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HomeMy WebLinkAbout08-01-12PETITION FOR GRArT OF LETTERS REGISTER OF WILLS OF CuM~~~LA a COUtiTY, PEl~1~ISY"LV"ANI~ Pet:iener{s) named be:o~u. who is~'a.. 1 ~ eaa of a~~e or older, app! t(ies) fer Letter as specified below, and in st:opert thereof aver{si the follo-~.va1o and respecttull,i request(s) the vault of Letters in the appropriate orm: Decedent's Information Q Name• MaN % E ~. l3A k~ 1~ File No• ~) -- I o~ -`~C~ a/k,'a: (Assigned by Register) a/k/a: J a/k/a: Social Security No: ~ ~ ~- ~'~- ~ ID ~ 9 Date of Death: ~ ~~ Age at dea ~ Q Decedent was domiciled at deaoth in CUMB~~LA~1 Count , ~~ (s re) with his/her la t principal residence at ~-1 I (1 N 1 ~ N T ~Il M ME T~ LE f'>4' C a~ ~~~~ Street address, Post Office and Zip Code City, Township or Borough Count Decedent died at ~~ I~10t1 NTA1 N ~ S[~MM~~ D~1L.~ PA LIJt~/1 i3~"RL>9~1~ ~i~} Street address, Post Office and Zip Code City, Township or Borough County State Estimate of value of decedent's property at death: ~n If domiciled in Pennsy!vania ............................ All personal property $ ~ ©l~lJ o ~~ If nat domiciled in Pennsy!vania ........................ Personal property in Pennsylvania $ If trot domiciled in Pennsy!vania ........................Personal property in County $ Value of real estate in Pennsy!vania ......................................................... $ TOTAL ESTIMATED VALUE.... $ r«„) ea estate to Pennsylvania situated at: (Attach additional sheen, if necessary.) Street address, Post Office and Zip Code City, Township or Boron Q N Couttt~y ^ A. Petition for Probate and Grant of Letters Testamentary ~ ~ ~: ~ ~ ~ c Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated ~'~'~' ~-`-' ~~y r"`- ~~~_ ~ anaCodicil ~; F thereto dated ~Ct' -, '! --• C. - State relevant circumstances (e.g. renuncintion, death of executor, etc.) ~ "} ~ ' © t,,~ ~Y . C,J ~'-" t-rr --1 Except as follows: after the execution of the instrument(s) offered for probate Decedent did not marry, was not divorce~as not a party a pen~ttf~ divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(8), and did not have a d 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 lite, durante absentia, durance 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), after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs (attach additional sheets, i/necessary): Name Relationshi Address M~U-~F_~c z ~ ~ SPous~ g3 ~iav N1+ ~ r...~ o C~ ~, ~/~'Ks-~ ~D~~~2 ~t~( !~?~iO~IG sT~ S~"Z~t.7~ 1/~-~~(!3 ~Q~( ~>~~' ~`f~' ~~a~ P~ '~57 Fo„n aw-nz Irv. tnilliznll Page 1 of 2 Oath of Personal Representative COIvIMONWE.ALTH OF PENNSYLVANIA } COUNTY OF } Printed Name ~ ~ 6i~Cs N Pctitio -,,,~,,, - ~ „-_- t-,~ tLitt i ~ ,~i,~t. HUU - C ~~ 3~ Printed Address The P-titioner(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 Petitionec(s) and that, as Personal Representative(s) ofthe De edent, the Petitioner(s) will well and truly admin' ter the estate accordin to law. Swt'r;n to or affirmed and subscrib d before Date / / me ~ day of By:~~ ~~ Date Date For the Resister Date FEES: Letters ...................... $-~~~4---s.z~~ ~`R~~ ~ (~ )Short Certificate(s)..... . ( )Renunciation(s)........ . ( )Codicil(s) ............ . ( )Affidavit(s)........... . Bond ........................ Commission ................. . Other ..,.,,., Automation Fee .:::::::::::::. ~~~~-s1~_ JCS Fee. .. . TOTAL ..................... $ ,~ l~ . P~ Please enter my appearance by my signature below: Attorney Signatur . ~/ ~/ Printed Name: ~ 6ti'll/1Y1~'~ ~~ Iti l~ ~~,5 Supreme Court Y, _ ID Number: I~..~~ Firm Name: b1115 (~'L ~" -(~ Address: ~ ti Q.r'r~ EC--~ Phone: 111 ` )V I'_1-~'j`1-~~ Fax: ~1 I ~ -"~ l t I -,~ ~ I ~i Email: Cg ry1 C r Id SVJ ~ CC3-ti1 DECREE OF THE REGISTER Estate of a/k/a: ~~e~v ~ ~ ~A ~,~ ~ File No• ~ ~ - ~ ~._ d~tj(~ AND NOW, , in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS DECREED that Letters G r nM l Pf l S I ~ f~ ! /f;/~/ are hereby granted to i l~ F L 1= Z in the above estate and tf applicable) that the instrument(s) dated described in the Petition be admitted to probate and filed of record as the last Will (and Codicil(s)) of Decedent. Register of Wills Form RW-0? rev. !0/!1/201/ Page 2 of 2 LOCAL ~-ti "r r}~, ~ ~:;'~'-.1~~. i CERTIFICATION OF DEATH WARNING: i~I~~F"to irate this copy by photostat or photograph. Fee fr~r this certificate, $6.00 P 18571572 Certification Number ~~ ~_ Type/Print In Permanent #33-265 fllack Ink ~~~? AIfG - I PFD 3~ 43 This is to certif} th;jt the Jnforn~arion here given is correctly col~)ied ±ion: an o~ri~rinal Certificate. of Death y~~ I ~. '._-~ ~ duly Piled with n(e as Local Registrar. The original ~{{~~'~ i~Q~~. certificate ~~~i!1 t>e ir~rwarded to the State Vital ~fM~R~[} (',Q„ Records Office fcir ~~ern~anent filing. t -------'~~+t.~te@.~.~ ~? ~' L•~.~cal Re~i~trar Date Issued COMMONWEALTH OF PEN NSV LVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CERTIFICATE OF DEATH Stara Flle Number: 3. Decedent's Legal Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number 4. Date of Death (MO/Day/Vr) (Spell Mo) Monte E Baker Male /9/- Z - 7 June 5, 2012 Sa. Aga-Last Birthday (Yrs) Sb. Untler 1 Year Sc. Under 3 Da 6. Date oT Birth (MO/D ay/Vear) (Spell Month) 7a. Birthplace (City and Stat t Forel try) Months Dsys Noun Minutes 59 Au cast 11 1952 7b. Birthplace (cogn[y) ea. Residence (Sta FOralgn Country) nce (Street antl Number -Include Apt No.) 8b. Resid e 8c. Did Decedent Live in a Township? ~ ~ + ~/ / /mil (76t~"~i~e//~~ ST OYas, decetlen< Ilvad in twP. 8d. Resltlence (County) -~~ 81. Residence (21p Code) ~., ~' /Decedent Ilved within limits of city/boro. lyap. 9. Ev US Arme as7 10. Marital Status at Time of Death arrled Q Widowed 11. Surviving Spouse's a (I wife, give name prior to first marriage) Q No Q Unknown Q Divorcad Q Never Married Q Unknow 12. Father's Name (First Middle, Last, Suffix) 13. Mother's Name Prior to First Marr • t, Mitldle, t) 14a. Informant's Name 14 . Rela onshlp fo D nt 14c. I~yr n s Malll Atld toss (Street antl Number, Clty, State, Zip Co e) ~ ! ~- ~S ' ~ ..q v ........ .................. qn. .................. ............°-..°-....°----°-° --~-°°-°---° ~~~~ - °-------°°°---°°----.°°- If Death Occurred In a Hospital: r1 Inpatient : Hospice Facility Decedent's Home ~ If Death Occurred Somewhere Other Than a Hospital: a Q Emergenry Room/Outpatient Q Dead on Arrival Nursing H ma/Long-Term Ure Facility Other (Specify) 156. Facility Nama (If not Inatltutlon, give street and number; 15c. City or Town, State, antl 2\p Code 15d. County of Death ~ 419 Mountain Street Summerdale PA 17093 Cumberland 16a. Method of Disposition Bu rlal remotion 16b. Date of Disposition 16c. Place of Disposition (Name of cemetery, crematory, or other place) Q Removal from State Q Donation Other (SPaclfy) /~- ~ / ~` ~ 9 O ~ /v~d-' 16d. Location of Disposition (City or Town, State, and 21p) 17a. Signature of Funeral Service Licensee or Person In Charge of Interment 17b. License Number ~~~6 ~7~- 0//6~~- ~_ Name and Complete Ad a ral eility 17c .~ . ~ o0 or: rrt 3~ f-~ICtI n(si- Ste. lJ ~i • { "7 f a ~' S8. Decedent's Education - Gheck the box that best describes She 19. Decadent of Hispanic Origin -Check the 20. Decedent's Race -Check ONE OR MORE races to Indicate what highest degree or level of school completed at the time of death. box that best describes whether the decedent the decadent conaldered himself or herself Yo be. Q 6th grade or less Is Spanish/Hispanlc/Latino. Chock the "NO" Q Whl Q Korean Q N Iploma, 9th - 12th grade boz if~~dent Is not Spanish/Hispanic/LStino. ark or African American Q Vietnamese Igh school graduate or GED c mpletetl 0~ ,not Spanish/Hispanic/Latino Q American Indlsn or Alaska Native Q Other Asian Q Som college redit, but no degree Q Yes, Mezlcan, Mexican American, Chicano Q Asian Indlsn Q NaYlve Hawaiian Q Associate degree (e.g. AA, AS) Q Ves, Puerto Rican Q Chlnase Q Gu anion or Chamorro Q Bachelor's degree (e.g. BA, AB, BS) Q Ves, Cuban Q Filipino Q Samoan Q Master's degree (e.g. MA, M5, MEng, MEd, MSW, MBA) Q Yes, otMr Spanish/Hispanic/[atinp Q Ja Panesa Q Other Pacific Islander Q Doctorate (e.g. PhD, Ed D) or Professional degree (Specify) Q Other (Specify) . MD DDS DVM LLB JD 21. Datedant's Single Race Selt-Designation -Check ONLY ONE to Indicate what the decedent considered himself or herself to be. 22a. Dacetlent's Usual Occupation -Indicate type of work Q White Q Japanese Q Samoan done tluring most of working IHe. DO NOT USE RETIRED. [3~{aek6i• African American Q Korean Q Other Pacific 151antler - - ~ ~ ~6N 5 '/r' Q American Indian or Alaska Native Q Vietnamese Q Don't Know/Not Sure ~/~~~/~~ / Q Asian Intllan Q Other Asian Q Refused 22b. Klntl of Business/Industry Q Chinese Q Native Hawaiian Q Other (SpecHy) 4 ~ ~ ~ T~_ ~ °r / ~~ / / ~ Q Filipino Q Guamanian or Chamorro ' ITEMS 23e - 2 MUST aE COMPLETED 23a. Date Pronounce Dead Mo Day 23 .Signature of Person Pronouncing Death Only w an applicable 23c. License Num er CERTFRIES DEATH PRONOUNCES OR June S 2O 12 23d. Date Signed (MO/Day/Vr) 24. Time of Death A rox . 5:00 A. M. zs. was Medical Examiner or Coroner Contacted? Ves Q No CAUSE OF DEATH Approximate 26. Part I. Enter the chain of a ants--diseases, Injuries, o mplications--that directly caused the death. DO NOT enter terminal events such as card lac arrest Interval: respiratory arrest, or ventricular fibrlllatlon without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a Ifne. Adtl atltlltlonal Ilnes if necessary Onset to Death IMMEDIATE CAUSE ---------------> a. Avpertena ive Cardiovascular Disease (Final tlisease or condition Due to (or ss a tonsequen<e of): resulting In death) b. Sequentially list conditions, Due to (or as a consequence of): If any, leading [o tM cause listed on Ifne a. Enter the UNDERLYING GUSE 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 qf): 26. Part 11. Enter of her 1 i but not resulting In the underlying cause given in Part I 27. Was an autopsy p rformed7 No s Diabetes Mellitus 28. Were aueo findln liable P`y g'ay' to complete the cause of death? 4 Q Ves No 29. If Female: Q Not pregnant within past year 30. Dld Tobacco Use Contribute to Death? Q Yas Q Probably 31. Manner of Daa[h ~ Natural Q Homicide Q Pregnant st time of death Q No Q Unknown Q Accident Q Pending Investigation ~' Q Not pregnant, but pregnant within 42 tlaya of tlesth Q Suicldc Q Could not De determined Q Not pregnant, but pregnant 43 days to 1 year before tlesth 32. Date of Injury (MO/Day/Yr) (Spell Month) Q 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 antl Number, City, State, Zip Code) 36. Injury at Work 37. I Transportation Injury, Specl 3g. Describe How Injury Occurred: Q Ves Q Driver/Operator Q Pedestrian Q No Q Passenger Q Other (Specify) 39a. Certifier (Check only one): ~ Certifying physician - To the best of my knowledge, death occurred due to the cause(s) and m r stated Q Pronouncing 6 Certfying physician - To the art of my knowledge, death occurred at the xlme, date, antl place, and due to the cause(s) and manner stated Medical Ezaminar/GOfon th b is mination, and astigation, In my opinion, death occurred at the time, date, antl place, and due to the cause(s) and manner stated Signature of certifier: Title of cartlfler: AC t in)x Coroner Licansa Number: 39b. Name, Address and Zip Cotle of Parson Completing Cause of Death (Item 26) 637 B88eh0re Road, Suite 39c. Oats Signed (MO/Dey/Yr) Matthew S. Stoner Actin Coroner ¢ an sbu PA 17050 June 6 2012 40. Registrar s District Num er 41. Registrar s Signature 42. Registrar Flle Date MO Day ^~ 43. Amendments ~{ ~ ( ~~ q R V 07/2031 Disposition Permit No.