HomeMy WebLinkAbout09-21-12` REGISTER OF WILLS
CUMBERLAND COUNTY PENNSYLVANI
SMALL ESTATES AFFIDAVIT ~, rn
For Insurance Proceeds c-~
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' (Original Death Certificate Must Accompany this Form) .~ ~ ,. c,,~ ,`~
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Deceased ~ ~ Case No. --
also known as _ Social Security No. ~Q t~-,~ ~7'7 `~
___-.___------_-_._____._ ....-------.___..-____ 1'
Before the R ister of Wil of said Coun personally came ~ ~ who resides
X11 ~_-~_-----_ rn~1~_ 1._....
at (Q..`~--,C~ e rr ~q~'1 e.,...-._ r_I ~ ~ _~ 7~~ _~__-_._._-__+ being duly sworn,
age QQ , a resident of
ses and sa s th .-....__ '~ ~.. __~_.~-~-----......_----- ' .5.1._
__ ...........~..... _......_~ .......... ..._....... ...... .....................oe the......... 0..... ......_.........
rre_S-~-... ~~r y-
m said County, departed this li e, at -_-Q[Le~,~,~Qf'K__~y~7_~ _ ~~~~ ~c2. day of
'~~, f~ l A.D. 20 _~~,_ o'clock -__ M., possessed of personal
property estim ted to be of the value of $ -.~_/,,.,_, ,-, _._.-._ ................., 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 whgr~jn,grounds for divorce had been established as defined in 23 PA C.S. section
The total amount of insurance proceeds payable by ~ nLl ~Q ~ c7~" L)~Q. does not exceed 511,000
and 60 days Gave elapsed since the death of the insured. The undersigned agrees payment cannot be made
under this AfTidavit 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 u ersigned.
That said decedent left espouse -whose name and residence is _-,___._._..._~~n~i -_ ......................................................................_.._.___-._.._............
and the followin as next of kin:
NAMES RELATIONSHIP RESIDENCE
-l ~>1 h r ne ,S~PI~IS
That the above named aze the spouse & 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,
Sworn ands bscr' ed to before me this
day of ____-_ _____., , 20 ~~ - Register of Wills:
Kindly enter appearance in the above case this
<~~,...........-._......~_~' day of -----..~---------.. ..............._..._..._...._____...................-...................._, 20 __---...-..._
-.-. _
~,~ .__.~.--- _----- Attorney
My co.~~++~~fres LD. No.
BE IT REMEMBERED, that as of th~`'~ ~ of C2~Z , A.D. 20 /02--
There has been NO ESTATE PROCEEDING RAIS~THIS DECEDENT AND NO LETTERS HAVE
BEEN ISSUED BY THIS COURT.
~/ -- ~aa- 163 k
Gtenda Fanner Strasbaugh
Register of Wilis & Clerk of Orphans' Court
My Commission Expires Firat Monday, January, 2014
WARNING: IT IS ILLEGAL TO ALTER THIS COPY OR
H105.112 REV. 1105 TO DUPLICATE BY PHOTOSTAT OR PHOTOGRAPH.
(FEE FOR THIS -
cEfiTlFICATE Ss ooh; CQMNIONWEALTH OF PENNSYLVANIA
". DEPARTMENT OF HEALTH VITAL RECORDS -
LQCAL REGISTRAR'S CERTIFICATION OF DEATH
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CERT. Nfa.` T 6 41..:.5 0 ~ 5 ~Q~a ,. 'v;~;~* D~ aly o,ll°D:~,"~2012
I g9TMENT 9E ~~'-'
Name of Deceden Gayle B. Gipe
F{Fsf Middle Last
Sex Female Social Security No. 2.04 - 26 - 8434 Date of Death Julg 5, 2012
Date of Birth July 18, 1931' Birthplace Newport.' PA
Place of Death Forest Park Health Center Cumberland Carlisle Pennsylvania
Facility Name County uty [krpUgh or Township
White..' `Sea~astress Armetl Forces? Yes or No No
Race Occupation t )
:Decedent's Carlisle PA 17015
Marital Status Widowed Mailing Address Forest Park Health Ctr.
Number 'Street Cmy or TOwO State
Informant Joy Camgbell' Funeral Director Sally A. Myers
Name and Address of -David M Myers Funeral Home Ittc. 64 N. 2n+d St. , Newport, ,;PA 17071.
Funeral Establishment
Interval Between
'Part I; Immediate Cause Onset and Death
(a) Chronic Obstructive Fulmonary Disease '~
(b) ,, Congestive `Heart Failure
(e) Chronic Kidney Disease
(d) Diabetes Mellitus
Fart II: Other Signi#icarit Conditions
t
Manner of Death Describe how injury occurred: '
Natural ~ Flomicide ^
Accident ^ Pending Investigation" `^
Suicide ^ Coufd not b~ Determined Ci
Name and Title of Certifier Carol Robison D.Q.
(M.D., D:O„ Coroner, M:E.) ;
Address 100` S. High St. , Newville, PA 17241
This is to cer#ify that the information here given is correctly copied from an ori',ginal certificate
of death duly filed with !me as Local Regis#rar. The original certificate w#I be forwarded to the
' State Vita'f Records Q#f'ice for' permanent ##ling. ,
-- 50.-455
cal gegistrar of VNa7.Rerprds 'S D~sind No
July 8, 201':2 O1 Barnett St., NeW Bloomfield, PA 17018
Dafe peteived by tncal aegistrer Street Adtlress ' Gity, Aorough, Townshp ' ' '