HomeMy WebLinkAbout08-30-12REGISTER OF WILLS
CUMBERLAND COUNTY PENNSYLVA NIA `
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SMALL ESTATES AFFIDAVI
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For Insurance Proceeds }
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to be used for Settlement of Small Estates under 20 Pa. C. S.A~3~102 ~ - ~, _;
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(Original Death Certificate Must Accompany this Form) ;,~' ~::~ ~~~''~
property estimated to be of the value of $ '~~ p p~ , - ,and possessed of real estate, the estimated value
and the location of which is as follows:
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after
execution of any testamentary writings whether or not offered for probate; was not the victim of a killing,
was never adjudicated an incapacitated person, and was not a party to a pending divorce proceeding at the
time of death wherein grounds for divorce had been established as defined in 23 PA C.S. section
3323(g): ;~
The total amount of insurance proceeds payable by 1` ~ ,/ E ~ ~.J ~ r$/il-Ll ~~r~~oes not exceed $11,000
and 60 days have elapsed since the death of the insured. The undersigned agrees payment cannot be made
under this Affidavit if a written claim for same has been made by a Personal Representative of the estate and
no other heir(s) having preference exist or have released their benefits to the undersigned.
That said decedent left aspouse -whose name and residence is ~ t l ~ Pry ~ ~/~ IZ.Ga ~~ ~
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and the following as next of kin: '~ C D ~ ~ ~ C ~ ~ ~''~ ~ ~ 1 `~ G ~r'~ ~ `~
NAMES RELATIONSHIP RESIDENCE
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That the above named are the spou and all the known next of kin of said decedent, to the best of my
knowledge and belief.
Your Petitioner avers there are NO KNOWN PROBATABLE ASSETS that would require an estate
proceeding. Therefore, NO ESTATE WILL BE RAISED AND LETTERS ARE NOT NECESSARY
Sig~ied
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RE IT REMEMBERED, that as of the ~~lday of ~ ~~,I1 Nn.'~ , A.D. 20 !~-
There has been NO ESTATE PROCEEDING RAISED FOR THIS DECEDENT AND NO LETTERS HAVE
BEEN ISSUED BY THIS COURT.
Glenda Farner
Register of Wills & Clerk of Orphans' Court
My Commission Expires First Monday, January, 2014
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H105.80~ REV (9/I;1
LOCAL REG~ST~,Q 'S CERTIFICATION OF DEATH
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WARNIN~:Ut-~i`s~e~~1't~~ ticate this copy by photostat or photo~r~ph.
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Fee for this certificate, $6.00
P 18385072 _
Certification Number
/1 Type/Print In
/~+` Permanent
~'~~ ~~~ ~~ Fy~ ~~ ~ ~hi~~ ir; tc; 1_~e.tlll. ri',at the i!li'orJrlatir)n here given Is
eorract?v cop~c~d 1J Ijit an e)li`_Jttal C elt,ficate ut Death
dul}~ filed t~tith rta: ns Local Ret~i,trar. The. original
_; certificate a•ilj il~ forwarded IL the titate tiital
~~~~'1A1~Z~J v'.JIJ~-1~ Re~ords t)ittce in. perJn~lnent ftI(I?~~.
CUMBERLAND CO., PA ~G'Y1Z-~~ ~
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----_--- - -- --- - 12
- Loral Reui~~trar Date ~sitecl
COMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF HEALTH ~ VITAL RECORDS
CERTIFICATE OF DEATH
' 2. Sex 3. Social Security Number~1O I'mber:
rank E. Barranco 4. Date of Death (MO/Day/Yr) (Spell Mo)
Sa. Age-Last Birthday (Yrs) Sb. Under 1 Year Sc. Under 1 Da 6. Date of Birth (MO/DaYNeaQ (Spell Moos h)247a. BiOh lace (Ci April 1 7, 201 2
^~ Months Days Hours Minutes P ty and Slate or Foreign Country)
84 May 24 1927 Staten Island, NY
8a. Residence (State or Foreign Country) gb. Residence (Street and Number -Include Apt No.) 8c. Did Decedent Live n al Towlnsh p? u^cv) Richmond
PA
ad. Resmente (County) 1435 Hilicrest Court ®Yes, decedent Ilyed in Lower Align Township
Cumberland 8e. Residence (zIP code> 17011 LvYP.
9. Ever In US Armed Forces? 30. Marital Status at Tlme Pf Death Q N°• decedent lived within limits of
I~ Yes Q N° Q Unknown Q Divorced ®Married Q Widowed 11. Surviving Spouse's Name.(If wife, ive n city/boro.
Q Never Married Q Unknown Eileen Ann Congdon g me prior cP first marriage)
12. Father's Name (First, Middle, Last, Suffix) a
Frank Emanuel Barranco 13. Mother's Name Prior fo First Marriage (First, Middle, Last)
14a. Informant's Name Ellen Sheridan
14b. Relat(onship to Decedent 14c. Informant's Mailing gdtlress (Street and Number, Cfiy, State, Ztp Code)
~ Eileen A. Barranco Wife
G _ _ _ 1435 Hilicrest Court, Apt. 103 Camp Hill, PA 1 7p11
¢ If Death Occurred in a Hospital: ~ ~ - - - - - .. ~ 1 a. P ~cce o eat Check onY one
e Q Eme ~ Inpatient rif Death Occurred Somewhere Other Than a Hospltai .~ ~ t _ _ _
rgency Room/Outpatient Q Dead °n Arrival Q Nursing Home/LO ng_Term Care Facility Othe 5 Hospice Facility - ly Decedents Home
15b. Facility Name (If not institution, g(ve street and number) t15c. CI ( PeciTy)
1435 Hillerest Court, Apt. 103 [y or Town, State, and 2Ip Code lsd. coffin
~, 16a. Method of Disposition Camp Hill, PA 1 701 1 [v °f Death
Q Burial Q Cremation 16b. Dale of Disposition 16c. Place of Dis Cumberland
m Q Removal from State Q Donation Position (Name of cemetery, crematory, or other place)
!€ Other (Specify) Cremation $ Burfaf of Ashes 04/19/2012 Evans Crematory
~ 16d. Location of Disposition (City or Town, State, and Zip)
y 17a. Sign of ral Serv a Licensee or Person in Char
E-t Sehaefferstown, PA 1 7088 Re °f'^t¢rr^enc lib. ur¢nse Number
E 17c. Name and Com lete Address of Funeral Facility FD 012 848 L
3 Parthemore ~unaral Home $ Cremation Services, Inc., P.O. Box 431, 1303 Bridge Street New Cumberland, PA 17070
~ 18. Decedent's Education -Check the box that best describes the 19. Decedent of Hispanic Origin -Check the
~- highest degree or level of school completed at Che time of death. box that best describes whether the decedent 20. Decedent's Race -Check ONE OR MORE races to indicate what
Q 8th grade or less is Spanish His the decedent co nstdered himself or herself to be.
Q No diploma, 9th - 12th grade / panic/Latino. Check the "NO"
box If decedent Is not 5 ®white Q Korean
Q High school graduate or GED completetl Panish/Hispanic/Latino. Q Black or African American Q Vietnamese
Q Some college cretlit, but no de l~ No, not Spanish/Hispanic/Latino Q gmerican Intlian or Alaska Native
Q gree Q Ves, Mexican, Mexican American, Chicano Q Other Asian
Assocelaoiesd eegreeee(e. g. AA, qS) Q Asian Indian
Q Bach I r' d gr (e.g. BA, AB, BS) Q Yes, Puerto Rican Q Chinese Q Native Hawaiian
Q Master's degree Q Yes, Cuban 0 Fiiipfno Q Guamanian or Chamorro
(e.g. MA, MS, MEng, MEd, MS W, MBA) Q Yes, other Spanish/Hispanic/Latino Q Samoan
® Doctorat¢ (e. g. PhD, EtlD) or Professional degree Q Japanese Q Other Pacific Islander
. MD DDS OVM LLB JD (Specify) Q Other (Specify)
21. Decedent's Single Race Self-Deslgnat(on -Check ONLY ONE to Indicate what the decedent considered himself or herself t° be. 22a. Decedent's Usual Occu
I~ White Q Japanese Q Samoan
Q Black or African American Q Korean done Burin gPation -Indicate Type of work
q Q American Indian or Alaska Native Q Other Pacific Islander g most of workin Ilfe. DO NOT USE RETIRED.
.7i Q Asian Indian Q Vietnamese Q Don't Know/Not Sure Attorney $ Partner
Q Chinese Q Other Asian Q Refused
Q Native Hawaiian Q Other (Specify) 22b. Kind of Business/Industry
Q Filipino Q Guamanian or Chamorro
ITEMS 23a - 23d MVST BE COMPLETED 23a. Dale Pronounced Dead (MO/Day/Yr 23b. 51 regal
BY PERSON WNO PRONOUNCES OR ) gnatu re of Person Pronouncing Death (Only when applicable) 23c. License Number
CERTIFIES DEATH 04/1 7/2012
23d. Date Signed (MO/Day/Yr) 24. Time of Death MD 424 770
5:45 pm 25. Was Medical Examiner or Coroner Contacted?
CAUSE OF DEATH ® Yes Q Np
26. Part I. Enter the chain f t --diseases, InJuries, or complicat(ons--that directly caused the tleath. DO NOT enter terminal events such as cardiac arrest,
respiratory arrest, or ventricular fibrlllatlon w(thout showing the etlolo APProximate
,
gy. DO NOT ABBREVIATE. Enter only one cause on a 1(ne. Add addltio nal Ilnes If necessa t Interval:
_________> a.
IMMEDIATE CAUSE -----_ Corona Art@ DIS@a Se ry- r Onset to Death
(Final disease or condition Duo to (°
resulting in death) r as a consequence of):
b. Corona Atherosclerosis
Sequentially list conditions,
if any, leading ib the cause Due to (or as a consequence of):
listed on line a. Enter the AFIB
UNDERLYING CAUSE
(dise injury that Due to (o as a consequence of):
Initiated the events resulting d,
... in death) LAST.
Due to (or as a consequence of): ~
s 26. Part 11. Enter other scant conditl t Ib H t d Sh but not resulting in the under) t
$ Ying cause given In Part 1. 27. Was ,
m Q Yes opsy pertormed?
v 28. Were auto ® No
psy flntlings available
-~' 29. If Female: to co mQpYes the cause of death?
t4 Q Not pregnant within past year 30. Did Tobacco Use Contribute [o Death? N°
Q Pregnant at time of death Q Yes Q Probably 31. Manner of Death
~+ Q Not pregnant, but pregnant within 42 days of death Q NO l~ Unknown I;~ Natural Q Homicide
~ Q Not pregnant, but pregnant 43 days to 1 year before death 32. Date of In u Q Suicide t Q Could not be degterimined
Q Vnknown If pregnant within the past year 1 ry (Mo/Day/Yr) (Spell Month) Q
34. Plac¢ of In 33. Time of Injury
jury (e.g. home, construction site; farm; school) 35. Location of In'u
1 ry (Street antl Number, City, State, Zip Code)
p 36. Injury at Work 37. If Transportation Injury, Specify:
C Q Yes Q Passers Operator Q Pedestrian 38. Describe How Injury Occurred:
f4 NO Q ger Q Other (Specify)
C 39a. Certifier (Check only one):
m Q Certifying physician - To the best of my knowled
Q Pronouncing Sa Certifyln h ge, death occurretl due to the cause(s) and m r staled.
LLI g p ysician - T° the best of my knowledge, death occurred at [he time, date, and place, and due to the cause
Q Medical Examiner/Coroner - OnI(~~asis of examination, antl/or investigation, In my opinion, death occurred at the time, date, and place, and due to thee ause(s) and m
Y ~i ~
Signature of certifier. ---U ~~ an er stated.
39b. Name, Address and Zip Cotle of Person Cbm piecing Cause of Death (Item 26) TI[le of certifier: License Number: MD 424 770 ^
~ Prathggsh Viswanathan M. D., 108 Lowther Street Lemoyne, PA 17043
39c. Date Signed (MO/Day/Yr)
40. Registrar's District Number ~ ~:
W 41. Registrar's 5
>~ ~ - ey ~~ ~ 42. Registrar File Oate (Mo Day/Yr)
c 43. Amentlments /~~ O /Z
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