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PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF CUMBERLAND 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: Mena Rivera
a/k/a:
a/k/a:
a/k/a:
Date of Death: 07/25/2012
File No: _ 2 i - 12 - j (~ 2 y
(Assigned by Register)
Social Security No:
Age at death: 93
Decedent was domiciled at death in CUMBERLAND County, pennsvlvnaia
principal residence at 1130 Dunlin Court Mechanicsbur Ham den Townshi Cumberland Coun Pennsylvania ith his/her last
Street address, Post Office and Zip Code City, Township or Borough Coun
ty
Decedent died at 5105 Inverness Drive Mechanicsbur PA17055
Street address, Post Office and Zip Code City, Township or Borou h
g County State
Estimate of value of decedent's property at death:
If domiciled in Pennsylvania ............................ All personal property $
If not domiciled in Pennsylvania ........................ Personal property in Pennsylvania $ 30,000.00
If not domiciled in Pennsylvania ........................ Personal property in County $
Value of real estate in Pennsylvania ............................... .
................. 150 000(10
TOTAL ESTIMATED VALUE.... $ 180 000 00
Real estate in Pennsylvania situated at: 1130 Dunlin Court Mechanicsbur Ham den Townshi Cumberland Count Penns Ivania
(Attach additional sheets, ijnecessary.) Street address, Post Office and Zip Code City, Township or Borough Coun
A. Petition for Probate and Grant of Letters Testamentar
Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated
thereto dated
and Codicil(s)
State relevant circumstances leg, renunciation, death of executor, etc.) N
~ 6
~' r?'1 7
Except as follows: after the execution of the instrument(s) offered for probate Decedent did not ma ~ C~''
divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S Wa3323divorce apart aper
adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person (g)' and ~fi~ve a i~id boi~2
~'^,' 3 ~.
NO EXCEPTIONS Q EXCEPTIONS QC
C'
-1 ,,,_ ~>
B. Petition for Grant of Letters of Administration (Ifapplicable) ~_'
c. t. a., d.b.n., d. b. n. c. t. a., pendente lite, durante absentia, durarlt~'minoritate
If Administration, c.t.a. or d.b.n.c.ta., enter date of Will in Section A above and com lete 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 [he victim of a killing nor ever adjudicated an incapacitated person.
NO EXCEPTIONS Q 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, if necessary):
Name Relationsh
Lydia M. Waggoner Daughter
Margaret Straka Daughter
Address
5105 Inverness Drive, Mechanicsburg, PA 17055
21 Roselawn Avenue, Lansdowne, PA 19050
Form RW-02 rev. 10/11/2011
Page 1 of 2
~ Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA }
} SS:
COUNTY OF CUMBERLAND }
I~ l _ ~'~~~~ ~
~~E~ L~ vE ltt~l~:r5
2811 SEP 20 AM 11 ~ 19
Petitioner(s) Printed Name Petitioner(s) Printed Address I-' ~'; ~ .
345 Orchard Street NW Vienna VA 22180- S ~~~T
Gloria M. Zawilski
The Petitioner(s) above-named swear(s) or affirm(s) the statements in the foregoing Petition are true and c9rr~ct to the best of the knowledge and belief
of Petitioner(s) and [hal, as Personal Representative(s) of [he Deceden), the Petitioner s) will well and ty(y ~lrpinis[er [he estate according to law.
Sworn to or affirmed and subscribed before ~/' Gr Date 9'- ~~ ~~~
met ~s~~ day o , 2C~2 ' Date
By h/ I ~ a ~ : Date
Date
For the Regis(er
BOND Required: Q YES Q NO
FEES:
Letters ..................... .
( 3) Short Certificate(s)..... .
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commissi ..~ .......
Other
S~
~~ ^
Automation Fee . ............. .
JCS Fee . ....................
TOTAL ..................... S
To the Register oJ'Wills:
Please enter my appearance by my signature below:
Attorney Signature:
Prin d Name: Craig A. Hatch Esquire
S reme Court
iD Number: 76361
Firm Name: Gates, Halbruner, Hatch & Guise, P.C.
Address: 101 M Emma Road Suite 100
~n+~ne,PA 1704'i
Phone: (717)731-9600
Fax: (7171731-9627
Email: C' Hatch(nl(:a1P~1 ~.~F' cnm
^, . J v
DECREE OF THE REGISTER
Estate of Mena Rivera File No: ~ l - I ~ - i I
a/k/a:
AND NOW, , in consideration of the foregoing Petition,
satisfactory proof having been presented before me, IT IS DECREED that Letters of Ptdministration
are hereby granted to Gloria M. Zawilski
in the above estate and (if applicable) that
the instrument(s) dated n/a
described in the Petition be admitted to probate and
Form RW-01 rev. l0/ll/1011
Fee for this certificate, $6.0p
P 1857656
Certification Number
e/Font m
manent
LOCA~I,S CERTIFICATION
WARNIIi ~~~~g,~pp~lcate this copy b OF CEATH
y photostat or photograph.
1. ~i..f ~5 .. ..
~I~IN~S~~sURTp~
l i~•a t"!'~
This is to certify that the information here given is
correctly copied from an original Certificate of Death
duly filed with me as Local Registrar. The original
certificate will be forwarded to the State Vital
Records Office for permanent filing.
ocal ~T e ~~ ~ ~
COMMONWEAIiN OF PENNSYLVANIA•DEPARTMENTOF HfAITH•VRAI pECOpDS Re`-~Sirar
CERTIFICATE OF DEATH Date Issued
-.....aa i(1VPSa Z. Sea 3. foWlsecurity NUmbtti
s,. Ag!-t,rt alrthday nnl sb. unde,l year x. thttlat l ~ Femal 108-36-9721
93 Months DaW t(aurs Minutes 6ateo/NRh IMO/ow/yearl lspell MOnM) Ia. BlRhplsee (C
ru. RgkyrR )sore er f I ~Dber 11, 1918 Ba
pe........1Vanla Ceuntryl %.Rendencl Strett antl Number-IrMWtA No. 7b. Birthpbq (C
Bd. RealMrRe (Ceunry) 5105 Inverness ^` 1 Bc. Old Deeedent Uve b a TewnMl
~~s~~~~ Drive Yea. d.pe p~
Ctmberland ant Hued in Hd~
i Ew M U53~ymed Forw7 4. Rggentt IEb code)
^ Yes ^ ~~
[! No ^Unknown 30. Marital yttus at flm! of DpM ~ Marrltd ^Ne, tlecldent Belo w11Mn IMNts of
2. FathMS Name (Flat, Mbdk, last, SufMt ~ Never Married ~ Unkmwn owed 11. SunrMry Speux's Nam! III
a a 8 Pla
~ 18. Decedent's Edutalb cket
laze W
n .Cheek the boa tMt best
aYf Plecl7anfesb
hlBMst dgree w Iwel N sch
agd
t
l
E
~tt
oo
ewntEend rt Me t
~ dN~
BM pads w leu en
p
Nkwnk odBB, -
~
tNt beN desrRM> wMth
^ Ne dlplana, 9th -12M Brute tt tM
b SeanlM/WNank/Lanw
che
k
Nyh schoN grMuate w GED eompletetl
^ Some nBep cndk
but ro d ,
c
bpa Mdttetlen! N net se.niaNNy ~
D.No, not Swnbh/N
,
gree
Auoesa(! dgrn Ie.B. AA, ASI bpanle/lathw
^ Yes, Mdlun, Meakan A
^ BKhelwS dgne lap S'4 Ae, et)
^ Mnhfs rkBrq Ie.B. MA
MS
M meRnn, [h
~ Yes, Puerto Akan
^ Yes. Cuban
,
,
Eq, MEtl, M9W, MBAI
O Doctante Ie.B. PhD, EdD) w PMebbnal define ^ YeA ether Spamsh/Nlspank/Lathe
e.. MD DDS DVM LLB ID (Specify)
23. Dttedenrs 31ry1e Ww sNE-
WhM Oe+igrwtbn -Check ONIY ONE t
h
d -"'~--- ^ othe
o
•
kate what tM decedent cons en
^BlackwANkan AmMCan ~Hpanese ~Samean b dhimseMw herseN toM
~ Amancan IMNn a Alaska Native ~ kpnan
^ VNhrmue
^ bier Indi ^ OMer hU/k Isbndtt
an
^ cMneM ^ other Allan ^ Dpn'1 knawMol Sun
^ ae/uaee
^ f11RRnp ^ NathN NawN4n
^Guamanan wChamp
r ~ Other (SplUly) ~
---
1I[MSE)a- MUST BE
Br PERSON kBlq U 3a. Oan P
o as Day 33 . SynttW
CERTIFIES DEATH PR~IIN[ES ~
T
l
s
U
z3d. r,,.. ~_. ,.. _ - _ Y 25, 201
! a hrspn Prwlg
2 urq
l
ncNIB De
LYnig P]. ~ 116. RNanonaMP [o Dttedant
w .......................
..........................
E oath DCCUrledba NOS
.. .•..•.tw ..•.•..•......• ~
t
•..•.. Ud..y.+teL'
N:
W
LI IIIWHent
•.••.•...•..
Ema
array Room/OUtwtNnt
a>D On AmNal
1%FaWwINmellfrot k at
..1.......__!:._!~! ...............
.••..
.I/ DeaM oxumd 5omaw
N
Ntkutkm, Blue strgt
.nenpmptt;
5105 Inverness Driv urslq Name/Lo
Iseclrye.Tewn sbt
e
]M. Method o/DkpeMlpn WnN <,
•'°a.s+aaf 21C$}~
y ^ Removal hom State ~ Craman°n
^ Donatbn
•
Y ilb. Date o/ ONlrosltlon
ahtt (Sp,clM)
E
i Btl. LoeFno„ er DNpmMp„ IcNy e. r ~Y 31, 2012
_
~tP Hill, PA 170sette,amzwl ,,,.
31BnN
F
unl>ral5
ITC N pe! AdMeu 01 came al Faclliry,
~i~ 21 '1•l,g
f /
(
` l
ps
(i~EE~
during mot of wwklry IHe.
;Intl o/ Bu~d~ry
Own Home
Z6. Part 1. Enttt tM GUSE OF DEATH ~~ ~-~ ~~ w~`°nt'ttedi ^ Yes ~ No
-d~so
resNratory arratt,w
aq'Inlunes,atompxatbns--tM[dkeRly caused the death. DO NOT enter terminal event
nwbr Rbn4Mn wlrhout shevMNthe etlolpBy
Apwwlmate
DO ND
,
T ABBREVIATE. Enter on orle
IMMEDIATE GUSE - ..- s h cause
_--- s such as can4c arrest
enaline. Add atldklpnal ll InhMl:
(final dlune w rondkbn
qn V ~ may}
~s>ti ~ ~T!`< Ms If nNessary ' Onset to Death
resWthlB In deah
I Due to (w as a conseputnce ol):
seppennally bt epneBbna, b.
if anY, badln/ to the cacao Due to Iw consequerrce o1J~
Ibtetl on Nrw a. Enter tM a a
UNOgRlYM1G CAIIiE
c
Due to for as • cons
~
n
eeuenu ofl.
alee tha
F
evenb •ewlUn
t d
.
In death)IAiT.
~
Due to Iw mepu<nce ofl:
3 26. Part 11. Enter wher ant cob as a w
Hlon 0 Md-
l Mbm
~ `_ K opt neekln( In the underlying nos! Blven In PaR 1
'
~
2T
W
-\Yt~.~
a L
C~a~e Ca. 3ai ~YS .
as an autapsy periwmatl7
Yes
39. If Female U Flo
ZR. Ware autopsy flndMBS avaHabk
lE NOtwgnant wkhin past year 30. DW Tobacco Use Contribute to Deaths
6 PngMnt at ti [o s'ompkn Me nose of deaths
Yea
me of tlaath ^ Yes
~ ^ NOt prgnaM, but prgnant wkhin eZ O
~ NO No
31Ntw•Manner o/Death
Nrtur
l
aH Oiderth
~ Unkro n
^ Not wgnant, but prgnant a30ay to l War M/ore tleath 31. Date of ln)ury (Mp/pa
^ Unknown H pregnant wkhin tM Patt War Y/Yr) (Sean Monthl p
a
~ MomkWe
~ AccWent ~ PeMInB InyesUptbn
Q Sukbe ~ Could not h dtt
3/. Mace of Inlury la ~. home; cpnstructlpn site; larm; school erminetl
33. Time a/Inlury
33. Lontbn of Inlury f3ereet antl Number, OtY. Stage, Zlp Cotle)
36. Inju
at W
ry
ork 37. I/TranfppRatbn Inlury, SpecHy:
^ Yes ~ ORVer/ 38. Describe New Inury Occurred:
~
Operator Q PedttMan
^
Paf`arlg°r ^ other lspecHy)
39a. Certlptt l[heck onlyoro): ~~
CertNylry physlWn
T
~
o tiro bqt o/ my
Pr°nwnNn6l1 CertHylnl ehyskyn - Te tll~yt befit pj tleaM occurred due tp [he eauub) and manner stated
~ Medkal Eaamlrwr/Croon - Dn tM
~ad
a, deatA pcsyrred
w
OasN p/ esaml ry
at tNe nme, date, and place, aM due to Me
Slgna[um pi artnNr: ~,l/ arid/ IngstlBrtbn, In my opinion, death occurred rauseDl and manner itatM
at the thee, date, and
TkN o/ Wn, and aIN to tM cwse(al and manner rated
3%. Name. Adtlrna and ZIp Cade o/ Peron urtlflrt: lul1~
t
~~l of Death Dhm 2GI ---
IsSO. Y.h. OO-w~S M V ~
O
, license Number: MD O•,lL
~
AD.Rgw aokeNet Npm
t'bvle ,QA 1}015-
7 / a1. ashn.tun
aZ ~-
3x., \ynea fAlp/ay/rrl
30
~ ~ q~
0
a3.Amendments -~~~rsfZ~ ~
y~~.'' Wc'C ACGIJ +.Rg4tnr 3012
a M r)
J/I 3/i au l.2
D4pparoen Permk No. 0729463
_-._-. -.
H105
- - - _._- .1I3
RFV D)/2011
~~ZS~p2o aMi~: ~~
5105
2012
PA7
Rolling Green /M~~.. .~.y_~,~°• °'^en.rwacel -
cansee er hrson In CMry! of Intprrnet ATE ll
eeme Number
FD-138630
! PA 17055
lb
caMnt Z0. DeeeMnt's Ran -Chad ONE OR MORE ~~~~•
lolMkate what
the daWent cpnsyerad M
Ne' msNlw MneH to be.
Whke
l+tlne. ^B4ck or A/rkan Amedan ONwe,n
~ Amerk
karm an Indian or Alaska Nanve ~ OMer Alvan
^Anan Indian
~NatNe NawaWn
Q FlBpkq ^ Guamanian w Chamwm
^ nwrwse ^ Samoan
CMck
da
k/
I~C~~Ei~ ~~ ~F~E ~F
,.
~'~I? SEP 20 AM I 1 ~ 19
ua~+ ~ ; :; RENUNCIATION
'S
;/OU~T
fr0.. A4
REGISTER OF WILLS
' CUMBERLAND COUNTY, PENNSYLVANIA
21-12 ~OIUZ
Estate of MENA RIVERA
Deceased
I, Lydia M. Waggoner
Dau>;hter (Print Name) , in my capacity/relationship as
of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be issued to
G1
oria M. Zaw>lski
~~/~~~~.
(Date)
Executed in Register's Offce
Sworn to or affirnled and subscribed
before me this day
of
(SI ature)
S 105 Inverness Drive
(Street Address)
Mechanicsburg, PA 17050
(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 ~_ da
of Y
_Zs}_? _.
Deputy for Register of Wills
pQ~fary Pudic IAL SEAL
KITTY M. SMITH, Notary public
My Commission Ex roP Hill eoro, Cumberland County
~+~Y Commission Expires July 29, 2016
(Signature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's Commission.)
Form RW-06 rev. 10.13.06
F~COF~D~.~ C~~
Rte ~7~ti} ~ !r,''i .t;~ ~ ...,+~. j
201? SEP 20 aM t t : 20
~:~.cr-~~, .;; RENUNCIATION
f~FY'l~~IAtV'SC;QURI
CO., A4
REGISTER OF WILLS
CUMBERLAND CpUNTY, PENNSYLVANIA
Z1 - I2 -
Estate of MENA RIVERA
I, Margaret Straka
Deceased
Dau>;hter (Prt"`N°me~ , in my capacity/relationship a~
of the above Decedent, hereby renounce the right to
administer the Estate of the Decedent and respectfully request that Letters be iss
Gloria M. Zawilski ued to
!1 ~D/ 2
(Date)
Executed in Register's Office
Sworn to or affirmed and subscribed
before me this
of day
_~.
Deputy for Register of Wills
Form RW-06 rev. [0. [3, 06
(Signature)
21 Roselawn Avenue
(Street Address)
Lansdowne, PA 19050
(C[ty. Stale, Zips
Executed out of Register's Offce
Before the undersigned personally appeared the
party executing this renunciation and certified
that he or she executed the renunciation for the
purp~o_se~s stated within on this J~_ da
of ~Lr~2.--~r~ei- ZO r L y
otary Public
My Commission Expires:~~
Y Z~~i~
SSggnature and Seal of Notary or other official qualified to
administer oaths. Show date of expiration of Notary's Commission.)
COMMONWEALTH OF PENNSYLVANIA
NOTARIAL SEAL
JAMES F GNARLIER
Notary Public
SPRINGFIELD TWP., DELAWARE COUNTY
My Commission Expires July 27, 2014