HomeMy WebLinkAbout07-17-12PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF C6lA1/~f7?1~N~ COUNTY, PENNSYLVANIA
Petitioner(s) named below, who is.-are 18 years of age or older, appiy(iesj for Leiters as specified below, and in
support thereof aver(s) the follow ins and respectfully request(s) the grant of Litters in the appropriate form:
Decedent's Information
Name: .T~L~/C T e6LLe/t~!'! File No: ~ /•Z- (,~ ^] 1
a/k,'a: ~'A-l;K ?, ~CGUirJ, Jr2_ (Assigned by Register)
a/k/a: Social Security No: ab3- //- ]880
Date of Death: ,TN.ly 9. 00/2 Age at death: ~p0
r
Decedent was domiciled at death in C tt.nt (~P,!'/~trtd County, P•nq ~ ~vM~i(st (srure) with his/~erlast
principal residence at (,ivldG'1 Liyitt~ S ~e/ieb C#r: '770 /~ CJturrh ~~% ~'. nnsbo~o %~7. Cw„br,~,t„~
Street address, Post ,O;;f~~tice and Zip Code City owns~~r Borough County
Decedent died at Gelcltn Liy~rly 4 UtrG~ C~r• • 770 ~j0/[r ~ure~ alp E: p enr-s~oro Tipp. Cum/~md,, ~~fl
Street address, Pos ffice and Zip Code City, Township or Borough County State
Estimate of value of decedent's property at death:
Ijdonticiled in Pennsylvania ............................ All personal property $ S ~~"~~
I/'ttot domiciled in Pennsy/vania ........................ Personal property in Pennsylvania $
Ijttot domiciled in Pennsylvania ........................ Personal property in County $
Value of real estate in Pennsylvania ......................................................... $
TOTAL ESTIMATED VALUE.... $ ~OGY~•~~
Real estate in Pennsylvania situated at: NONE ~'~a
(Attnch additional sheets, irnecessary.) Street address, Post Office and Zip Code City, Township or Borough ~ r"'~`ounty
C... T C~
A. Petition for Probate and Grant of Letters Testamentary ~' <- tom- `''~ r''
Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated ~:r t:? and @odicil(s~ ;, rr,
thereto dated _. V` `~ ""~ %~ C==%'
C., -, ,~.., r
~,~~
State relevant circumstances (e.g. renuncintion, death ojexecutor, etc.) ~ ?. ~,~; ~~
~ ~ ~=.
Except as follows: after the execution of the instrument(s) offered for probate Decedent did not marry, was not divorced, pot a party to~'.d,,~endi~j
divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(8), and dtd not have a clr~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. u., d. b. n., d.b.n.c•.t.a., pendente life, durunte absentia, durunte 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.
~1V0 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 (attach
uclctitia:ul sheets, i/ necessary):
Name Relationshi Address
rio~~ m. cum a ~~ F~oM l~gY ~9,oT x'/33
A /7~fd
Fo,m RW-0? r-ev. !D/I1;?011
Page 1 of 2
Oath of Personal Representative
CO'~t~iONWEALTH OF PENNSYLVANIA }
COI;NTY OF CLI.M IJ~'i?LJ4N~ }
LL~~2 Jt1L { 7 PM 12: a~
Per,;ionerUl Printed Name Petitioner(s) Printed Ad ' ~. ~ ~~ - . T
V'1 o[.F T /11. L~ELt,u/!7 ~3 G/ Fi¢FE~Dp/si ~~, AST t~ / ~~O ~., P/~
T?ae Petitioner(s) above-named swear(s) or affirm(s) the statements in the foregoing Petition are tn~e and correct to the best of the knowledge and belief
of Petitioner(s) and that, as Personal Representative(s) of the Deceden ~he Pe itioner(s)gw~ill well and truly administer the estate according to law.
Sworn ±o or affirmed id subscribed befor ~ ~ j ...C- L,~ /~i'1 . ~.~L--.~.-e~--~^Date T ` ~ `7 ' 1 L
me ih~ ~`l day o~ '` ~ ' - , ~- ~ 6'~- Date
BY: _ 1 r<~~-~,r~l Date
For thn_ Register Date
BOND Required: Q YES ~ NO To the Register of Wills:
FEES: Please enter my appearance by my signature below:
Letters ..................... $ C+
( '-~ )Short Certificate(s)...... ~ ~
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commission ................. .
Other
+:Ei ~' ;
Attorney Signature:
Printed Name: C..//!1/7/GS ~ c~IP~~S `~
Supreme Court
ID Number: 38~~3
Firm Name: N/9t
Address: (p (f p~
1rle~tictn%csbW,~o. PA J7osS'
~~
Automation Fee ...............
JCS Fee. _~ ~ ~~ C'
TOTAL ..................... $ oc `~
Phone: ~7/~ 7~ot'O ` ooZ09
Fax: 7/7-~/
Email: CES ~ C~mn ~s
DECREE OF THE REGISTER
TiYly~ ('e//u rrl
Estate of .~ c11 f . Ce~~uM . ~ ~k %. [~Q~~un~~,r~ ~kk File No: 2/- /.? ^ (`~.] 7
a/k/a:
AND NO\~', ~ t 1,,~ ~~, ~ ~ ~ C' i '~- , in consideration of the foregoing Petition,
satisfactory proof having b presented before me, IT IS DECREED that Letters t~ ~A/ll~iliS~~
are hereby granted to ViD~Ef /Jf, ~E~~ufi
in the above estate ai;d cif applicable) that
the instnunent(s) dated N/fR .
described in the Petition be admitted to probate and filed of record as the last ~~'ill (and Codicil(sjl o_ Decedent.
P
Register of Wills ~ I
~, ~ ~ ,t ;,L~ .'.,~ ~~_, ~ ~ ~ ' ,'.
Fo„» aw-n? ,~~,,. tn~~~iznit r ~~ Page 2 of 2
LOS ~ ~~~~~~,. AR'S CERTIFICATION OF DEATH
WA ~ r.'tt~i~ i~l~ t I to du licate this copy by photostat or photograph.
P
?C12 JUG. 17 PM !2= 07
Fee for this certificate, $6.00 This )~ to certiC>~ that the information here given is
co(rectly copjed 7rou~l ain or)gmal C,ertit)cate of Death
,,,~,~.t~~. ~. ~ riuly filed ~~ith me a~~ Local Registrar. Thy original
r. n
~~~~~ ~~~, certificate v;ill [)c 6iu~warded to the State Vital
~„ {~1 R(°cords Offrcc~ Vin( ~;»~nnuient filing.
1~7~1~~~~4 >
Certification Number
Type/Print In
Permanent
Black Ink
1. Decadent s Legal Nart
sa. Aga-Last Birthday (Yi
60
ga. Residence (State or 1
CAUSE OF DEATH '
26. Part 1. Enter the rhain of events--diseases, Injuries, or complications--that directly caused the death. DO NOT enter termina'inee Add adtlitlonald llnesrlf necessary
respiratory arrest, or ventricular fibrillationwli/tf.hyout sh~olwing t~hae~etiyology. DO NOT ABBREVIATE. Enter only one cause on a
IMMEDIATE CAUSE ---------- ----> a. _ - ~ ~L '~-" I ~ ~ ~~~'~
(Final disease or condition Dua Y (or as a consequence o1):
resulting In death) ~~ /~~ ~~ V ~~ a u
Sequentially list contlltionz. b /V Du to (or as a cons quanta of):
if any, leading to the cause ~~ ~ ~~ ~/OS Gov ~~_ ~it ~~ ~~ ~Y.a~
listed on Ilne a. Enter the c
VNDERLVING CAUSE Due to ( r n of):
(dlaeaae or Injury that ~~-~„-, T-/~J'L a [~~ve Kew ,t_.S %Q Y-
Initlated the events resulting d. Due to (or as a conse~t ueFice of):
In death) LAST.
Did Dacadant Liva In a Townanipr
Yes, decedent Ilvetl in
No, decedent Ilvatl within limits o1
twp.
Q Yes .. ,. No Q Unknown Q Divorced ®Never Married (] Unknown
12. Father's Name (First, Middle, Last, SuMx) 13. Mother's Name Prior to First Marriage (First, Middle, Last)
Jack T- Callum Sr. VIoNt M. Hurrt__-_- ,._ __,_,
14a. Informant's Name - 14D. RelailonsnlP to uece.,sn. ++~......,....-...-._._.....-..__. ___ ,_-. _
Violet M. Callum MOTHER 4833 East Trittdls Road Maehanitxbury, PA 17030
~,s~ ....................
a. ace p eat Dn y, on. .............................. ..................ti ......---..... _ .....
.........e ................ s~....... _ ...
1..1
--•••••"""""""""" """"""""""""-'~~~~ ~~~~~~~••••~•• ............................(I! Death Occurr d Somewhere Other Than a Hospital: ~ Hospice Facill Decedent's Home
$ If Death Occurred In a Hospital: ~ Inpatient
Daad on Arrival
1
Nuraln Homa/LOn -Term Cars Facility
Other (Specify)
yy Emar envy Room/OU<patlant
ber;
d City or Town, State, d ilp Coda ISd. County of Death
15c
num
15b. Facility Name (If not institution, give street an
br
tf
C .
Last P~nnsboro TowruhlP. PA 170'11 CLUnbg~rland
~n
on
6old~n LINny b R~habilNa
ition Q Burial Q Cremation
f Di
h
d 16b. Date of Dbpositbn ibc. Place of Dispo sition (Name of cemetery, crematory, or other place)
spos
o
o
16a. Met
~ DonatiDn dMts Rgfpitsbry
Hu oil
~
,€ p Removal from state
other (sveciry)
and 21p)
wn
Scale
i
T Jul 9, 2012
17a. ature of Funeral Se y
a
rvice Llcansa Parson I of Interment
17b. License Number
2 ,
,
ty or
o
16d. Location of Disposition (C FD-014151-L
Ph11ad~Iphia, PA 17033 D, Per.,laar k,
17c. Name and Complete Atldre55 of Funeral Facility 26th 6L NnM~ , PA '17103
1 660 South burp
C311b~R L. ~a1
th
Ab NY F
Dacadant of Hispanic Orlgln -Check the
19 20. Decedent's Race -Check ONE OR MORE races to Intlicata what
~ es
e
18. Decedent's Education -Check the box chat teal dasc
h .
that best describes whether the decadent
b the decedent consitlered himself or herself to be.
I- .
highest degree r level of school completed at the time of tleat ox
Chock Lhe "NO^
ti
L ~ Whlta Q Korean
Q gth grade or lass a
no.
Is Spanish/Hispanlc/
anish/Hispanic/Latlno.
I
t S Q Black or African American [] Vietnamese
Q No diploma, 9th - 12th grade s no
p
box It decedent
anir:/Latino
h/His
i
S Q American Indian or Alaska Native Q Other Asian
Q High school graduate or GED completed p
pan
s
®No, not
Chicano
Mexican American
l
n
M Q Asian Indian ~ Native Hawaiian
0 Some college credit, but no degree ,
,
ez
ca
Q Yes,
Ri
n Guamanian or Chamorro
Q Assoclafe degree (e.g. AA, AS) ca
Q
b
C Samoan
Q F IlDino Q
® Bachelor's degree (e.g. BA, AB, BS) yes,
an
u
Q
anish/Hispanic/Latlnp
th
S ~ lapanesa ~ Other Pacific Islander
0 Master's degree (e.g. MA, M5, MEnB. MEd, MSW, MBA) er
p
Q Yes, o if
~
Q Doctorate (e.g. PhD, Ed D) or Professional degree (Specify) y)
Other (Spec
.MD DOS DVM LLB JD
t the decedent consitlered himself or herself to be.
h
di
sual Occu tlon -Indicate t
pa VPeo
n
22a. Decad
21. Decedent's Single Race Self-Designation -Check ONLY ONE to cate w
a
In S
done Burin t of working Iifa. DO NOT USE RETIRED.
mos
® White Q Japanese ~ Samoan
Q Other Pacific Islander Qr'OOMy t~.l~rl[
Q Black or African American Q Korean
tn
mese
Vi Q Don't Know/Not Sure
e
a
Q American Indian or Alaska Natve Q
Asian indlan Q Other Asian Q Refused 22b. Kind of Business/Industry
Q Chinese Q Native Hawaiian Q Other (Specify) Rmtall Food Industry
0 FIIIpIno ~ Guamanian or Chamorro
Parson Pron
t
Si
ou clog Dea n e
th Only w e aPPllca
23c. Ucensa Number
ITE S 29e - 29d MUST BE COMPLETED no
23a. Date r Dea Mo Day r) gna
ure o
23b.
BY PERSON WNO PRONOUNC[S OR
~
3 ,
7y 1 .`
`/`
, `' J-
~ ~ / ` L~ L
CERTIFIlS DEATH
23tl. Dace 51 qtl (Mp /Day/Yr)
/t /s ~~7 24. Time of Death
L; (S Ip /s.~ ry No
25. Wa M dl I E i C f ct d7 Q Ves '
c~
~'
~P/tia ~Ct
770 Poplar Church
Approximate
interval:
Onset to Death
~'f /ate
l~lyv'tt~c
/~ /I h~
to complete the cause of tleath)
29. If Female: - 30. Did Tobacco Use Contribute to oaamr 'a.tu~a~• `~-°•" 0 Homicide
Not pregnant within past year Q Vas O Probably ~yy'['~
Q Pregnant st time of death ~cNp Q Unknown 0 Accident O Pa^ding Investigation
Q Not pregnant, bu[ pregnant within 42 days of tleath Q Sulcitle Q Could not be determined
Q Not pregnant, but pregnant 43 days to 1 year before tleath 32. Date of Injury IMo/Day/Yr) (Spell Month) 33. Time of Injury
Q Unknown If pregnant within the past year
Yas O Driver/Operator O Pedestrian
Q No Q Passenger Q Other (Specify)
39a. Certifier (Chet ionly one):
~ Certifying phy ician - To the best of my knowletlge, tleath occurretl due to the cause(s) and manner stated t annar s
~ronp ncing 8. Certilying physic) - To the best of r.k wledga, d occurred at the time, tlate, antl place, and tlue o <ha cause(s) and m fated u anner
Q Metllcal Examiner/COlO - he basis of ~ ,and 1 ligation, In my opinion, deatgh occurred at the <Ime, date, end place, 'Qtl d^e. oc =^- se(QS) and m ~s stated
•~ Title of certiRer: / I` {, S~ `G (/)7'•+ License Number:~~[a r~~~-; ~R Lf
Signature of certifier: r d rM D
av/Yrl
S
L(tcal Ree~strar Date Istiued
COMMONWEALTH OF PENNSYLVANIA • OEPARTM ENT OF HEALTH • VITAL RECORDS'.
CERTIFICATE OF DEATH Stafe Flle Number:
2. Sax 3. Sotlal Security Number 4. OaN o1 Death (MO/Day/Yr) (Spell Mo)
Jack T. Callum Jr. Mals 263-~1-7880 Jul 9, 2012
Jndar 1 ya.r s[. une.r 1 Da 6. Data of Birth (MO/Day/Yaar) (Spell Month) 7a. Birthplace (city and sBt«a, r~~ :gCcOo~ntrv)
>ntha D.ys Hours Minutes March 8r 1952
rthnl.e. ceDUniv) BOYldar Count __
~Gl ~is~g.~ !%
Disposition Permit No. ~ / ~s~ /~
s -._, ,-
:l ~- 10-070/Z
H 105-143
REV 07/2011