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HomeMy WebLinkAbout09-18-12Reset PETITION FOR GRANT OF LETTERS REGISTER OF WII,LS OF `u.ri 6c : ' ~~+ ~ COUNTY, ]PENNSYLVANIA Petitioner(s) named below, who is/aze 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 rite appropriate form: Decedent's Information Name: ~~a~.y ~~y /~Ji~~</(.rcr a/k/a: a/k/a: a/k/a: Date of Death; 9 ~~~ ~ Decedent was domiciled at death in principal residence at .~9 F-~ Street addreae, Post Omce and 7Ap Decedent died at ~i's~is /rlyd.c9/ Street address, Poat dice and 7Ap Code Estimate of value of decedents property at death County, File No: ~~ ~`~-' ~~~b (Assigned by Register) Social Security No: /9/ Y,2 90 3 ? Age at death: _ s 7 City, Township or Ibrouah (State) with his/her last Cou/nty1 Ctty, Township or Ijdomiciled in Pennsy[vonla ............................ All personal PmPetty $ ~3~ c n O Ijnot domicrYed in Pennsylvan(a ....................... . Potsonal property in Pennsylvania $ /jnot domiciled in Pennsy!amnia ........................ Personal property in County $ Value ojrad estate in Pennsylamnia ......................................................... $ '~ TOpTAL ESTIM/ATED VALUE.... $ 0.00 Real estate in Pemsylvania situated at: any ryic ~-r ~ n / a e •../ L9 ~ / s ~C ~7. ~d~Sc~( [tie ~n /~v, (Attach addinortal sheets, if necessary.) Street address, Post lNlice nod 7dp Code Clty, Towoddp or aorong6 County ^ A. Petition for Probate and Grant of Letters Testamentary 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 rdevnot drennaMOCen (ag, nnuncfedon, death of urcatsr, eat) y 1's1 Except as follows: after die ¢xecution ofthe insttument(s)offeredforprobete Decedentdid notmarry, was not divo ~'tapaz~to ap divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § :f323(g), t have~hikl a adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person, C!a ~:-: o NO EXCEPTIONS ©EXCEPTIONS cc,l Z? ~' _. nf's'. B. Petit[on for Grant of Letters of Administration (lfapplicable) ~$ t3. c,t.a., d.b.n., d.b.n.c.ta, pendente lire, duran absentia, dur~'i7~ If Administration, eta or db.n.ui:a, enter date of Will in Section A above and complete list of hei rrs. Except as follows: Decedent was not a party to a pending divorce proceeding wherein the grounds for divorce had been established as defimed in 23 Pa, C.S. § 3323{g) and was neither the victim of a killing nor ever adjudicated an incapacitated person. NO EXCEPTTONS O EXCEPTIONS Petitioner(s), after a proper search has/have ascertained that Decedent left no Will and was survivedby the following spouse (ifany) and heirs (anach additional sheets, if necessary): Name Relatioaehi Address d~~ /.Ji'tc/a'nc- 5 O/3e o?9 /7icfj~.~y~../~r ~a>r/ (~'i,/r4 ~a/~., Form RW-02 rev. 10//1/2011 Page 1 of 2 Oath of Personal Representative COMMONWEALTH OF PENNSYLVANIA } ~• / } SS: COUNTY OF C U ~dci~~J } ORiciEl Use Only Petition s) Printed Name Petitioner(s) Printed .Address ~ 3~~«r,~~ a~ ,~~.~, ~w~ .Qoa~~ ~~ a% P~ ,~-~- The Petitioner(s) above-named swear(s) or atfutn(s) the statements in [he foregoing Petition are we and comxt 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 tmly administer the estate according to law. Sworn to or affirmed d subscribed before ~fht /~ •~ ~--- Date y~i f~i Z me ~$~` day of N.2. ~ _ _ Date sy: Far the Regiarer BOND Required: Q YES NO FEES: Letters ...................... $~ 3~~ ( cj )Short Certificate(s)...... .1V • C?( J ( )Renunciation(s)........ . ( )Codicil(s) ............ . ( )Affidavit(s)........... . Bond ........................ Commission .................. Other Automation Fee .............. . ]CS Fee .................... . TOTAL ..................... Estate of a/k/a: File No: 02 ~ "" ~~ - >/~~ ~} AND NOW, ~ 0 ~~ C It ~.(~I~.CYI D£'1~ ~%/ ~, in consideration of the fore$~ing Petition, satisfactory proof having been presen before me, IT IS DECREED that betters }~~ L /1 I S ~l`QTl °Yl aze hereby granted to ~CQ fl i ~r 1(' k h P r- 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)) of Decedent. .~- Q P1 /L ~t egister of Wills' ~~,~ ~ ~,r FormRW-OZ rw. toiuizou ~" ~J`j Page 2 of 2 Date To the RegLster ojWLLLs; Please enter my appearance by my signature below: Attorney Signature: N Printed Name: ~'' ~ Supreme Court ~j ;? Q1 '~X;i. ID Number: r t"'i i ~ _~+. F rm Name: wa Address: ~ nn Phone: Fax: Email: 1 g DECREE OF THE REGISTER S. t7n _ ~ ~ 5~ $ ~ ,.QQ LOCAL REGISTRAR'S CERTIFICATION OF DEATH Wpl~~~{~~~ duplicate this copy by photostat or photograph. REt~.'~E~'i IEYtlLS Fee for !hi9 certificate, :$6.00 20t2 SEP 18 PM 12~ 42 This is to certify that the information here given is correcCly copied O~om an original Certificate of Death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital c~R~ecord Office for permanent filing. C~~~~®a.c~w~xn~' SE,P 1 32012 Local Registrar Date Issued ' Gwri ". S COllRT P 1888232~~oCOal~ ~~ Certification Number Tvpe/Pr COMMONWEALTH OF PENNSYLVANIA - DEPARTMENT OF HEALTH -VITAL RECORDS CERTIFICATE OF DEATH aaenva Legal Norma ( B,t Mleme oat, s"mw .sea w rv"robe. 9. Dn<e r p n ( °/p.rnr! is n ) E z g v Mala 191-42-9032 S@ptember 11, 2012 Harry R. Brickner a. Age-Coat Irtnaav rv.al 6 una.r v 6. rote pi 6 n (Mp/oar rear) rspeR Monm) rt rtnplae. t n ena store pr Gpmgn c°untM 57 °n[M1 ova N°"' '""` March 7, 1955 x~liala PA >b. Blrthplvice (COUntyl . R.aleenP~st..e or Fo a gn Country) eb- neiraence (Street vnd Number- Inclutle Apt No.) gc. Dle Deceeent Llve In a TownsM1lpi 29 HicXOrytown Rd- Qpvea. eecment nyea rn_ Middle:@x [wp. e t~@~~a~~ a lzlp <oee) s c ONO, aeceaen<INea w¢mn uml<a °r city/bo.°. 9. Ever In V$~ G ezi Marltal5ta< at Tlme of Deetn M I e 0 W wee rvlvln{Spouse's WVme II/wife, Hl"e name pear to Rrst martla{e .r `e 10 1e " ) O Vnkn°wn ~ Vei ®N O Unknown 0 D ~ N Joni CiOUff@r ° 12. ner'aN m Mlaale, sanl.) ) d ` cl Do o G).aa Nr.ra.{. INrm Mleme. Laaq 6~Ne~Yiem~-lorL L n Bri crter nal .e a z9 nm IPm pe<ment ~ 4b mm.m.nra M.nm{Aeercaa ao-eet.nor rvumb.r. otY. state, coact ~t z g Bric]cner wi £e JOni 29 Hic owrz Rd-, Carlial@, PA 17015 s a Noa It - ..... ... _... .G._.. ....... .. I ....... .... ii'oe~Fn'o-dFv::ed'in ........i:._....__ ~n'Siiene....._ ................................."02~~:.4.4.'somed; `p pq.y on9 ..... ...._. pe nme ... p p ra De.<n a M1erc ode. roan a N°:pii:i: "'ry'Ae:6 ~ .clilq _-C]'....2:a:nC•a.H .. a m/o"[patient Deaa on A.nya rvur.m Nome/Lpn -Term care G.nutY OtA.r (sp r me n . M ~ b. F .,. t n namu n, eroe :tree[onti namber; t ty asc. op prmwn, st.<e, one zlp cpae ssa. cpvnty r Deam 15 M.5. Hershe Medlcal'~,Center Hershe Pa. 17033 Dau hln 1fia. M p msPpnao O cremation b. D r Dlrepation la of Dnpoalnan Irv a pt ".meeerv, arcmatorv. or omen prom) . B" a . i I p 6c Q p e o-pm st.< Dpn.apn Beet 15, 201 L@tort Cemetery E om.r s ti) L Pe It n 1 fie. maaapn p as a ° (otv arm ~, sta<e,.m np) v>.. sr{n. at F"n.ra se m cneree at m<e.m.m 1 u<enae N"mber b Carlial@, PA 17013 138504 vc. N .nor complete Aaaress ar F¢gerel Facluq 3 Hoffman-Roth E1.zne sl Home & Cremnto 19 North Hanov@r StrEEet, Carliole, PA 17013 ~ caeent'a Eeuce<lon-CFack Me ba mv<bas<EVacNbea ene ixpanlc Orlgin-check me sRace-Check ONE ORM Intllcate whet [ tO scM1n°I Cnmpleeetl a<metlme pr cream. boa M1at best aezcrlbaz wnatM1er Me tlecetlent the aeceeent conzreeree M1lmseli °r hersel(to be. M1I I l ° !~ Htn puce a lass is spanisM1/Hispanic/Letlno. EM1eck tna "N °" ~ WM1lte O Korean ~NOalplome, 9th-11<M1 grace box lfeecetlen[Ia n°[6penign/Hlipanlc/LVtlno. OBrackerghicangmeNCan ~V QNlgn scnool6raeuate nr GEDCampletetl IXNO.n Ian/Nlap•n14L. pAmenc.n rntllan °r Areska Native DOtM1e~ASean ~ 5 colle{ reel[, but o es e¢ ~ V s, Mealcan, Me an Amerlcen, CM1lceria 0 Asian Inelan ~ Natlye Nawelra H Q. p q ee ee (e.g. qq qsl p Y <.n p enm..e p D pr cnemorrp .~nlm ~ : wean R la p e a a.{re.!a. esl p v , O Hupmo O samaa~ e p M ore (e-a M Msw, MBA! O Yea. o .. .maM1/NlapanWtatino p .. .ne.e O an.. Padnp roamer o p O D ee to g. ono, EeD) o. P.pFesslp a aeoa (speclry) _ O Omer (speclry) a MO DDS DvM ug ~D cetlen['s 51ng1e RVCe Self-Designat°n-cM1eck ONLY ONEto lnalcate wM1et tM1V tlecetlan<cenaleeree M1lmsellor M1erself <o be. sVSUaI OCCUpet Inelcete tYPe °F wor4 z2,® co a e o wnrte p t.vaneaa O sampan ne m at pF wprkmg a e~o0 NOT USE RETIRED. a m q Hl.ck pr Ar.m.n Amerman OK Opener Patlnc lalamer Sel£ Employed 0 n nalan or Alaska Nvave 0 V 0 po t Kn w/NO[ Sure . rrm n p p Aa , n O o e nzise p R.r"am zzb. was °r B":m.aannpua< e p cnmese O N n p omen !ipeelryl Excavating CO. O HRPInp O D m cb.mpr,p pam n s z{e - a { M LEr p Ep a. re Pr an a Deaa taro oar r) . sl{n.<"rc pF Peraon Prono¢non{ Doo on v w en avp ro e e. m.na. rv"m er ev 9 / ~ ! a P{wsoN wwo PROrvopne{a oR cERrnles DEATH zsa. Date sgnm <Mp/D.v/Yr) z9_ nme o . n p i 3 53 25. Wes Mealcal Exvminer °r Cnrnner COnfec[eei Q CAUSE OF DEATH Approglmate 36_ P rt h Enter the the n p1 events- tlrsease; rnjurles, °r cempllcetlpns--mat alrcctly cvusee me tlea[n, DO NOT enter [erminar events such vs cvrelac:Nest ~ Interval: rexpba<ary arrest. ar ven[rlcular flbNlla<lon wrtM1OUt aM1°wlnH me e<Iplogy. DO NOT ABBREVIATE. Enter only one Cause on a Ilne. qaa aaaltlonel Ilnes 11 necessary Onset to DeatM1 r~ IMMEDIATE CAVSE --------> a. C4r~o\hC IY f'F G5~ 1 (Floor elaea.e pr apmm~on o 1pr uena °q: i D° ' r.,"rang In Beam, i P 1 I ,S.a ~- b ~ E_ r.nY Ua«pnempn:. Du. old:: cote prl: ~ n ~e < pn " aaing tp me<auae w. 11 ~IA~ u a l m 2TLS ue pn me .. E r e a. o"e w mr as. cona¢paenae pN: ! ~s~ez e.~n Vnz D 9 t ! w l V Itlne m. ~ " n N s ) tl Pert ll Entet other 26 nt 1 n but opt reaulang In ma untleaying c euse Hlven rn Part l a tppsy perrormeei 2> n yea No ~ 3g. W autopsy flntlingi availvble ~ <O mpleie the ceuze of tlee<M1i Na ' li 3p. p1a Tnbacc° U Nlpute to peami a 31. Manner o Deet M1 O N year r Q V 0 vrobvblY ~ N urar ~ Noml lee me o f eeam 0 P l p Q N ~ Unknown ccreen< ~ Pe^tlln Yas<IHatlen 0 A ~' 0 N t , bu<pregnanC wl[nrn 92 eayz °t tlea<F a< r ~ s c ee 0 Coule be tle[erminea p rv 3 maw ep 1 year before ea.m . Date ai Inju~. tMp/Dey/Vq I6pel1 manta p unknpwn lr Pregnane wrtnm ene a•st war .nme pnnjury o .Place pF Injury te.g. name: cpnatr"torah rote, term.:copal) . m<.<mn pi Inj"ry tsaea.na Number, ty, state, zlv cpaq .Injury at wprk Tr etlon Injury eclfy: peacrlbe Npw Injury Occurrae: o r o p e~/D <p o P o rv o Pa ore er o p..n::iseeal6n er (Check only anal: 39 C l ~ C rt Iryln or my knpwlee{e, eevm p the ceus<rz) ene m tea e [ ® P rtltyln ma base pi my knowletlge eeam °ccu Nee et [M1e time, ea<a, vne p anti aue to <M1~e cauaeta) anti m tetl ~e ~ o°r O Mmmal E.amm /carp"e .npn, one/pr m~eatigaapn, m m a Impn. a.am paur.ea x tn. am., eme, anti pma..na e . m me uusep) ene m tea .Hoer: retie pr artmar: rn n mber: y.\OOb1?SG L ' 3gb Neme. naarefa .ne zip cpa. pr I o.~p~oe <r-~1t3Tr~~t Medl c Date 17033 s - "`a ("q / nn ~r an }~~ng cal Center Hershe P ~ t\ ~,.,,`~ tl. , y, a. - i i i a. negrs<rar s Olztnct Num er Reglet r ~ e Date Mo • r Y r` ~-ate ~ D ~ DlappaapnPe.mh P~~4~i.2aa-. RE>.D:-293 D>,2p32 ~£C~(~D OFFK~ 6F ~, rr, ~,- ~.alJitrs v~ ~~ RENUNCIATION 1812 SEP 18 PM 12~ 42 REGISTER OF WILLS ~'i'`''~i~~ ~`~'~ S COUR? Cum 6c i ~~ ~ COUNTY, PENNSYL~~~D CO.. PA Estate of ~3~~'x /T ~'"~~` ~ .Deceased /'!!/ /. /J rtc /t 'It/ 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 Jane ,~/ ~/'~~Ka<~ 4/ 8 /~~Z (oaten Executed in Register's Oice Sworn to or affirmed and subscribed befo me this ~ ~I day of , ~• ~_ Deputy for Register of Its Executed out of Register's Office Before the undersigned personally appeazed 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 Nomr}~ or other official qual~ed m adminiscer oaths. Show date ofexpiretion ofNocery's Commission.) Form RW-Od rev. /0.13.06 //t/ ff"~y /toad (Street Address) //-- p / rlrSK / ~ ~7oiJ (City. State. ZipJ RECQROE(~ o~>~ ~ REG!S'~R. s~~ `,ELLS RENUNCIATION ?.012 SEP 18 PM 12~ 42 C~::;. r; REGISTER OF WILLS Q~~'S (;()URT Cu~6c-~~^~ COUNTY, PENNSYLVAN(jIII.A~ ~.. ~ Estate of /~A~ ~ ~ ~~" y~cl ,Deceased 1 /1'Jerer/. f< ,( Q~r< Yee ~ , in my capacity/relationship as rymm Name) ~o „G.j~ ~ of the above Decedent„ hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to Jour ,~ ~~,~ ,~,~~~ 9 ~/f3/2~i"z-- (~e) Executed in Register's Offue Sworn to or affirmed ~~subscribed bef a me this ~ ' day of e~C ~C~ m 'e.r , ~~ Deputy for Register of 1 Vills (Signmrae) (StreetAddresr) (City, Sane, 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 otFicial qualified to administer oaths. Show date of expiration of Notary's Commission.) Form RW-06 rev. 10.13.06 f~~ O~k;E OF REGIi; ~ LN ~'~ U~LLS RENUNCIATION 2ff12 SEP f @ PM (2~ 42 REGISTER OF WILLS i"t`n' ~ `"' Cu,~.s~-~<.,d Ot~hUW'S COURT COUNTY, PENI~J~ CD„ PA Estate of .Q,9~~y ~ ~~"'Y~`'• Deceased I ~,~~~,~ /rj ~i~~ kn~i , in my capacity/relationship as (Prier Name) a., y~ of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to R- )~ - i? (Date) Executed iu Register's Office Sworn to or affirmed and subscribed befo me this ~~ day Deputy for Register of R is (~~We) ~TC 5. ~vul,,.~ ~. rs~r~~u~ P. a. i, Pa )SaaH (City, Sane, Zp Executed out of Register's Office Before the undersi€med 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 Seel of Notefy or other olrcia( qualified m administer oaths. Show daU; of expiration of No[ary's Commission.) Form RW-G6 rev./0.13.06