HomeMy WebLinkAbout08-03-12PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF ~~ 1~~;~~~ COUNTY, PENNSYLVANIA
Petitioner(s) named below, who is/are 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• ~vrl~ s t/ C c~S~i i/Q FileNo• ~ ~~'~ --(~~ ~~
a/k/a: (Assigned by Register)
a/k/a:
a/k/a:. Social Security No: 3 & `~ ' 3 G '- 7 SC ~ ~'
Date of Ueath: Age at death: 7 3
Decedent was domiciled at death in L ttiM 6 tr ~ANd Count %'%/~• (Stare) with his/her last
principal residence at J ~/ Cv/~NtbtrR i~r !_ ^~~~'I~ C~tmb~r/fr~~
Street address, Post Office and Zip Code City, Township or Borough County
Decedent died at ~~~ ~y SPt~~~~ ~~sPt'~'~' ~ Ct4rrt~ /t'~( Ck,~b~~~pvd` /~.~-
Street address, Post Office and Zip Code City, Township or Borough County State
Estimate of value of decedent's property at death:
If domiciled in Pennsylvania ............................ All personal property $
Ijnot domiciled in Pennsylvania ........................Personal property in Pennsylvania $
If not domiciled in Pennsylvania ........................ Personal property in County $
Value of real estate in Pennsylvania ......................................................... $
TOTAL ESTIMATED VALUE.... $ S. S ~ ~
Real estate in Pennsylvania situated at:
(Attach additional sheets, ijnecessary.) Street address, Post Office and Zip Code C1ty, Township or Borough County
^ A. Petition for Probate and Grant of Letters Testamentary C7 =_
Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated = 7 and C'baicil(s)~ ;
thereto dated ~ ~- m ~ 7
*-- ~ -
State relevant circumstances (e.g. renunciation, death ojexecutor, etc) ~;' 1
Except as follows: after the execution ofthe instrument(s) offered for probate Decedent did not marry, was not divorced, s qua party to~endin~ I ~ ~_ r a
divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(g), and d~chave a chttltborn os..- -r
adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. ~ ~y ~ ;=
^ NO EXCEPTIONS ^ EXCEPTIONS D •~ ~,q
G3
~] B. Petition for Grant of Letters of Administration (Ifapplicable)
c. t. a., d.b.n., d.b.n.c.t.a., pendente lice, durunte absentia, durante minoritate
If Administration, c.t.a. or d.b.n.c.ta., enter date of Will in Section A above and complete list of heirs.
Except as follows: Decedent was not a parry to a pending divorce proceeding wherein the grounds for divorce had been established as defined
in 23 Pa. C.S. § 3323(g) 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 (ifany) and heirs (attach
uciditional sheets, ijneeessary):
Name Relationshi Address
~io+n . ~ I~ GorUs+t~Ne So/~ % C~~Grmht~ ~~~ ~_,,/.~114 /~~ t7
a;
Form RW-n1 ,•ev. ln~ll~znll Page 1 of 2
~ft~G ''~'~'~:',rF1CE 4F
~,.~ `,~~ ~.v
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF 1'~ ~nn1~ .V ll J~.Vi 1~1 }
2 At~`=i~UseY 2~ 13
OFiPH/,I"~1'~i~OiJt~s
.,
Petitioner(s) Printed Name Petitioner(s) Printed Address
/~tU~~n.1S i CU„Ij 1f/t? I LCD (.lM i
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) of the Decedent, the Petitioner(s) will well and t ly administer the estate according to law.
Sworn to or affirmed and subscribed before .~ /S L.,-,~t.,i,, f Date `~" 5 --
me t ' ~ day of F ~~art Date
$y: ~~ Date
or the Register Date
BONDRequired:QYES ~NO
FEES:
Letters ..................... .
( ~ )Short Certificate(s)..... .
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commission ................. .
Other ........
s UC
Automation Fee .............. .
JCS Fee . ....................
TOTAL ..................... S
To the Register ojWi!!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
Estate of -~"_.)C`~ (~(Y`jS I~~ C'~'(~5~ (~~ FileNo:,'~1` ~,~ - C~~~`~ ~
a/k/a:
AND NOW, 1C-1- , a~ ~ a , in consideration of the foregoing Petition,
satisfactory proof having bin presented before me, IT IS DECREED that Letters ~ ~(`~ -h(m
are hereby granted to ~~~~r ("zn ~-{~ YL __
in the above estate and (if 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)) o1FDecedent.
Register of Wills ,~ r ~;"„•,~ ~~ fj~,~~~ •
Fa•m RW-01 ,•NV. ~nitiizn~r ~~•~.(, k}-/ Page 2 of 2
~.C~~J~-~. REC~.t ,, BAR' I~~~'~F'~°T~C~ ~ f....J~'A 41
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MBERLAND CO.. PA ~~-~ - ~ ,- 7
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P 18819089
_ __- --_ --- - ,~ft'V1 tier
Type/Print In COMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF HEALTH ~ VITAL RECORDS
Permanent rCaT~P~cOTE of DEATH
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Suffix) 2. Sex 3. Setlal Security Number 4. Date of Death (MO/Day (Spa
Middle
Last
Fi
t
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,
s Legal Name (
. Decedent
Thomas N. Constine Male 388-36-7811 July 30, 2012
S Under 1 Year Sc. Under 1 Da 6. Data of Birth (MO/Day/Vear) (Spell Month) 7a. Blrthpla (City a d State or F Ign Country)
(Yrs) Sb
st Birthda
A
L
W42
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1 939 Mar
.
Mentna D.ya Heura Mlnpt.a February 20
73
,
7b. BIKhPlaca (County)
8 a. Residence (State or Foreign Coun<rv) gb. Residence (Street and Number -Include Apt No.) gc. Did Decedent Live In a Township?
t Pennsboro twP
E
. C lum~~ d_
1 4 F .
as
Yes, decedent llyea In
8 d. Resltlenca county2
~ ~
n
decedent lived within limits of city/bOro.
Q No
9 er 1 and
Cum
. er in US Armed Forces? 10. Mar ,
He. Residence (Zip Code) 1 7 O 2
ital Status at Tlme of Death Q Married ~ Wltlowe 11. SurviNng Spouse's Name (It wife, gWe name prior to first marriage)
~es Q No Q Unknown Q Di vorced Q Never Married Q Unknown None
ff
' 13. Mother's Name PrlOr to Fint MarNage (First, Middle, Last)
1 ix)
s Name (First, Middle, Last, Su
2. Father
Neil Constine Lucile Kitzingler
1 Informant's Name 14b. Relationship to Decedent
4 14e. Informant's Mailing Address (Street and Number, Clty State, 21p Code)
17319
P
e
a.
Thomas Constine Son a
rs,
196 Constine Court,Ett
~
G
wr ... ... ........................
ace o eat ... ec,_on.y one .... ......... ....... .... ... ......... '
ital: LI Hosplu Facility IJ Decedent's Home
Th
n • Hos
Oth
S I t Death Occurred in a Hospital: ~ Inpatient ! p
er
a
If Death Occurred Somewhere
Emer •ncy Room/OUtpatlenx Dead on Arrival
gWe street and number;
Facility Name (If not Institu[ion
SSb Nursin Home/LOn -Term Gra Facility Other (Spec) )
SSe. City er Town, Stab, d 21p Code lSd. County pf Death
nd
l
b
l
,
.
Holy Spirit Hospital er
a
, Pa 17011 Cum
Camp Hil
~ 16a. Method of Disposition Q BuNal Cremation 16b. Date o1 DlsposlSion 16c. Place of Disposition (Name of cemetery, crematory, or otMr place)
~, pRemPyalfrpmstate pDpnatlPn g~1 /12 Evans Cremation Service
other (speelry)
Location of Dlaposltion (City or Town, State, and Zip)
16d
Sarvl License r Arson In Charp O1 Interment 17b. License Number
17a. Slg re Fu
.
P
l ~
FD011897-L
a
Leo
a,
17c. Name and Gompleb Address of Funeral Facility , Eno 1 a , Pa 1 7 O 2 5
Sullivan Funeral Home, 51 N. Enola Dr_
°
a Decedent's Education -Check the box that best describes the 19. Decedent of Hispanic OriSln -Cheek the 20. Decedent's Race -Check ONE OR MORE races to Indicate what
18
a
..- .
highest degree or level of school completed at the time of death. boz that best describes whether the decedent the decedent considered hlmselt or herself to be.
n
K
orea
Q Bth grade or less Is Spanish/Hlspanic/Latino. Check the "NO" QWhlta Q
Q Vietnamese
i
can
Q No diploma, 9th - 12th grade box if decedent Is not Spanish/Hispanlc/Latlno. Q Black or African Amer
Q Other Asian
tiv
l
k
N
a
a
e
as
$) HI[h school gratluate or GED completed No, not Spanish/Hlspenlc/Latino Q American Indian or A
Q Nature Hawsilan
Q Some collage credit, but no degree Q Ves, Mexican, Mexican American, Chluno Q Asian Indian
Ian or Chamorro
Q
Chi
nese
Q Associate degree (e.g. AA, AS) Q Yss, Puerto Rican Q
amesn
ino Q
Q FIIl
p
Q Bachelor's degree (e.g. BA, AB, BS) Q Ves, Cuban
nic/Latino Q Japanese Q Other Pacfflc Islander
h
Hl
/
spe
0 Master's degree (a.g. MA, MS, MEng, MEd, MSW, MBA) Q Yaa, other Spanis
Q Doctorate (e.g. PhD, EdD) or Profeszlonal degree (Specify) Q Other (Specify)
e. . MD DDS DVM LLB JD
t the deceden[ considered himself or herself to be. 22a. Daudent's Usual Occupation - Intllcate type of work
h
di
cate w
e
21. Decedent's Single Race Self-Deslgnailon -Check ONLY ONE to In
done during most Of working life. DO NOT VSE RETIRED.
Q White Q Ja Panese Q Samoan
Q Black or African American Q Korean Q Other Pacific Islander.
Q American Indian or Alaska Natlye Q Vietnamese Q Don't Know/Not Sure 22b
Klntl of Business/Industry
.
Q Asian Indian Q O[her Asian Q Refused
Q Chinese ~ Natlye Hawaiian Q Other (Specify)
Q FIIlpino Q Guamanian or Chamorro
ITEMS 23a - 23 MUST BE COMPLETED 23a. Date Pronounced Dead Mo Oay r 23 . Signature o Person Pronouncing Death On y when applica a 23c. License Number
BY PERSON WHO PRONOUNClS OR
CERTIFIES DEATH ~L' ` (°'~
23tl. Date Signed (MO/Day/Yr) 24. Time of Death
tj ', y ~ ~~ ~s 25. Was Metlical Examiner or Coroner Contacted? Q Yes No
CAUSE OF DEATH Approximate
Enter the cha'n of events--tlisea es, Injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest Interval:
s
P4K 1
th
26
D
.
.
ea
respiraeory arrest, or yentrlcular flbrlllatl i out showing the etiology. DON T A REVIATE. Enter only one cause on a Ilns. Add additional Ilnes If necessary Onset to
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IMMEDIATE CAUSE ---------------> a.
(Final disease or contlitlon ~ Due to (or as a consequence of):
resulting In death)
b.
Sequentially Ilst conditions, Due co (or as a consequence of):
If any, leading to <he reuse
listed on Ilne a. Enter [he
UNDERLYING GUSE Due to (or as a consequence o1):
e• (disease or Injury that
F Initiated the events resulting d.
q In death) LAST. Oue to (or as a tonzequence of):
26. Part 11. Enter other I Ifl t ditions contributing to death but not resulting In the underlying cause given In Part 1 27. Was an autopsy Darformed7
Yes
i 2g. Were autopsy findings available
~ to complete the cause of Oeeth7
vas
It Female:
29 30. Did Tobacco Use ConMbute fo Death? 31. Manner of Death
.
Q Not pregnant within past year Prlobably
Q Yes O [~Matural Q Homicide
nant at time oT death
Q Pre ~ .
~ No )known Q Ac<Ident Q Pending InyestiBatlon
$' g
but pregnant within 42 days of death
nant
Not
re Q Suicide Q Could not be determined
,
p
g
Q
Q Not pregnant, but pregnant 43 days to 1 year before death 32. Date of Injury (MO/Day/Yr) (Spell Month)
Q Unknown If pregnant within the past year 33. Time of Injury
3a. Place of Injury (e.g. home; construction site; farm; school) 35. Location of Injury (Street and Number, Clty, State, Zip Gotlej
36. Injury at Work 37. If Transportation Injury, Spec Hy: 38. Describe How Injury Occurred:
Q Yes ~ Driver/Operator Q Pedestrian
Q No Q Passenger Q Other (Specify)
39a. Cy~~~Ifler (check only one):
death occurred tlue to the cause(s) antl manner subtl
l
k
d
now
e
ge,
~Cartifying physician - To [he bas y
Q Pronouncing & Certifying ph cia To the best of my knowledge, death oecurretl at the time, data, antl place, and due to the cause(s) and manner stated
Q Metlical Examiner/Coron a balls of examinatlon, antl/or Investigation, In my opinion, h occurre~at the lima, date, antl place, antl due to the causes d m rated
~~
i
s33
l
s
Signature of certifier: Title of certifier- License Number/rIp
39 dMSS an Person C letl use of Death (Item 26) 39c. Date 51 ed ( /Day Vr)
r~
< ~. Z
40. eglstrar s 1st c 41. eglstra s Ig tore . 4 Ra la • FIy~a1 Date Day
r`te' ~~~~ r
43. Amendme u
O ~ ~! i p..s M105-143
D15po5I11on Permit No. {•O l ` ` REV 07/2011