HomeMy WebLinkAbout11-08-12PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF (l~ryl~p ~ ~(~ na 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 Inform lion I /I
Name: ~- ~ JGt2bti'I/C
~e ~
a/k/a:
a/k/a:
a/k/a:
Date of Death• C
Decedent was domiciled
principal residence at ~
(State) with his/her last
Decedent died at / `/ G /(t t~ Sm ~~ e tv ['G~y 6 P~~Ga~l CG/t,~ f~~a~
Street address, Post Ofnce and 7rp Code City, Township or Borough County
Estimate of value of decedent's property at death:
If domiciled in Pennsylvania ........................ . .. All personal property $ ~~G~
If not domiciled in Pennsylvania ...................... .. Personal property in Pennsylvania _
$
If not domiciled in Pennsylvania ......................
Value of real
t
t
i
P
l
i .. Personal property in County $ .:
es
a
e
n
ennsy
van
a .................... ................ , , . , , , ... , $
TOTAL ESTIMATED VALUE.... $ C , Q ~ d
Real estate m Pennsylvania situated at:
(Attach additional sheets, ifnecessary.)
State
street aaaress, Post Office and Zip Code City, Township or Borough Count
y
A. Petition for Probate and Grant of Letters Testamentary // / ~t2 C i ~ , tD`~.
Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated _ ~~tJ U 4 / / ~ and Codicil(s)
thereto dated
State relevant circumstances (eg. renunciation, death ojexecutor, etc.)
Except as follows: after the execution ofthe instrument(s) offered for probate Decedent did not many, was not divorced, 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(8), and did not have a child born or
adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. _
(iQNO EXCEPTIONS ^ EXCEPTIONS
^ B. Petition for Grant of Letters of Administration (If applicable)
c. t. a., d.b.n., d.b.n.c.t.a., pendentelite, duranteabsentia, duranteminoritate
If Administration, c.t.a. or d.b.n.c.z.a., enter date of Will in Section A above and com lete li f heirs. ~°~
_~~ ;~-?~
Except as follows: Decedent was not a party to a pending divorce proceeding wherein the grounds for divorce had br~ e~blished al7d'efined =-.-; C7
in 23 Pa. C.S. § 3323(8) and was neither the victim of a killing nor ever adjudicated an incapacitated person ~? 7 c~ c; ; ;-~
~NO EXCEPTIONS ^ EXCEPTIONS I _ ,- ,
~T---fig ~
Petitioner(s), after a proper search has/have ascertained that Decedent left no W ill and was survived by the following spou~i~2tttty) and he~(anac~
additional sheets, if necessary): ~-> ~ _,~
Name Relationshi Address ~ --, r y t-rt
S
i
~ v ~ ~ 2 ~Ci rC ~O ~-,
o ~ J ~ 2~ c+~'G s'o
Fonn RW-02 rev. !0/11/d0U
File No: - - ~~_
(Assigned by Register)
Social Security No:
Age at death:
~~ ~~
G~ ~
Page 1 of 2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA }
/'' / } ss:
i~
~~-~•~~,J ~ ._ ,'f ~~ C1~ CSC Only
~~ll? ~~~ -8 ~~ ! I : ? ~
i
Petitioner(sj Printed Vatne ;~` i-..
Petitioi e I 1'
s
ST~° e ~, /~lbl~r c. 4 y~
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 Dece , the P o r(s) will land truly administer the estate ac~co/rding to/law.
Sworn to or affirmed and subscribed before Date /-' U~ l~ ~ /~
met s day of Date '
By. ~ Date
For the Re~isrer Date
BOND Required: Q YES ~ NO
FEES:
Letters .......... ..... .
( ~) Short Certificate(s)..... .
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commission ................. .
Other
r~~ t~ ......
~ys~
Automation Fee .............. .
)CS Fee . .................... ,
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 ,~~ ~@k dGi 2 ~~r s'~C File No• ~-
AND NOW, ~ x.,10 A A'1Uif' ~ ~(~
~- ~ ~ 2 , in consideration of the foregoing Petition,
satisfactory proof having been presented before me, IT IS DECREED that Letters
are hereby granted to T p~ h0_ n ~-p [~r, D 1 i~~~ Z~ _ ~S
in the above estate and (if applicable) that
the instnunent(s) dated _~ ^ ~^ '^ ^ - -
described in the Petition be
Forn,nwnz ,-w. tnittizni~
to probate and filed of record as the last Will (and
Register of 1~ills "
i~il(s)) of Decedent.
2 of 2
__ __ _ _ _
ulOS.ltn~ q5V iqu n _.__ _
LOCAL ~'~~~~'I~S CERTIFICATION OF DEATH
WARNINGk~1t'~~ •ig~l tx~~ plicate this copy by photostat or photograph.
ree ror cros cenujcate, ~o.uu _ "' ` ' _ •" ' 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. Tl)e original
~~~~k~JV ~ ~,~:}r~,i certificate will be forwarded to the State Vital
Cl)~g~~(~'(~ C~•1 Records Office for perm ant filing.
P 18849.569 •
Certification Number
Type/PnM In
Pannenant
d~
` Local Registrar Date Issued
GOMMONWEALTN OF PENNSYLVANIA . DEPARTMlNT OF MEALTN . VITAL RECORDS
CERTIFICATE AF DEATH
L Decedent's Legal Neme (First, Mkld •, Last, .) 2. 3. Sofia SewrRy Number 4. Deq o Dast (MO DeY r Spa 1 Mo
SZ~PHEZQ A. JUZSASZC Male 174-20-1237 ~B~g~
3e. AE.-Last ebehdw (yra) s . can 1 rwr s can a s. D.u sireh Me w . r (Spell Month) 7.. sl P •u GM •na tea or FerNEn Ce ntry
r
82 Months Days Moue
Mlnubs January 30 , .1930
7b. glrNplau (County)
W. Rasldenca (Stale or Foralgn Country) gb. ReaiWnca Street • NumWr- InUU • Apt No. . Dld Decadent LWe in a Towns Ip
PA 142 S x teen th S t . Q vo, aewdene Ilved In
M'P-
ed. R.sleenc. (co.lnty~
Cunberl8 N. Resldenp (21P Code) o, deeedertt Iiwd wlMin limits of ~rYL7 C.LCILtifg=Zli~^.'a cRy/hero.
9. Ewr in US ArnNd Forces SO. MarRal Status at Tlma Ma M• 11. SurvMng Spouse s Name wNe, gWe name prior to flrat marnap)
)~] Yet Q No Q Unknown Q DWOrosd Q Never MaMed Q Unknown
12. Fat s Name first, Mi le, Last, S ) 13. er's Name Prior to First Marriage first, MIEN, Last
Ivan Juzbasic _
s N• f 14b. R• t onshlp to Daadartt
^t
`~'
l~~
~
J
b
i
J
~ 14e. 1 rmsM • Malling Ad rasa Street and Num Gty, Staee, 21p Gode
~
ap
EarL
L.
uz
as
c,
r.
on 142 Sixteenth
St. New Cumberland Pa
1707
Daeth Ocwrrad In . Nospital• InpatNnt -
•
. ... . ..... ... .................................. . ........ ..
.. . .........
If DeaM Omtrred SoRleMlllere Ot ~ Than a Nospltal: t~ NwPica Fac111ty ~ DacadenCS Nome'•
6me Reem/OU ONd en ArrNal Nunl N -Term Gr. FaG1 OtMr S aG
lib. FaNI Name not Inrt/tutlon, gwe streee and num r iSe. C1ty or Town, SteN, an 1 Code iSd. Co my Death
d
b
142 ixteenth St. New Cumberlan
PA 17070 Cum
er and
lge. M ad • n 6urlal Gemetlon 1 Dab D4pesltlon 1 P ap o Dlspeaftlon Name cametery, crematory, or otMr p eCe
Q R.mov.ltromsaa Q °°n.H°^
Other Oct 25, 2012 - Indiantown Gap National Cemetery
1 Q1sPOaWnn (fJlrOaS n, Sbt•, and 21p
e, t'A 1 / VlJ3 17•. SISnP~IrP _ cane M UCMM• or Person In CM • of I rrrr•M 176. UunN Number
~e~ ~ ~
~ ~D~ ~ ~-
17u Name and Compktte Addreq of Funeral R•GIRy
~ ig. Decadent a Education - the box Mat describes Ma 1!. Decedent Nlapanlc Ong n -Check the 20. Dacadent's 0.•u -Check ONC OR MORE razes to Indicate what
Mghest degree or Ieyal of school completed et the time of daaM, box that beat descnbp whetMr the decadent the Wcadant considered hlmaH or MrpH to be.
Q gth grade or laze b Span4h/Mkrpank:/I.aHrw. Chet[ tM "NO' Whlb Q Korpn
Q No diploma, gM -12th grade box H decadent Is not Spenbh/MlspenltJ4tlno. Q EleCk or Afrlun Amenun Q Vletnemea•
~ Nigh sGteel graduaN or GED complNed No, not Spanbh/NhipanWLWno Q Amenun Indlen or Alaska Native
Q OtMr Aslen
Q Some ce1Np eradlE. but no decree Yes, Mexican, Msselun Amenun, Chluno Q Aalan Indlen Q Nature MawaiNn
Q Asaocbte decree Ie.g. AA, AS) Q Yes, Puerto RICM Q Chines: Q Duamanian or ChamoRo
Q BacMlOr'a degree (e.g. gA, AB, 0.4) Q Yes, Cuban Q Fi1lPlno Q Samoan
Q Marten's degree (e.g• MA, MS, MlnL Mld, MSW, MBA) Q Yes, otMr Spanlsh/Mispenic/LaHno Q Japanese
Q Other Paeifle Islander
Q Doctorate (e.g. PhD, [dD) or PreMabnal degree (SpeeHy) Q Other (Speef/y)
. M DDS OVM LLB l0
21. DecadenNa Single Reu SeM-Deslgnetlo -Check ONLY ON! to Indk:ate whet Me decadent considered hlmael er MrseH to 22a. Decadent•a Usual Ocwpatlon - Indlub type of work
Whlta Q Japanese Q Samoan dons during Mort of working Ilfe. OD NOT USE RETIRED.
~gNek er AMUn Am
ri
K
e
can Q
orean Q OMer Peelle IaNnder
Q Amenun Inden or Alaska NatlYe 0 Vktenemese Q Don't Know/Not Sure
Q Asian Inden Q ocher Afian Q Refused 22b. Kind o Busines Industry
Q Chinese Q NeGw Naweilan Q Other (SpeGfy)
Q Filipino p ou.m.nNnorCh.morro Electronic Mfg.
w PERWN WMO MIONOYNCfi OR w ~ o w r Sn•tuM arson roneune nB eat n Y w en .pP ee • c. cause um r
Ci
2sa. D.a E M ) ~ ~. TI
~E~[
~ _ ` 2S. WN MsWlui WmInK or Coroner CongetedT Q Yef NO
CAUSE OF OEATM
Approximate
26. PaR 1. Enter the ch.!.: e? _- _-=-,-Skaaases, INunea, or eompliudonf-chat tllrectly caused the de.M. DO NOi e_~npr urmin.l events such as cardiac arr•aC Interval:
roaPiratory arrert, or wnMCUlar flbnlletlon without ~1~ tM Kb1o3y. DO N ~ 6jlEVJ/LT~ Entel tl1~B~~use on • Ilne. Add •dditlensl Ilma If necassary Onset to Dseth
5 1
I
/
L...
A
/
/
/
`
,
/
` 5 L
L
.
`
IMMEDIATE uusE > a. G
(Final dWefae or condltlen DW to (o Y • eonsaquen of):
raautting In death) b. /•O L /[ \ A /)/ /L- ~ i _ / /~O
1f s -V /V(R/ i /` L rT~ +~ s~
SegYlnNally Ilrt rxfndlHOna, zee t0 (Or ea a WnNquenu Off:
If any, IMding to tM cause
listed on Ilnt .. enter the - .
c
UNOERLYIMO CAUH
Due to (or as • eensequenu of):
(disease or inlury Mat
Initlaeed tM awntt reauRing a.
in deeM) LAST. Due t0 (or seeuenee ot):
as a can
16. PaR 11. Enbr oMer alanlflcant ~Itl .Ib ~« d - h but not resulting In a can erlYing ewae gMn In Pert 1 27. Was an eucop.y W
Ye No
2i. Were autopsy ridings syaiNb •
- 2g. I fame to compieq Me cause of death?
Yea
d T
Q Not Pregnern wlthM pest War •
obaece UN CoMrlbute to DeK
Y 31. Ma~Der of OaaM
Q Pregnant K qme of daaM ~
~SI Q ProMbly
o Q Unknown $NSWreI Q NomkYde
A
i
~
Q Not prognant, but pregnant wRAin 42 days of dNM Q
cc
dent Q Pending Imrastigation
~Q Not pragneelt, but pregnant 43 days M 1 year before dMth
Q Unknown It Prognant within Ma part veer
32. Data of Injury Mo Day r SpNI Menth) Q SuleWa Q Coukj not M detennlned
33. Tma o Injury
34. Placa of Injury e.g- home; mnrtruetlen sRe; term; s ool) 35. Lootlon o INury (Street end Number, City, Spb, 21P Gode)
36. INury K Work 37.1 TranaportaHen Injury, SpeeHy: 3g. DeaMbe New Injury Occurred:
Q r.s Q Drly.r/op.reeor Q Pwe.tn.n
Q No Q Pawnger ~Q Other (SpeeKy]
3fa. 4 (CMCk only one
Q GreKying phyNWn - To tM best of my knowledge, death occurred dw to the cause(s) end manner sbtW
~'Fronouneing i GrtHying phyNeian - Te Me hart of my knowledge, daaM oocurrod at ell Hme dat and Placa, and dw to the cause(s). and manner rtatW
Q Medlin Examiner/
o
-
n /or InwsHgeclon, In mY opinion, d~~rred at the time, drte, and placa, and due to t/h~e~/yyy~{,e(/•)~,~nd rnannlr aLb/y
Slgrlature
O
/
urtMer• TItM e/ ceKlRer._ LJcanN
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43.Amendmenb <
DlsposRlon Penult Ne. ~ ~ ~ ~ ...~~ H305-14!
REV 07/2011
LAST WILL AND TESTAMENT
OF
STEPHEN AMBROSE JUZBASIC
I, STEPHEN AMBROSE JUZBASIC, of the 142 Sixteenth Street in the Bureau of New
Cumberland, Cumberland County, Pennsylvania, do make, publish and declare this to be my Last Will
and Testament, hereby revoking all Wills and Codicils by me at any time made.
ITEM I: I direct that all my just debts and funeral expenses including my grave marker and all
expenses of my last illness, and any and all taxes assessments imposed by any governmental body as a
result of my death, whether on property passing under this Will or otherwise, shall be paid from my
residuary estate as soon as practicable after my decease as a part of the expense of the administration of
my estate.
ITEM II: I give devise and bequeath my estate, whatsoever the same may be and wheresoever
the same may be situated to my wife, ANNETTE M. JLJZBASIC, providing she shall survive me by thirty
(30) days.
ITEM III: I also bequeath to my son, STEPHEN ANDREW JUZBASIC, all shares or rights to
future royalties earned by the Screen Actors Guild which was bequeathed to me by my sister, Barbara
Ahearn.
ITEM VI: In the event my wife, ANNETTE M. JUZBASIC, predeceases me or dies on or
before the thirtieth (30"') day following my death, I give, devise and bequeath all of my estate, whatsoever
the same may be and wheresoever the same may be situated as follows: ~ r
~ ~ ~,:,a m_ rC
1. Six-tenths (6/10 or 60%) to my son, STEPHEN A. JUZBASIC; and m ~ ~ - .`~~,-. ~;' ~.n
2. One-fifth (2/10 or 20%) to my son, THOMAS G. JUZBASIC and ~ ~~' 06 `- ~ l
cr`~ -.,
E... y
3. One-fifth (2/10 or 20%) to my son, KEVIN A. JUZBASIC. n~~' - ~ ''
~ cm - c-~
z:, ~ ;==
~ --, .. ;.~ ra-r
ITEM V: I appoint STEPHEN ANDREW JUZBASIC, my son, Executor of this ~ Last Wil , ,~ `~
In the event STEPHEN ANDREW JLJZBASIC fails to qualify or ceases to act as Executor, I appoint my
Stephen A. Juzbasic: '~ t
Witness #1 initials:
Witness #2 initials:
Witness #3 initials: .~.
Page 1 of 4
sons, THOMAS G. NZBASIC and KEVIN A. JUZBASIC, as Co-Executors of this, my Last Will.
Neither my Executor no Co-Executors shall be required to give any bond or bonds.
ITEM VI: I direct that any person contesting this Will or attempting to defeat its dispositive
provisions, if they are unsuccessful in their efforts, shall forfeit any distributive share of my estate to
which they are entitled under this Will and direct that their distributive share go, instead to the other
person taking under this my Last Will.
ITEM VII: All of the interest of the beneficiaries hereunder shall not be subject to anticipation
or to voluntary or involuntary alienation nor shall they be subject to any execution or attachment.
ITEM VIII: In addition to the other powers and authorities granted to my personal
representative by Pennsylvania law and by the other terms and provisions of this Will, I hereby give to
my personal representative the following powers and authorities effective without court approval and
until actual distribution of all property; to compromise any claim or controversy; to make distribution in
cash or in kind, or partly in cash and partly in kind, and in such manner as my personal representative
may determine and at valuations finally to be fixed by them; to invest in all forms of property, including
any stock or other securities in any corporate fiduciary or its successor without restriction to investments
authorized for Pennsylvania fiduciaries, as my personal representative deems proper, without regard to
any principle of risk or diversification; to sell at public or private sale, to exchange, or to lease for any
period of time, any real or personal property and to give options for sales, exchanges, or leases, for such
prices and upon such terms or conditions as my personal representative deems proper; and to allocated
receipts and expenses to principal or income or partly to each as my personal representatives deem proper
in their sole discretion.
n.l E ~nJ
I subscribe my name to this Will this~.day of ~ ~ ~ , 2008 at G v 1-'1 ~ R ~~`! ~~
Commonwealth of Pennsylvania, and declare it is my last Will, that I sign it willingly, that I execute it as
my free and voluntary act for the purposes expressed, and that I am of the age of majority or otherwise
legally empowered to make a Will and under no constraint or undue influence.
~-
`~'I'~PI~N AMBRO JLJ ASIC
Stephen A. Juzbasic:~~
Witness #1 initials: ~~{{
Witness #2 initials: ~,
Witness #3 initials:
Page 2 of 4
WITNESS STATEMENT
On this l~~ day of ~ f^C~~~s' , 2008. the Testator STF.PHFN AMRRncF n r~u e err ao,.i.,.oa .,.
us, the undersigned, that this instrument was her last Will and requested us to act as witnesses to it. The
Testator signed this Will in our presence, all of us being present at the same time. We now, at the
Testator's request, in the Testator's presence and in the presence of each other, subscribe our names as
witnesses and each declare that we understand this to be the Testator's Will, and that to the best of our
knowledge the Testator is of the age of majority, or is otherwise legally empowered to make a Will, and
appears to be of sound mind and under no constraint or undue influence.
We declare under penalty of p 'ury t the foregoing is true and correct, this f 7 ~~ day of
~~ , 2008, at L/1 ,Commonwealth of Pennsylvania.
(witness signature) (printed name)
residing at d9d`7 ~r~L~~ ~l, , ~f~ ~~(L,
(street address) (city)
Lvu~1 ~~c~ ~.rn ,~.
(county) (state)
' / ,
i
J~
~~ z~~~ ~..L. ~~,riq/ey
(witness, ignature) (printed name)
,,')
residing at ~~ylC~/~~ ~~~
~
(street address) ~ ` (city)
~~~~~ ~~
(county) (state)
(witness signature)
~~ahQ'~ l~riSca ~ ~
(printed name)
residing at ~S ,~~ ~ rQ n ~ 7`
(street address)
~~n ~~ lCt-n
~Pw ~~ ~~/an ~
(city/)
/'"• ~ .
(county) (state)
Stephen A. Juzbasic: ~ Q,
Witness #1 initials:
Witness #2 initials:
Witness #3 initials:
Page 3 of 4
SELF-PROVING AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
I, the undersigned, an officer authorized to administer oaths, certify that ST PHEN AM S
NZBA C, the Testator, and b9 T , ,.
and p~`lh ~~(. t-Sco/ ,the witnesses, whose mes a signed th a ched and
foregoing instrument and whose signatures appear below, having appeared before me and wing first
been duly sworn, each of them declared to me that (1) the attached and foregoing instrument is the last
Will of the testator; (Z) the testator willingly and voluntarily declared, signed and executed the Will in the
presence of the witnesses; (3) the witnesses signed the Will upon the request of the testator and in the
presence of each other; (4) to the best knowledge of each witness, the testator was, at the time of signing,
of the age of majority (or otherwise legally competent to make a Will), of sound mind and memory, and
under no constraint or undue influence; and (5) each witness was and is competent and of proper age to
witness a Will.
(Witness)
(Witness)
,,/yam
vV `~ ~- ~Witn Peck
Subscribed and sworn before me by that STEPHEN AMBROSE NZBASIC, the testator, who is
personally known to be or who has produced a J ~Y~ ~ ~ LJ C.`UJS~., as identification, and by
a1 ~~1C1~ , a witness who is personally known to me or who has rodu ed a
~L~,~~ ~ yE` J~,¢'~ , as identification, and by
,a
witness who is personally Jk~>nown to me or who has prod ced a
as identification, and b r ~;r~ tea.
Y O .L~ T ~ SGo ~ , a witness who is personally known to me or
who has produced a ~ r ~'U~r' %~~ f e ~~ ~ da of
as identification, this y
Dec~e--Ml~r ,Zoos.
COMMONWEALTh1 tJP PENNSYLVANIA
Notarial Seal
Courtney L Keefer, Notary Public
Notary Publi Royalton 13oro, Dauphin County
My Comrrtission Expires July 6, 2010
Member, Pennsylvania Association of Notaries
Page 4 of 4
Stephen A. Juzbasic:
Witness #1 initials:
Witness #2 initials:
Witness #3 initials: