANT OF LETTERS REGISTER OF WILLS OF Cumberland COiJNTY, PENNSYLVANIA Petitioner(s) named below, who is/aze 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: Eleanor M. Weitzel a/k/a: a/k/a: File No: a/k/a: Date of Death: Julv 7. 2012 (Assigned by Register) Social Security No: Age at death: 79 Decedent was domiciled at death in Cumberland County, penntylvania (ware) with his/her last principal residence at 117 North 33rd Street Camn Hill Boroueh Cumberland Street address, Post Onice and Zip Code City, Townehlp or Borough Couoty Decedent died at 117 North 33rd Street Camo Hill Boroueh Cumberland Pennsvlvania Street addresa, Poat Omce sod Zip Code City, Towoahip or Baroagh Couoty State Estimate of value of decedent's property at death Ijdomleiled in Pennsylvania ............................ All personal properly $ 1,000.00 /jnot domiciled in Pennsyvania ........................ Personal property in Pennsylvania $ IJnot domiciled In Pennsylvanra ........................ Personal property in County $ Value ojreal estate in Pennsy(vania ............................ ............................. $ 10 On n.nn TOTAL ESTIMATED VALUE.... $ 11.000.00 Real estate in Pennsylvania situated at: 117 North 33rd Street Camp Hill Boroueh - Cumberland (Attach additional sheets, ifnecessary.) Street address, Past Omce and Zip Cade City, Towoahip or Borough Couoty ® A. Petition for Probate and Grant of Letters Testamentary Pefitionm(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated bone 2, 1997 and Codicil(s) thereto dated Hnshand, William T. WeirzeL nredeceaced drnedent nn hme 29 9019 Stste relevaet dreumstaocn (e.g. rmaulodoq depth of execuror, silo) Except as follows: after the execution of the instrument(s) offered for probate Decedrnt did not marry, was not divorced, was not apar[y to a prnding divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(8), aad 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 ([f applicable) c. t.a., d.b.n., d.b.n.c.t.a., pendente lire, durance absentia, durance minoritare If Administration, c.t.a. or d.b.n.c.Ga., enter date of Will in Section A above anti 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 zv Petitioner(s), after a proper search has/have ascertained that Decedent left no Will and was survived by thr, followinguse (if any) atulheire (att~ additional sheets, ifnecessary): ~~?7 S~ , .Q r4-- ~`rx C: Name Relationahi Addrea ~ ~" :_ 7~ N ~~~ Farm RW-01 rev. loiuilou Page 1 of 2 Oath of Personal Representative ~ f' ~, t~,-• COMMONWEALTH OF PENNSYLVANIA } L~..7,~-~' '' ;' } SS: COUNTY OF Cumberland } ~, Petitioner(s) Printed Name Petitioner(s) Printed Address 117 N. 33rd Street Cam Hill PA 17011 ~ '' Andrew T. Weitzel Linda A. Warner f/k/a Linda A. Fiasche~li 138 Trotters Wa , Torrin ton, CT 0679 ..~~~ ~•~ The Petitioner(s) above-named swear(s) or affirm(s) the statements in the foregoing Petition aze true and correct to the best of the lrnowledge and belief of Petitioner(s) and that, as Personal Representative(s) of the Decedent,,t P~e loner(s) will well an ly administer the estate ac~cor/d1ing to law~/.f / / f.G2-- ~ ~.. Date .J N/ / Gs' Gy ~~ Sworn to or affirmed d subscribed b~e~f~o`re k Date J~~N ! I, l~ me this day f ~~"v~ Z Date BY~ ~ Date Fo a egister BOND Required: Q YES FEES: NO To t)ae Register of Wllls: r~an~.. peter my anoearance by my signature below: ~a l Letters ..................... . ( ~) Short Certificate(s)..... . ( )Renunciation(s)........ . ( )Codicil(s) ............ . ( )Affidavit(s)........... . Bond ........................ Commission . ................. . Other ((I •••••••• Automation Fee .............. . JCS Fee ..................... _ TOTAL ...................... $ ~ 0.00 j~~. S~ Attorney Signature P ' to ame: Lisa Marie oyne Supreme Court ID Number: 53788 Firm Name: Coyne & Coyne, PC Address: ~^^~ *~~-~-^« er C:aTn Hill_ PA 17011 4227 Phone: Fax: Email: 717-737-0464 717-737-5161 liaana .nyneand nypP ~nm DECREE OF THE REGISTER Estate of Eleanor M. Weitzel File No: ~ ~ _ ~ ~ ~ 7 a/k/a: ;~ ~j ~ " in consideration of the foregoing Petition, AND NOW, s_ C ~L,~ ~ .__1-~ y ~ ~~ satisfactory proof having bbdn presented before me, IT IS DECREED that Letters Testamentary are hereby granted to Andrew T. Weitzel and Linda A. Warner f/k/a Linda A. Fiaschelli in the above estate and (if applicable) that the instrttment(s) dated June 2 1997 - described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent. Register of W~ls~ J~,-,~~~',,, lS C; ~ ~(..~. r' II~-"" `- Form RW-02 rev. /0/II/20/1 Pagel of 2 .... . LOCA~~RAR'S CERTIFICATION OF DEATH WARN ~ T, II ' ~1~t~ plicate this copy by photostat or photograph. ~ui~~e~ vL.. ,~u~S Fee for this certificate, $6.00 P 18615095 2012 JUL 17 AM B= 27 ORPHAN'S COtlRr CUMBERLAND CO., P4 This is to certify that the information here given is correctly copied from an original Certificate of Death duly tiled with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. -~~ Q~`" JUL ~ 0 212 Certification Number .5 pa/PHm m PBI ck lnk< ~i Local Reg)strar Date Issued OF FENNSYLVPNIF • DEPARTMENT OF HEPLTH VITTL PECOPOs CERTIFICATE OF DEATH e z Le a ...e Icl s Mltltlle, Laat. suitir) en _ urlry rv n Ime/oay/rrl lspe I mol ° n 1 3 5 o t Eleanor Weitzel F. 168 26-4E192 Jul 7 2012 ag=-L.at Blahe.y Iv.x) unaet a ve.r una.[ 1 Da 6. D.<e or ahtn IMO/Davneaq IBpell month) a. glrtnvlaee Inw ana states o. vo.mgn coumrvl nn[h Daya N°ut In„t x mium. PA 79 Tlarch 15 1933 Blanplaa rc°„nry> Cameron b e a sleen[a lsmta °r Fotalgn ceuntrvl eb. Rezmen<a fstte.<ane Number- mcluae Tp[ rv°.1 Dla D e n nip/ e a o P nns lvania , , t Iwm m Camp Hill ' °" °" Ba. seance rcppnry) 117 North 33rd St. ' - °"' P (]-ssnberland ¢ale.n[. tzl a.l 1 ~N t Iro¢a wltmn II,.,Bx nF <rtv/nn O. ~ v o e n us atmea Foran atl e sees or Deam O M rnetl o wmowaa a so..-wing spnuxe :.vama ur wires. sores „am¢ vrwr to next marrmg¢I o: 1Oo `p Tr 7p N oD Dlyprcea o N ,rites oD ~ a1. shays Names IFI t M ema Last, moral x n st war ge al xt. mleme. Lam 3~ m o Smi th Norman A. Martha R. Obenrider 19a. lnrormant'a Name 1 b. ele<IanzFlp to OeceOent (°rmant's Mallrng htltlraax ISt antl N mbet, CIN. Sbte, 1 ~p 0 Linda Warner Dau titer 138 Trotters Way Torrington, CT 05790 G ......_...._. ._ ........ .. .... ...._......_._._. ..... '....,ace e.«..o~,y one ""' " .. "" ' ~ e S : i ... .... ....... n Deam ........._ ..... .... ....~.° ...._.. i~ ur7ed aNOxphal. [] paiie;:i be~,;::6e 5om J:riere o<nat Vna,; a'Poapimi:"' [Y a~iii$ ...._ aed;,r:'A ozwc¢ F pm¢ o ° f m/outpal¢n< a.a nn Mrrlval o Nusing soma L / ong-Term Care Fac Other IspaclNl m a d' 156. lity ama 11 nn<Instl<u <lon, glue ztrae<antl number: antl tle N of a< o er[°~ zp 35tl 117 North 33rd St. Hill PA 17011 C1~mberland ~, ba. M noes or Dlavoanon e.rw o o.ma<lon Sbn. Data or Dlxpoxrtlon <. places of olsponuon Irvama of cemenry. <•amatorv, o, Dent, plaal I p mo°al n° Sps ate p DOnanon om..t =N) 07 11/2012 Mt. Calvar C;ematar 2 oc Sbtl. L atlon of °ISp°xltlnn IClty or sown, State, antl Zlp) g o u rv15 b. Licenze N er T m ~ Harriabur PA 014819 vc. Names .na complan Tmtexz or Funeral F tlury ~ rs-Harney Funeral Home Inc. 1903 Market St. Hill PA 17011 ~ atl x EtlucaNOn -Check tM1e bo. [hat pesC tlescrlbaa the 19. Decetlen<°r Hispanic Otlgln -Check tM1e ONE O0. MORE racez to Intllca<e what a. ° ° M1e n B i<tl¢grva err Iwel aI rcneol compl¢[ea v[ tna time o1 tlea<M1. a tribes whatM1er ene tlecetlem cetleni consleeretl M1 mseu or M1 rze o be. x a t e a l O eM B; ate e<1¢xz 5pan sn/Hlapanlc/Latlne. Check tM1°"Nn" whlta p K an tl O rva ploma, Stn-11tH great bor lr tl°ceeent is no[Spenrzn/HlxpanlULa[Ino. ~ Black err FM1lcan American 0 V < "a O Nrgh acnom graeuata or GED comvlatae $~ y Izn/Hlzpanl4Latlna ~ gmar can In nor hlaska N ti 0 O al a ~e r ~ Hx p s cou tlge crams nut no aegrae O eklcan nmaacan, cnlcano ~ nxlan O N lnalan i.¢ wa I a P a a e -1' a Ts) R Han O thoraxes p c o. cnamo..o y`< ° e . , g z a es) O Y o Fn l n o s . BA . Pa ^ x n p o M a w. a and Ixpan tlnn BT) o Y xn/H le/La o , e . o D err ,[lac Ixl.neat e a M e •~~ e ` ao ~. P~ o . e M ~ a p o D . F D E > t . e w lsee=lNl o Omer Ispaerro DDShovm L MS oea.nr u a ingla R.ca sesb oealenxmn -enaek aNLV DnE <o Inamates what ine aeaa¢m <onxmarea nlmaar o. natxelF m be. Daceae..r: uxaal ° a Npe or wo.k ~ wm~. p fapane O Samoan ne auring most °r wo.kme ~i~• DO Nor vsE REngeD zC o B o kprean o o clac Iaana.r . aa n o. m.xka Naa„e o 0 0 0 .~ w/Not s,..es Re is to ed Nurse p na.~lo~e ." o tl l . o R r,,.¢a c Ina or aoxlnaxx/ „ ,., ry b k e o cnmaaa o N n o o nar< p =Iro %° o Nupmo O c cnamorro Hospital u ITENE333a-3Btl MVST BE COMPLETED 23 a. cetl Dee ) 136.5 or person F[pnnuncing Devcn On was ap lei 23c Number p RBON WNO PRONOYNCES Og ^~/~ I^. ERTIFICS EATN pT / r J ix r ~-~ CIO S - J G , . a / F ~ L/ /~/ a / {- t-J e I D yy~'/~~ ) Z - J' 'CJ / e cal E t°`[.m vex 0 CAUSE OF DEATH 3 rent cna note ntx--tllseeses In)urler,etcompllcatlana--that Elrectl yT auzetl [he tlea<M1. nel events such as cartllac arrez< 6. Pa y O near term) Interval: w 0 O rezplre ry arrest er ven<rlc lay flbrlllatlan wl[nou<ahowlry [M1e etiology. ABBPE qTE En<er nly D O one cause nn a line Tea etleltlonal Ilner IF necessary D N VI o Onzet to eatF //~~ `,~ ~ 1 ~ ~ IMMEDITTE cTUSE -_______._ a. Ilti VA h C4.- {~ E(xL_ciblBi NYOJ N.1 9 i Ipmal ma opmaon Dua to for ax Bona.°uan r): am ~~ a tazmtme ¢ l muy uzt conmtlonx. oo¢ to tot ax a conz¢vuan« oq: n .w, i~ aamg to m¢ c.oaes natea on Im me <. n RLVIN~ c u Dua to for ax . conzapuenca orl: ~~e t ~ a a¢or n)urv - to rexmung a. m a..m <u r.e ) z Do. to w. ax a =o..xe o.nte °N: • ~ o zb. P.rt n. Encer Dora. I s b.t n°<r¢amang m ma yna¢aYing =suxa gw¢n m p.,t I v. w tovar petrotmaea a O v O rv ~ topsy flnaingz ayalleble 28 <e co mple<e tM1e cause err tlevtM1i O Vea ~ N , <o use conttlbpta to Dean> 1 M r or Da.m e It v a= ° y o rvot p.agnant wRnln vaac Yaat o p prpbanlY o o ~o<~ta p Nnmmlae ~ o Pt.gnant a <Ima nr aaa<n o N o Dnknpwn o Tc[laan< o panaing lnya,<LaNnn n n p p..gnant u<pregn.nt w¢nm az aevz or aa.m p smaae p coula not ba eete.mmea No p t vregn.ns b.t pregnant a3 a.vx to 1 year nemta teen .Data or In),.ry IMO/Day/yr) Ispall Moncn) o anknnwnlrpreg.,an<wlmmtne past y¢.r .Tlmep rnn,ry place °i In)ury (e. g. homes: cnnserucNOn zlte, M1rm, school) B_ Location oI Inlury IStree[ antl Numbest, <l N. 5<ate(Zlp Ceael e nrk r a o In)uty, nN: o t h 36. Describe Hew ln)ury OCCwretl: o y o D yet/ pt at¢ o p xtrl.n p no O wxxan err p Dt er lsve=Iw) e n 3C rt <ler^CM1eck only one): a t rtlNl g physlclvn -TO the best err y knawletlge, tl°atM1 ° yea tlue a xa ) T O p n a c rtlNing pnysrclvn - o eM1a best or my knew a g¢. tleatn n <t he sore, ea<ezantl place, antl tlue <o the teasels) ana manner z[a[ee ca e . e O Mem l aamm / - ax eaaml n,,.. ny iot n. h o orlon aaatn o..ut.m a<m¢ ama eats t~e -, ana pl..a. ana au¢ <or,a caux¢Iz1.na m nar t.[aa an a G QeL i 4 ~ ~ ~ L L. ~ f~4f ' a .~5 'f mna rtlner: Y{T _ '(.Dn 37 q.8 ~ <e an T g t b as .ax ene zip coat of Pat n complean n pmm 161 ' r 39~~° Imo/D.ynn ^^ e_5 /JBSH/kRlnn- Q-~A P€Z- 39/2 TR SN2GC- 2D ~P ~P ~ t LL ~ t ~ 1, l / O e ~ . Pe strata sex c<NUm er 1. Rea s tar s Ignature glxtra D < M a1. ge a e o DaY r) . Tmentlmenta Dlxp°xlae,, permit N°. 0740611 REV on1D11 '-' . 'l LOC t~ISTRAR'S CERTIFICATION IJF DEATH WAR k`~I^ - t~tluplicate this copy by photostat or photograph. ~I~IF:~;.r u,~~c Fee for this certificate, $6.00 ~~~~ ~~~ ~ ~ ~~ 8 ~~ ~Pi-IgN~S ~~;Fr P 1867.469~~~~x~ Certification Number Type/prim In H r~ This is to certify that the information hart given is correctly copied from an original Certificate of Deatl~ duly filed with me as Local Registrar. The original certificate will be furwarded to the State Vital Records Office for permanent filing. ~:~~ -r ~u~V Z a ko~2 Local Registrar Date Issued COMMONWEFLT HEgLTH•VITAL RECOPDS CERTIFICATE OF DEATH 1. DBCeamea Lesal Name IHn<. Mmale. Laxq mm.) wIH Number a of Dean Imo/DadY.l (spell m^) 5 s a William J_ Weitzel Male 208 -24-3868 June 22 2012 . qae-u rtnaay Ivrx) sb. under t vea. er 2 Da s. pa<Pf Hlrth IMO/wv/m..l (spell Menm) . BL~ lea (el<~. ne~a<Pr~o len country) Ta ° 7 en<M1 Dayx Xenr In,.` ~ 4 arri 8 August 8, 1933 Tb. BIrtM1place (COUnHI ne g ealtlenu tear Fo< n Country) 86. Pealdence (Strew vntl Number-Include qp[ N^.) Pe ~v e1g H=. Did pecedent Llve In a Townshlpi nnsy ania 117 N. 33rd St. ores, aeaaent u.ea m _ t""°' ea. Rexm<n=e ~ anr~ C Hill GYUnber l .Inp ceee. 1 11 amp wee wmm~ nmlu of e<yroero. us grmea r=.n . M a a I e w. en a Df wlro, eme name Paor w n.a m.rrl.gel 1O ~ `n rl w I ^' ' rr ts : a No V nknuwn O o etl o rr I.tl o Dnkne h ~~ .m.: a home (FI mlml<, u s..el:) rt l t 13. wa•a N. m. Prn.r m artrage IFlrx<, Mlaela umr G rn Joseph J. 47eitze ertrude Wa ierm.nra N.me tab. R. xnlp <e eae<n< atl D [ oat r . a M Ilne gaaro.a Ise a Nemb<r city, star ae eoae et S Linda Warner Da hter 138 Trotters Way, TOrrington, CT 06790 Ii DaaM Oaut=ed rna XO [glnpalan< ' If DeatM1 Occurred 9amewM1er<OMa Tlhana X^xpltal:~~~~ ~~~~r]~HOSpICe Fac111H ~[~Ueceeen[i H^me EmergeneV floom/OUtpalent 0 Davtl on NrH<I Nur'zing Xome/Len -Ter Care Faclll er ISpecrry) ~ 13 b. Fa=Illty Name tl1 n^<Ins<Itu[lan, glue xtrce<antl number; Sse. CIH or Town, s<a<, one 21p c p se_ ~P =- ^ is ~e <ls a Hol S irit Hos ital Camp Hill, PA 1 J11 [ . . n r nd ~, v. MatM1etl of Olapeal<ron ~ HuXel O Cremation b l6b- Date of Dlspozl[lon =. PIa=<ai Dlxpexltl^n (Name o1 cemetery, cr<me<ory, or o[ner place) 16 $ no a<e DDanatle^ meotM1.r (speeNl o 06 27 2012 Mt_ Calvar C:eme to f ea n=. ^e lbtl. L [I f OI p Itlon (CIH ^r T^wn, 3[ste, a d 21p1 1Ta. 9 na[ a of Funeral 9arvlca Llcenaee a s^ M1a=ge of In<erment 1Tb. L canoe N bar m Harrisburg, PA 014819 v=. Name one cpmwae gamox m FPnera FaenH ers-Horner E4neral Home Inc. 1903 Market St_ Hill PA 17011 ~ 1H.O<catlent'z Etluutlon-Cneck [h<bax [he<beat tlencrrb<a tM1e 19. Oeceden[of Hlspanlc OrlHln-Cneck [he 3D.Oecedent's Race-CM1eck ONE OR MORE indicate what <o Flgnext tlegroe or level M s=hoal comple<etl a<fM1e time oT death. boz tM1a[ ba[ tl<acrlbex wM1etM1er the decetlem tna daatlen[ crsnxldercd himself or herself to bv. 0 BM grad<or l<aa SpanIFM1/Hlspanlc/La[Ina. CM1aktna "N O" 0 K 0 N^tl pl^ma 9tM1-12eM1 grade box li de=aaant ra n^ xh/HlspanlULetlno. OBlack or girl=an Amed=an ~ V i n school grvduata or GED completetl d(N o, aM1/XI nlyta O q nor alvzkv Netwe ~ HlgM1 o« ! l dr ~ s =allege =real[, bu<no degro< ~ Ves, Merti<e n M<xlcvn gmerlun, Chl=ano ~ gslvn lndlan Q Nafl ve Hawallan Q gisoclae degree (e. q51 Q V can ~ C 0 G or «amorro R n l' ® B e Ie.g B. A, AH, H51 ~ Ves, Cuban pr~o o s;l',n:~ o H e . p m a a.g . I•. mq. ms. M msa, M Bp p vex e m spanisb/Hlspvnl=/Lawn O ~ •^_ = O «ner peen= Ixiaaa<. e D D . (.. EaDl a mieaena a.gro. (speeNl _ O Dm.r 1':palN) sa L S 3 ~ecetlen[' 91n81e Rece eli OezlgnaIan-CM1ak ONLY ONEta rndlcaawM1atne tlecetlent =^nxitlerod M1lmself or M1eraali to be. 23a. O<cedent'x VZUaI DCCUp -Intl tae Hpe of work un f< W M1I[a Q Ja ~ Samoan done tluang meat ni w^rkinH II p0 NOT VSE RETIRED. 0 gr<ck o=AFNCan Am r an ~ Ko 0 O<M1< tl11c l lande o 0 a Indren or Hlab Nalva O V 0 D w/N t Sure Claims ({d US ter P n o a. ^ O o e nxien p Remaa b. Kma of auxmezs/Inauz<ry i :;~e1e o ch o N o O<her IspeeN) n al o ma o F o Gu n~ cnamo.ro Insurance an ^ M93Ha Satl MVST gE COM L O 23a. DV [e Pranounu 33b. 31gnaturea P<raran Preneuncing Deafh OnN when appilca a c. Llcenie Number BV PERHON WMO YRONOV NOES OR ~ Liter rl ^ r ~C11 oc`+4 z3a. o:~s a lHn< Imo/D.y/rq nrD<atM1 wl Medma Ea.min.r er serener men<ae<di o srN CAUSE OF DEATH 3 - mlenex pRC -tna<alr =nv <aean. Do ..[n. .rala rvor.n<.r <erml .[ =.m<x< : ao M1 eu . ne mm~o .ne .l a v ~ .~~ a < ea er reno-l l ,. wmne.a I~g m ~aPmgy. Do NOr nea e urE. En<er env en<=apx<on . P ~ rv u .e~naa .emuenal lm<xuneax:. On.w eo oeab ry IMMEpIgrE CgV9E ------> a. Ph1fit~MON f Rc- ! D<Fy S IXna tlixs.er =entlraen p ler... =en,.Rnen r . e e ..zulnng In ee.<M1) b. Ll~ry~}-r Gs~NGC>"2 ? Lily ua =emm~ena, Dna e 1 . = n a ml: n < g..a n ~ ~ LE~ tl, ~~.mni t.m< . Enu. mee t. (~ u vm nogni G uusE D.,. <e ler ax a =enxew nee erp ~ lal INurv ~ ma m~ to r.aummg e. l l ~ T In a e Dae t r.a a =on ena an) e w x<ea ePo 36. PaR ll. En[er e[M1a II bu t de n of raaultlnH'~. {fie un lying cauzv glV<n In Partl autopsy performvdi i Wa ~ 'O Vas Na (J ~ IlzJ~ ~~rj n J~ t n ~ 1 ~ e_tw aopxy nnamga a..alame Ll.~ll T [M1e cause of dea<M1i p u a $ V N ~ o x jl f Fe .l Oltl e e co == ux vahi taD <r T b n oat 33 0 M1 ~ O [ Prognen<wl<hln oast r v<e O =^ a O Nes n blY u=al mlc lae s P~gnvn<vt <Ime of eeath n Vnknown 0 gccitlant 0 pendlnH lnvas<Ig+<I^n na I<hln a2 days of dea[rc O N P g t, b e preg ~ s Iclde 0 could no[ be determinea H 0 Nat prognen; bu[ pre n 3 oars [01 ar beb deatM1 < .Dale ei Inlury (MO/OV V r) (Spell M^n<nl p Vnkn^wn if PreHnan<wl<M1ln<ePa<Yeer .Time of Inlury . ple=a m mlury aa. beme, .nnx<ru=nen an.: m.m; ameep . w=.nen of Inh.ry tso-.et .ne Neme<r, nH, state, ziv ceeel . In)ur a er4 3T_ NTrenzportvHan Iryury eclH: Dexcrlbe How Inlury Occurred. Q y ~ D er/O [o ~ P p rvo O waxen <• p «M1er lspeoiN) 39x. Certlfler ICneck only one): ~urtlNln pbyan.n-rem<ben of my knowledge. a..m o==wreeew <o ena c.uzeb).nam x ~ P rtlHing phyxl=lan -Ta tM1e beat ai my kna ledge, tleatM1 occur.ed v<<M1e time, tlate a d place, antl tlua to the cauae(x) antl manna a<a[atl e 0 Medical Ea.amine /Ca n Me ba a ei a and/ar Invea<Ievtlan, In my oplnl^ M1 red at the time, tla[e, and place. antl tlua <e tM1e c Isl d m n < Ida ni= .~'/~ mbar !>1•d Gr4 fR `7 ~/ 51 e T art - f 39 N.me gaa .aa .na zip c. er Per. n ca.xem De n m.,.,;b) pla[I ~t ~ ' ~ = n<a (m./Dav/vrl O N JT ~ck( /l E TK 1~- I ~ I ~~~ 1 . R.eu[r.. a Diann Nn . aesXma .< <r ror ,< a < Mo D.y r 7-a~~ G a .Z Di,peaaen P<rml< e 0740562 REV o~/auit OATH OF NON-SUBSCRIBING WITNI+:SS(ES) REGISTER OF WILLS ar COUNTY, PENNSYLVANIA Estate of G~~~ancr' /~• ~~`~~ Deceased ~enn~ T~'.~ V~~' I~Z~I and s~ o'~li Td/, (each) being duly qualified according to law, depose(s) aLnd say(s) that she / he /they was /were well- acquainted with C~2anar ~ _ yX/-ec 7 ~ and am/are familiar with the handwriting and signature of the decedent, and that the signature of _ C ~~a we-- /~A- l(/~~'~-~ to the foregoing instrumentlpurporting to be the Last Will and Testament/Codicil of L~ ~2a~,-- (,iiii : G1/ec T ~.~ is in his/her own proper handwriting. arrisbwra,~~ 171a~-- (City, State, zip) ~~- (Signaru'tiJ - a3go L.~..~rc;s ~,¢~ ~~ (Street Address) ~./0~.2, ~ i~aa~ (City, Stotg Zip) Executed in Register's Office Sworn to or affirmed and subscribed befgre me this ~ ~ day Register of Wills G ~' ~ !'Yin ' ~ G? 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