HomeMy WebLinkAbout08-15-12PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF Cwr~~~ /Z C~ Id ~ 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: ,t!./ CSr"L~`r-T<' ~ds/~,= File No• ~ ~ - ~ a -~~~
a/k/a. - ~0~~ ~~/ ~ (Assigned by Register)
a/k/a:
~~a' Social Security No: -,5"6 - ~ g
Date of Death: ~ \_ ~ ~9 ~-L Age at death:
Decedent was domiciled at death in ~'y~~~/2L,a/~ A County, Pt=!/!./SYL~•~iJ iA(slate) with his/her last
principal residence at `~Y~~- 4r..r ~` yo `~ N ~ ~~! Q ra Co.r ~~\
Street address, Post Office and 7.1 Code ~ ~ ~r`^~~ - - "
p City, Township or Borough County
Decedent died at ~o•rG~-~-~~.~ \~ U7 ~Z ~~o~ ~ `~~~~ .~ (1
Street address, Post Office and Zip Code Ctty, Townshtp or Borough Count
Y State
Estimate of value of decedent's property at death:
If domiciled in Pennsylvania ............................ All personal property $ l~l ~ O~y , o 0
If not domiciled in Pennsylvania ........................ Personal property in Pennsylvania $
If not domiciled in Pennsyh~ania ........................ Personal property in County $
Value of real estate in Pennsylvania ......................................................... $
TOTAL ESTIMATED VALUE.... $_ ~~ .o ~ o , o c
Real estate in Pennsylvania situated at:
(Attach additional sheen, i/'necessary.) Street address, Past Office and Zip Code City, Township or Borough unt
y
t7 =~
^ A. Petition for Probate and Grant of Letters Testamentar ~ ~~ x'
Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated ~ ~ m ~ ~'
thereto dated '~ .and C~cil(s)'~_~ C3
r• ~ _,7
-~ r~-1
r:.-.-
State relevant circumstances (eg, renunciation, death oJexecutor, etc.) `'~ r_-
Except as follows: after the execution of the instrument(s) offered for probate Decedent did not ma n C. ~` _r ''r-
ny, was not divorced, w®tGf'a pa to ndin . ` -~
divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. 3323 ~ g_ V"
§ (g), and didnvot~tve a child;i~orn or
adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. y
~~
^ NO EXCEPTIONS ^ EXCEPTIONS ~ ~r
B. Petition for Grant of Letters of Administration (Ifappticable)
e.t.a., d. b. n., d.b.n.c•.t.u., pendentelite, durunteabsentiu, durunteminoritctte
If Administration, c.t.a. or d.b.n.c.t.a., enter date of Will in Section A above and com fete 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(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 (if any) and heirs (attach
udditionul sheets, ifnecessury):
Name Relationshi Adc
GE= A,C,O .~: /~o~rc-- Sl3aN0 // W LavTHt= J
L I n~ n S ~e_l /~.uv6~lTC~Z '
L~ bz..,
~i51Titl~.C Fig! F, ~ rtR ~L ~. !~N Ur; /~T~ /~iL~ T fix[ r
Fornr RW-02 rev. /0/ll/1011
~, t'i4
!Zu
Page 1 of 2
~~ D
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA }
~nr'~I } ss:
COUNTY OF ~~C[~_ }
Us~t7n(y'L ;Rll I C'
t~lZ BUG I5 AP~f li~ 10
Petitioner(s) Printed Name Petitioner
(
) Printed Add
r VU ft
//~~
`
s~
`
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 truly administer the estate according to law.
Sworn to or ffirmed and subscri d before ~~~~!~-~~~ Date ~ 1~ - Zo ~Z
met day of ~ ~ , ~ Date
By' Date
For the Register Date
BOND Required: YES ~NO
FEES:
Letters ...................... $
(~ )Short Certificate(s)..... .
(~ )Renunciation(s).........
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond .. ......................
Commission ................. .
Other ....,,,,
Automation Fee .............. .
1CS Fee . .................... - ~U
TOTAL ..................... $
To the Register ojWills:
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 _ L1-~~-Qt (}~ Q ~}~'~ File No: c, I- `~ - U ~~
a/k/a:
AND NOW, ~~- I ~ a 1 ' , in conside ation of the foregoin Petition,
satisfactory proof havin een presented before me, IT IS DECREED that Letters
are hereby granted to
in the above estate and (if applicable) that
the instrument(s) dated _ ` "
described in the Petition be
Fon„Rw-n2 ,•ev.ln~t~~znt!
to probate and tiled of record as the last Will (and Codicil(s)) of Decedent.
egister of Wills
~/ ~~~~ ~.
Page 2 of 2
H 105.805 REV (9/I li -- - - - - -- - _ - --
LO%,, ,,GiT~AR'S CERTIFICATION OF DEATIH
WApp~~L~1~ i~is~,~llll~~k'to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00 ~Q 11 AUG (S ~~ ~ ~ ; ~ i
Urlf Hf`UV J VU~.J~T
Ct1ME3~RlAND CU., PA
tlecedenC Ilved in G _ Mi .~.al tQl~
twp.
decedent Ilved within limits of
P 1862684?__ ~~ ~K,~-..~~
Certification Number - J~ 14/t~r~
Local Re~i~•trar Date Issued
TVPe/Print In C
Permanent -. COMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF HEALTH ~ VITAL RECORDS
cedenra Le CERTIFICATE OF DEATH
gal Name (First, Mitldle, Last, Suffix) Stale File Number:
L'1ese~-matte R051E 2- Sax 3. Social Security Number 4. Date of Death (MO/Da /Yr 5
Female 159-56-6988 y ) ( Pell Mo)
age-Last Birthday (Yrs) 6b. Under 1 Year Sc. Under 1 Da 6. Date of Birth (Mp/Day/Year) (5 July 7 , 2012
8C' Months Days Hours Minutes Pell Month) ]a. Birth nlar~ Iri... _.-~ ~._._ _. _ -
Ju1y 17, 1926
b. Residence (Street and Number -Include Api No.) g
5 Hilltop Circle 6
r_
`~
_W
.~
`~
Fr'anzis3ca Penz ..°.. a t first, Mldme, Lasq
Informant's Mailing Address (Street and Number, City, Stale, Zip Code
911 W^e Louther St_, Carlisle, PA 1
Funeral Home & Crematory
This is to ,:emit}- :hat the information here given is
cx>rrectly copied fr~~.-nn an rn-igfnal Certificate of death
duly filed °,nith me a, Local Registrar. The orig=final
certificate ~~°ill h ~or~Varded to the State Vital
FZecords Office for ~:u~rnrujent Filing.
138504
Street, Carlisle, PA 17013
20. Decedent's Race -Check ONE OR MORE races to Indicate what
t
h
e d
,c.
vy
ecedent considered himself or h¢rself to be.
f21 White
Q Black or African Q Korean
American Q VleTna m
Q American Indian
Q Asi
I ere
or Alaska Native Q Other Asian
an
ndian
Q Chinese Q Native Hawallan
D P no
l
l Q Guamanian or Chamorro
Q la
p a
nese Q Samoan
0 Other (Specify) Q other Pacific Islander
8th grade or less ° - e at the time of death. box that best describes whether the decedent
No diploma, 9th - 12th grade Is Spanish/Hispanic/Latino. Check the "NO"
Q High school graduate or GED comple[etl box If decedent is not Spanish/Hispanic/Latino.
Q Some college cretllt, but no de ~ No, not Spanish/Hispanic/Latino
Q Associate d¢ gfeE' Q Yes, Mexican, Mexican American, Chicano
gree (e.g. Aq, qS) Q Yes, Puerto Rican
Q Bachelor's degree (e.g. BA, AB, BS) Q Yes, Cuban
Q Master's degree (e.g. MA, MS, MEng, MEtl, MSW, MBA)
Q Doc[orat¢ (e.g. PhD, Ed D) or Professional d O Yes, other Spanish/Hispanic/Latino
egr¢e (Specify)
. MD DDS DVM LLB JD
~ Ves ~ No Q Unknown ~°~ 1°' a sat I Ime of Death Marrietl ~ W
Q Divorced Q N
12. Father's Name (Firs[, Middle, Last, !iuffix) ever Married Q Vnknown
Eduard Schwarz 1
14a. Informant's Name
=
Gerald J_ Rosie 14b. Relationship [o Decedent 1
G husband
c
r~ If Death Occurred in a Hospital: ~' -jr, ~------•
Patient ----•--••~ ...... ....... lSa. P ace o Deaf
Q Emergency Room/Out
patient Q Deatl on Ar ~
rival e If Death Occurred Somewh
.
lSb. Facility Name (If not Institution, give street and number; Nursing Home/LOr
• 1s
orest Park H
ealth Center c. clcy pr rpwn, state, ar
16a. Method of Disposition Q Burial Carlisle,
Crem
Q Removal from State
Q Donation ation 166. Date of Dis
Position
?~ Other (Specify) '
July 201;
~
Y~
4 16d. Location of Disposition (City or Town, State, and Zip)
Carlisle, PA 17013 1]a. SI
fFUneral 5i
~
8 12c. Name and Complete Address of Fu nerai Facility
Hoffman-Roth Funer
l
~ a
Home &
lg. Decedent's Educati Cremato
9 NOL
~ on -Check the box that best describe
highest degree or level of school com I<•[ d s the 19. Decedent of21
Panic Orlgi
21. Decedent's Single Race Self-Designati
White on -Check ONLY ONE to Indicate what th
d
Black or African American
Q Japanese
Q Korean e
ecedent consi
Q Samoan
Q American Indian or Alaska Native Q Vietnamese Q Other Pacific Islander
Q Asian Indian Q Other Asian Q Don't Know/NOC Sure
Q Chinese
Q Filipino Q Native Hawallan Q Refused
Q Other (Specify)
Q Gua avian or Cha morro
I
B TEMS 23a - 23d MUST BE COMPLETED
Y P 23 Date Prono
ERSON WHO PRONOUNCES OR
CERTIFIE u
' Dead (MO Day r) 236. Sign
S DEATH (,~, J
' +t O / a
C
2 Dat~ 51 ned Mo/Day/Vr) 24 Time f D •
during most of working Ilfe • DO NOT U E RETIRED.
Hostess
Cind of Business/Industry
Restaurant
u °.2 O / ~ o Ra`~ S/8
~( /~.~ C~rIZ-Ch~ ~ /~/~'
~j~L~ b S / P - L
25. Was Medical Exa finer or Coroner Contacted] ,
Q Ves
26. PaK 1. Enter the chain of e
`t __tlise CAUSE OF DEATH Q P1o
_
ases, injuries, °
respirato r com plica[io
ry arrest, or ventricular fibrillation with
ns--that directly caused the death. DO NOT ent
i4PProximat
out showing the e er terminal events such
tiology. DO NOT ABBREVIATE. Enter onl
Y one caus e
as cardiac arrest
Interval:
IMMEDIATE CAVSE -------____..___~
9 e on a Ilne. Add ad
.-. tlitlonal lines if necessa
ry Onset t
D
(Final disease or condition o
eath
resulting In tleath)
Q
b Due to (or as a con ce
sequen of):
.
Sequentially list conditions,
if any, leading to the cause Due to (or as a consequence of]:
listed on line a. Enter the ~
~
~
VNDERLYING CAUSE ~- ~ n
/9'
W
(disease or Injury that ~t
D t ( q f)
F initiated the events resulting d
.
(n death)LAST.
26 Due to (or segue nee of):
a . PaK 11. Enter other sgficant c yiCi
t-t
!•O
~ ~
f^+
~_ _
~ ~ ~ ot resulting in the und¢rl in
Y e ca°se i
g ven in part 1
S 27. Was an autopsy performed]
29. If Female: 28.
Were autopsy finding available
E
s
[}IQot pregnant within past yea
r t
o plate the cause of death]
30. Oid Tobacco Use Contribute to Death] coQ Yes [-}~
' Q Pregnant at time of death Q yes Q Probably 31. Manner o f Death
~ Q Not pregnant, but pregnant within 42 days of death ~~ Q Unknown •~tural Q Homicide
t- Q Not pregnant, but pregnant 43 tlays to 1 year before de
th Q Acciden t Q Pending Investigation
a
Q Vnknown if
pregnant within the past year 32. Date of Injury (MO/Da Q Suicide
Y/Yr) (Spell Month) Could not be determined
Q
Q Ve Q Driver/Operator Q Pedestrian 138. Describe How Injury Occu rretl:
Q No Q Passenger Q Other (Specify)
Cytlfl (Ch k ly )
Q~C rtifyi g phy i( T h b t f y k 1 dg tl h tl d t [h
0 P i g 8 C rtifying physician - To the best of my knowled e(s) antl manner stated
^ Medical Examiner/COr~ris f ¢ Inatl~n, antl ge, death occurred a[ She time, tlate, antl place, and due to the cause(s) and m ann
° x ~ /or Investigation, in my opinion, death occurred at the time, date, antl place, and duertotthe~ ause
Signature of certifier ~F//J ~ ) ~ (s) and m r stated
b Name Adtlr d ZIb C tl ~ p Title of certifier ¢
T U/ C PI tl g C f D th II[ 26) ~ F /O LI N b Q .510 tt ~ / L
Disposition Permit No.__~ ~~ ll ~ Uol H105-143
-- -- - - - - - _. _ _. _ REV 0]/2011
n _-_
`~ ~? AUG I S Alf ! I: I I
ec° -~E i~vo cod p
.~
RENUNCIATION
REGISTER OF WILLS
~CJf'J~~=iZL/JN ~ COUNTY, PENNSYLVANIA
Estate of L / ~ ~ L ~, 7-TF l~vSi F
Deceased
(Print N
ame) , in my capacity/relationship as
I~t>S/3~N ~ of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
[~
i7vs i~-
2~ ~C..
(Dale) ,
(Signs re)
9/l W Lo U~r.*-~~I2 ST
(S~reer Address)
(Cety, Stale, Zrp)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this _~ ~ day
of
a~ ~-.
i
- Deputy for Register of Wills
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.)
Fcrm RW-06 rev. 10.13.06
~~~ ii~ , ~u~: i ; ~ ','all ~C
~~~±zauc ~s a~~~: i i
- RENUNCIATION
OFPH>=~,N'~ ~VUri
CUMBERLAND Cc~., PA REGISTER OF WILLS
y FT~a~ ~ COUNTY, PENNSYLVANIA
Estate of ~ t ~ 5G= L a 7-~ ~
I, -~..:~
CAS/E"
Deceased
(Print Name) , m my capacity/relationship as
-~~ y~ H T ~ t ~ of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
i~ ~~i
(Date)
1
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this ] ~y
of ~~
~ (, -~~
Deputy for Register of Wills
-_•
~~~
~ (Signature) ~/'
~3/ P T Ot ~c I~
(Street Address) ~
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 ofexpiration of Notary's Commission.)
Form RW-06 rev. 10.13.06
~ (l ~r' ,.i i I~Jt.
~,
~~ , r
~~~t~ , ~°,r- ,~;~~ s ~
r . •..vJ
?~:~ f 2 Ai1G I S A~4 I!~ I I
RENUNCIATION
GhFHI~~ ~ ~~~U,~ ~
CUMBERLANb CO., Pq
REGISTER OF WILLS
.G//3L-~z1/J N'~ COUNTY, PENNSYLVANIA
Estate of L/.
jZoS/E
I, C~~ d2G
Deceased
(PnntName) , m my capacity/relationship as
- .S~/y
of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
;n..
ZtZ
(Date)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this day
of
Deputy for Register o
Form RW-06 rev. 10.13.06
(Si ature) J
(StreetAddress)
( ry. Stue Zrp)
Executed out of Register's Office
Before the undersigned personal appeared the
party executing this renunc' on and certified
that he or she execute a renunciation for the
of rposes stated in on this ~_ day
~' a r ~ ~
Nota P `f ` ~ ~~~
ry ubhc
NIy Commission Expires:
1~1Gr~~~, 1 I , ~
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date ofexpiration of Notary's Commission.)
~ ~I~
_i r , 1
State of California
County of Stanislaus
S
proved
(Seal)
=U an sworn to (or affirme
20~ by )before me on this
me on the basis of satisfactory evidence to be the
appeared before me.
Signature
~~c~ahon aF @~ifl~ o~ Ueseieue ~s;,e
1S~i~~ to ~V~pnn F-~Qrrell