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PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF CUMBERLAND COUNTY, PENNSVANIA - ~ ;.z;f
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Petitioner(s) named below, who is/are 18 years of age or older, apply(ies) for Letters as `~~ ~~ified berI~tw, acid it
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support thereof aver(s) the following and respectfully request(s) the grant of Letters in the appro~x~te form: ~ . ~ , -~-
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Decedent's Information
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Name: SHAWN M. MISHKIN File No: ~ ` ~~~ _- ~ '
a/k/a: (Assigned by~gister) ~:' ~--- '~'R`
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a/k/a:
a/k/a: Social Security No:
Date of Death: October 30, 2012 Age at death: 43
Decedent was domiciled at death in Cumberland County, pennsvlvania (Stare) with his/her last
principal residence at 816 Sycamore Circle, Borough of Camp Hill, 17011
Street address, Post Office and 'Lip Code City, Township or Borough County
Decedent died at Hershey Medical Center, 500 University Drive, Derrv Township Dauphin PA
Street address, Post Office and Zip Code City, Township or Borough County State
Estimate of value of decedent's property at death:
If domiciled in Pennsylvania ............................All personal property $ 15,000.00
If not domiciled in Pennsylvania ........................Personal property in Pennsylvania $
If not domiciled in Pennsylvania . .......................Personal property in County $
Value of real estate in Pennsylvania ......................................................... $ 5~,~p()_p()
TOTAL ESTIMATED VALUE.... $ 65,000.00
Real estate in Pennsylvania situated at: 816 Sycamore Circle, Borough of Camp Hill, PA 17011 Cumberland
(Attach additional sheets, if necessary.) Street address, Post Office and Zip Code City, Township or Borough 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 and Codicil(s)
thereto dated
State relevant circumstances (e.g. renunciation, death of executor, etc.)
Except as follows: after the execution of the instrument(s) offered for probate Decedent did not marry, 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(g), and did not have a child born or
adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person.
0 NO EXCEPTIONS 0 EXCEPTIONS
/® B. Petition for Grant of Letters of Administration (If applicable)
c.t.a., d.b.n., d.b.n.c.t.a., pendente lite, durante absentia, durante minoritate
If Administration, c.t.a. or d.b.n.c.t.a., enter date of Will in Section A above and complete 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 the victim of a killing nor ever adjudicated an incapacitated person.
Q 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 Relationshi Address
Holly A. Mishkin Spouse 816 Sycamore Circle, Camp Hill, PA 17011
Nadia P. Mishkin Daughter 816 Sycamore Circle, Camp Hill, PA 17011
Form RW-02 rev. ~oilrizoll Page 1 of 2
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Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
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Official Use Only
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Petitioner(s) Printed Name Petitioner(s) Printed Address ~ ;=- ~~-~
Holl A. Mishkin 816 S camore Circle Cam Hill PA 17011 T~ ~.~ e
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 Decedent, the Petitioner(s) will well and truly administer the estate according to law.
Sworn to r affirmed a subscribed b ore ; •> ~/G~>' ~j ~ ~ ~-~1~.i) Date ,~~ ~ ,a Z
me th's v ~' ~..'~a of ~r/~ ~~°~" , ~~~ ~-- Date
,Y
By: ~- ~ ~~ Date
Register
Date
BOND Required: Q YES Q NO
FEES:
i ~;° ~; 2~
Lette s ...................... $ J•
( ~) Short Certificate(s)...... Clt~
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commission ................. .
Other ........
Automation Fee ............... t'
JCS Fee . ................... .
TOTAL ..................... $ --'6~`-
To the Register of Wills:
Please enter my appearance by my signature below:
Attorney Signature:
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Printed Name: Shelly J. Kunkel, Esq.
Supreme Court
ID Number: 64485
Firm Name:
Address:
717-236-6100
sikunkPl.w~snmindsnrin~ cam
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SCREE OF THE REGISTER
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Estate of SHAWN M. MISHKIN File No: ~, ~ "' ~ ~~ ~ ~ ~ ~i
a/k/a:
____
AND NOW, 1 ~ /`~"•? ~' r ~~ i~ ~ ~ in consideration o
satisfactory proof having been presented before me, IT IS SCREED th Letters ~
are hereby granted to •
in the above estate and (if applicable) that
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the instrument(s) dated
described in the Petition be admitted to probate and filed of , c rd as the last Will
Register of Wills
and Codicil(s)) gf Decedent.
foregoing Petition,,
77 ~ /~~.5 ~~~ G~ ~ ~%1..~
Form RW-02 rev. 10/ll/2011 ~ ~ Page
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COMMON W EALTH OL PENNSYLVANIA • DEPAHTME NT OF HEAITH • VITAL NECON US
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1 Decedent's Legal harne Ifirst, Mioole. Last, Sulf it) Z. Sez 3. Social Security Numbers` a N4' Da[r of Dean IMO/Day/Yr) Spell Mol
Sh
awn ht. Mishkin Male October 30, 2012
Ade La st Bin noay sues) Sb under 1 Year Sc. L, hoer 1 Da - 6. Dale 01 Birth (MO/Dar/Year) ISpell Month) 7a. Birthplace (City anU S[a[e or Foreidn COUm ry7
i 43 Mdntns Day, Hours Minutes July 11
1969
' , ]b. Birthplace (County)
T Ba Nes,ur nee 151 ate or Foreign Co untrvl
~ ' 8b. NesiUence 1St. eet and Number ~ Include Apl Nol
816 S
C Bc. Did Decetlen[ Live in a Township?
^Yes
decedent lived in
sd Ret~drnde lcddnryl ycamore
ir ,
Iwp
y Cumberland ae Nr,drn,elzpcddrl 17 1 ~3ad,de<edemueedwmnrmt:a ('amp~{i l l aty/bdr~
9. Ever n uS awned tore es? 10 Mortal Status at Time of Death rl U ^ W id owed 11. Surv'ving Spouse s Name Ile wile dive n to pr'or to firs[ marr'agr,
^Y
~
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es
no ^Unknown ^ Dvo ceo ^ Never Married
^Unknow
.a i2 f other's Namr 1Fus t, Middle, Last, Su if i vl 1 3. Mother's Name Rr br to First Marriage IFIrS t, MidUle, Lastl
1
= Ica In loan ant s Namr lab. Relation mip to Decedem l
Nolly A Mishkin Wife ac In lorman['s Mailing Adorers 19treet and Number, City, State. Zip Codel
816 S c more Cirl Cam Hill PA 17011
.............. ,. ]6a. Place or Drat (Check only one GPy~
Death O<c ~ d H p ~ ~ ~~~ ~ p ~ ~ ~ II D Ih Occurred Somewhere Other Tha 1 a Hosp Ial. ~~~ U Hospc L Airy ~ ~ ~ ~ ~ ~~~~
[~ Deted ent's Hon e
~ ^ L"red - N n,/~ Ip I t ^ U d n Arr vat ^ Nursing Home/long Term Care Facility Other IS
ecl
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.Sb FarI :y h ,e 11' n n, div er, and ,u hoer, p
y
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lSc. City or Town Stale and Zp Code 16d
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Hershey Medical Center .
ounty o
Death
Derry Twp PA 17033 Dauphin
IG. M.Ir o0 OI UrsposmOn Burial ^ Cre motion 16b Date of Disposlt'lon 1&. Place of Dispdti[ion (Name of cemetery
«em stor
or Ocher
la<e
^ Nrrnu. al prom Star ^ Don
Or ,
y,
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' Otnerlspeo~yl_____ 11/2/x012 Beth El Cemetery
~~ .ru to. al~un er U,s position ICity or town. State, ono Z~pl
~Harrisburg, PA I7a-Signature of Euneral Service Lice nsae Person In Charge of Interment I7b. License Number
FD-138866
.; tic. name ono Complete Andress of Luneral Facility
Hetrick-Bitner Funeral Horne 3125 Walnut St. Harrisbur PA 17109
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' IB. Uece Beni s Educatldn - Check the Doa that best des<rib es [h<
hidne sl Oedrer Or level dl school completed at [ne tune of death.
^ B[^ draur or less 19. Decedent of Hispanic Origin ~ Check the
b0, that best describes whe the! the decetle nt
is Spahtsh/Hispanic/Latino. Check [he "N O" 20. Decedent's Race ~ Check ONE OR MDNE ra es to indicate what
the decedent considered nimsell or nets ell to be
While ^ Korean
^ ho O~ploma, 9;h ~ 17th grade b r it decedent if not Sp anis n/Hispanic/la nno. Black Or AlRCan American ^ Vietnamese
^ High school drag w!e Or GEU com pie teu No, not Spanish/Hispanic/Latino
~ ^ Amencan Indian Or Alaska Native ^ Other Asian
^ SUrne code dr credit, Out no dtdree Y<s, MPaiCa n, Ml~K an AmenC an, Chicano ^ Asian Indian ^ Nativt Hawanan
~assoc~a;e degree led. AT, ASI
~ ^Yes, Puerto Rican ^ Chinese ^ Guamanian or Cnamorr0
^ Barn elor's Oegree Ird dA. AB, BSj ^Yei, Cuban ^ Filipino ^ Sa mO n
a
i ^ Masts is dedree a g. MA, MS, MEng, MEd, MSW, MBAI ^ Yes, ocher Spanish/HlS panic/LdtlnO ^ lapdnese ^ Other
Paci tic lslandrr
' ^ UJC Orate leg VhD. E001 or Profession al Degree
N1U UDS, DVM LLB IDI 15pecifv) ^ Other lSpe«fyl
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71 Ur'eu en;'t Sindle Nace Sell-Uesidnation ~ Check ONIY ONE to indicate what the decedent <oniiaeretl nimsell or herself to be. 22 a. DrceOen is Usual Occupatbn ~ InOicate type OI woes
~l's'^Itr ^ Japanese ^ Samoan tlone during most of working Isle
DO NOT USE RETIRE U
^ Black or AlHCan American ^ Korean ^ Other Pacific Islander .
.
Beta 11
1
^ American Inoldn or Alaska Native ^ VIe [n an,err ~ Don'1 Kndw/Not Sure
' ^ Asian InO~an ^ Omer Asian ^ Refused 22b. Kind of Business/Industry
: ^ cn~nr,e ^ NaryeHawaiian ^ omerl9periryl
^ F,l
n Self-Em to ed
p y
ip i
n ^ Guam nlan or Chamorro
ITEMS 23a ~ 23d MUST BE COM PLE iED
BY PERSON WHO R 23a. Uate Pronouncetl Deatl IMo/Day/Yr) 23b. Sid nature of Person Pronouncing Death (Only when applicable) 23c. license Number
gONOUHCES ON
CERLIL IES DEAiH October 30, 2012
73u Ualr Sig ne0 lMO/Ua y/yrl 2d. Tirne 01 Death _
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?'HJ 25. Was Medical E<aminer or Coroner Contacted? ® Yes ^ NO
CAUSE OF DEATH Apprda n, ate
76 Partl. Lntrrtnecha~nolrv n -d~,rases.inidrlr,,orcornplicat~ons-tn,tdde«lyuu:edmedeam. DoNOrenurlerminaleaantst„rnafordia<a.rest IntrrYal
s
I
I
'
v
I yes Viratory arrest. or ven,ricula
r Il brillation without mowing the e[iO Jody. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional Ilnef II necessary ~ Onset to Deaf
IN,MEDIArE cwsE ...- --.. a Gunshot Wound To Head
IF,r,I msra,r dr condn~dn
Due to jot as a consequence ol).
~. sulbnd ,n ceathj
b
Srqurrt,adv nst cond~nont Dur tD for as a consequence oft. '
nsneu onalm~a ;OEnter inrr
Uh UEN LYING CAUSE Oue Id (or as a consequence oil
.ease r a~.lury may
~^,,,a:ra ~ne ryen;s rrs,.N~nt __
i ~ralhi LA$r Due tU IO! as a cOnfeq tie n(P 01).
_
2 .o Pan 11. En~er other c ~. trb ul ng [ it but n01 yes ultin n [he and I '
Sl: n,ncdnl cdnUrld g i er ying cause given In Pan I
Z]. Was an autopsy pe rformeo?
^ Yes ® No
7
i. I . ra r
30 28. Were aura psv findings availaolr
to mpele [hr cause Ol 0eat11?
cO^ Yes No
F1
^ hue preg na n, wi i n past Yea1
[ Uid lobaccu Use Contribute to Death?
~ Yes ^ Probably 31. Manner of Daath
^ Natural ~ Homicida
^ Vrrdnen r,e
ot uea[n
^ hul Vredna t, bit Vreanant within e2 days of dead ~ NO ^ UnknO wn ^ A[Cid ens ^ Pending In vest soot
~ Suicitle ^ COdld not be Ue[ermrinrU
- ^ not pr ed na nt, b~; Vredna n[ c3 Dsys to 1 seer before dee;f
k
I
^ 32. Dart of Inlury IMO/Da Y/Yrf ISpell Montnf
Un
nown I
prednan; within tnv past veal
October 30, 2012 33. rln,e of In
I~lr 06.03 P
3
r '. V;a:r of in1„ry je d ncrn e, construction site; tarn, school
I
3uslrles's
35_ LOCalwn of Injury IStreet and Number, City, Stale, Zip Codel
4242 Carlisle Pike, Camp Hill, PA 17011
Inlur, at work 37 II Irons po rt a:ion Inlury, Spe«fy. 38-DescNbe How Inlury Oc curred_
^ rrs ^ DrLrr/ovrr,tDr ^ Prdestrl,n Gunshot Wound To Head
® No ^ Passenger ^ Other lSpe«lyl
13
~ 9a Cr r;, Il er I',neck only duel
^ Certi!yind physician l0 the best of my knowledde, death occurretl tlue to the cause lsl and manner stated
^ vronou n«nd & Cer tllyind physl«an To [ne best of my krsowledge, death occurred at the time
tlate
and Dlace
and tlue to the causels) and ma
,
,
,
nner stated
® Mrmcal Eaarnln rr/Coro/,r(~ pn the Dasis~f ekymna tion. and/or investigation, in my opinion, death occurred at the time, date, and place, and due to the ca usels and rna nntr s:atec
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s,dnawn• DI certir,er ~ / %', l ~ ~ (-..-~~ ~~nue of cern6er-_Chie( Deputy License Ndmbrr_
I 3
~ L 9D r.a e. nudre ss anti [.p Code of Person Completing Cause of Deat h~l em 26I
A'P 39c. Date Signed (MO/Uay/Yr)
IBa
onelger, 1271 South 28th Street, Harrisburg, PA 17111 October 31, 2012
0 Nrd~s tea is DIS IrICI NulnDe! a 1. Reg ar's Signature
f ~. / c2 Re '
grstrar File Dale (MO/Day/yr)
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