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PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF- C, MIno ji2 OJ COUNTY, PE-N,"NSYLVANIA
Petitioner(s) named below. who is;"are 1? ears : f a-ge or older, apply(ies) fcr Letters as specified below.. and is
support thereof aver(s) the follow:n and respectfully request(s) the grant of Letters in the appropriate form.:
Decedent's Information 11 ll((~~
Name: ~Ir~19QC n?~ L File No: ~A
a/k'a: (Assigned by Register)
a/k/a:
a/k/a: Social Security No:
Date of Death: -Tlsi/D41=) Age at death:
Decedent was domiciled at death in Cumw County, "'Ji G, (state) with his/her last
principal residence at qy0 (,1,,(~i,f n, 4 &1P0 = ~'nrvt Carlisle , S„cti-1n 9'ni lckn
Street address, Post Office and Zip Code City, Township or Borough County
Decedent died at 1r(;r(i&lQ iZQ! ;once (Y A, naO, Cfr Cnrll<IQ C=Wanj PA
Street address, Pos ffice 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 $ Woo nn
If not domiciled in Pennsylvania Personal property in Pennsylvania $ _
If not domiciled in Pennsylvania Personal property in County
$
Value of real estate in Pennsylvania $
TOTAL ESTIMATED VALUE.... C 4
Real estate in Pennsylvania situated at: WA
(Attach additional sheets, ifnecessary) 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.) p
N ~~ryry
Except as follows: after the execution of the instrument(s) offered for probate Decedent did not marry, was no ed, was n6n pa"?"O gLroding
divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 332 did nol4ve a n or
adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person.
r-r rz-i
❑ NO EXCEPTIONS E] EXCEPTIONS C/)
B. Petition for Grant of Letters of Administration (If applicable) C:]"; =lc
c.t.a., d.b.n., d.b.n.c.t.a., pendente lite,~l truxte absenWduru ' itute
If Administration, c.t.a. or d.b.n.c.t.a., enter date of Will in Section A above and complete list (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.
JZNO EXCEPTIONS ❑ 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 Relationship Address
♦ I 7056
7
r
Form aw-02 rev. 101112011 Page I of 2 ~ylt~
Oath of Personal Representative Official Use Only
COMMONWEALTH OF PENNSYLVANIA }
} SS:
COUNTY OF C~YY1 ^~Q yt }
Petitioner(s) Printed Name Petitioner(s) Printed Address
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, die Petitions ) ill well and truly administer the estate according to law.
Sworn to or affirmed a subscribed before ~ Date 61 ~Q,
me_ d yofDate
By Date
For the Register Date
BOND Required: [DYES F~NO To the Register of Wills:
FEES: Please enter my appearance by my signature below:
i L~`C1
Letters $ ~ Attorney Signature:
( ) Short Certificate(s)..... .
( ) Renunciation(s).........
( ) Codicil(s) 0 iv
( ) Affidavit(s)............ -_rn 4-5
Bond Printed Name: r- C 3
Commission Supreme Court r~ + j
Other ID Number:
G -0
Firm Name: Address: Phone:
Automation Fee Fax:
JCS Fee . Email:
TOTAL $
ppryR tt DECREE OF THE REGISTER
Estate of I~ LL File No:
a/k/a:
AND NOW, _ ,5C, in co si eration of the foregoing Petition,
satisfactory proof having been presented before me, IT IS DECREED that Letters -Adn'o
are hereby granted to iQ pjin C7
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.
Register of Will A
Form RPV-02 rev. 10/11/2011 j1 Page 2 of 2
11105_W( Rf'V rC11
LOCRkJEGISTRAR'S CERTIFICATION OF DEATH
WAR 59 @iReEt@iuplicate this copy by photostat or photograph.
REG+
Fee for this certificate, S6.00 to ce)tik that the information here oiven is
SE P 24 P11 3~ a ~;N 5Fp„))telly Cop)ed from an original Certificate of Death
d
\t;IA filcd
30 with me as Local Re Llurar. The original
cellihcatc will he l~)nearded to the State Vital
ftecOrds Olt)ce liar permanent filing.
ORP HIM
"OURT
P 1888238Btvo
CO., PA SO 16/2012
Certification Number
~ Lodi Rcg?strar Date Issued
4 Type/Print In COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS
Permanent
Black Ink CERTIFICATE OF DEATH State File Number:
1. Decedent's Legal Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number 4. Date of Death (MO/Day/Vr) (Spell Mot
MICHA
EL P. DEGRACE 218-64-0566 Sept 1h( 2012
5a. Age-Las[ Birthday (Vrs) 5b. Under 1 Year Male 5c. Under 1 Da 6. Date of Birth (MO/Day/Year) (Spell Month) 7a. Btrthp lace (City and State or Foreign Country)
59 Months Days Hours Minutes Dec 8, 1952 Baltimore MD
_=L 7b. Birthplace (County)
8a. Residence (State or Foreign Country) So. Residence (Street and Number - Include Apt No.) Sc. Did Decedent Live in a Township?
Penns Ivania 940 Wa oad
lnut Bottom Road as, decedent lived in South Middleton
8d. Residence (County) a twp.
Cumb er 1 and Se. Residence (Zip Code) 1 7 5 No, decedent lived within limits of city/boro.
9. Ever in US Armed Forces? 10. Marital Status at Time of Death M Married 0 Widowed 11. Surviving Spouse's Name (If wife, give name prior to first marriage)
Yes :93M. D Unknown 0 Divorced 0 Never Married D Unknown Vera Chapma
O n
12. Father's Name (First, Middle, Last, Suffix) 13. Mother's Name Prior to First Marriage (First, Middle, Last)
August Gonsalves DeGrace ertha Nawlnn
14a. Informant's Name 14 b. Relationship to Decedent 14c. Inform Y. ant's MelliBng Adtlress (Street and N aumber, City, State, Zip Code)
0
Shy DeGrace Daughter 1557 Spratle,y Road Richmond VA 23228
G
..............................:........15a. P ace o Deat... _ _ _
pre
e1 pn
s If Death Occurred in a Hos ital: ~ -
p ~ Inpatient ; If Death Occurred Somewhere Other Than a Hos ital: p
E ergencyR o.-/Outpatient tv LJ Decedent's Home
0
m 0 Dead on Arrival _ Nursing Home/Long-Term Care Facility Other (Specify)
qe 156. Facty Name (If not insti[utlon, give street and number; SSc. City or Town, State, and Zip Co.. 15d. County of Death
Carlisle Regional Medical Center Carlisle, Pa 17015 - Ctxnberland
16a. Method of Disposition 0 Burial ® Cremation 16b. Date of Disposition 16c. Place of DISPOSItion (Name of cemetery, crematory, or other place)
E3 Removal from State E3 DDnatlon
O Sa t 17, 2012
Other (Specify) p Ctmlberland Crematory Tsr
16d. Location of Disposition (City or Town, State, and 21p) 17a. Signatu Funeral Serv a Lice or Person In Charge of Interment 17b. License Number
Carlisle, Pa 17013 F_ 012909 L
0 17c. Name and Complete Address of Funeral Facility
R^^~ Funeral Home 255 York Road Carlisle, PA 17013
o4i 18. Decedent's Education
- Check the box that best describes the 19. Decedent of Hispanic Origin - Check the 20. Decedent's Race - Check ONE OR MORE races to Indicate what
I- highest degree or level of school completed at the time of death. box that best describes whether the decedent the decedent considered himself or herself to be.
0 ath grade or less is Spanish/Hispanic/Latino. Check the "No' 0 White
No dl l h 0 Korean
p oma, 9th - 12th grade box , decedent is not Spanish/Hispanic/La21no. ack or African American Vietnamese
~-ii igh scool graduate or GED completed o, not Spanish/Hispanic/Latino 0 American Indian or Alaska Native 0 Other Asian
0 Some college credit, but no degree 0 Vey, Mexican, Mexican American, Chicano 0 Asian Indian Native Hawaiian
0 Associate degree (e.g. AA, AS) 0 Yes, Puerto Rican
0 Bachelor's degree (e.g. BA, AB, BS) E-3 Yes, Cuban O Chinese 0 Guamanian or Champ—
0 Filipino 0 Samoan
0 Master's degree (e.g. MA, MS, MEng, MEd, MSW, MBA) Yes, other Spanish/Hispanic/Latino E3 Japanese 0 Other Pacific Islander
Doctorate (e.g. PhD, EdD) or Professi onat degree (Specify) E3 Other (Specify)
. MD, DDS DVM LLB JD
21. Decedent's Single Race Self-Designation - Check ONLY ONE to Indicate what the decedent considered himself or herself to be. 22a. Decedent's Usual Occupation - Indicate type of work
0 Japanese Samoan done during most of working life. DO NOT USE RETIRED.
~-01ack or African American 0 Korean 0 Other Pacific Islander
0 American Indian or Alaska Native 0 Vietnamese 0 Don't Know/Not Sure 11L11Qiown
0 Asian Indian 0 Other Asian 0 Refused 22b. Kind of Business/Industry
E3 Chinese Native Hawaiian 0 Other (Specify)
0 Filipino 0 Guamanian or Chamorro t1T1known
ITEMS 231 -WH hiO MUS PRONOT BE CO NOEMPLETED 23a. Date Prono ed Dead (Mo Day Vr) 23b. Sign afu re of Perso
PERSON n Pronouncing Death ly when applicable 231. License Number
CERTIFIES S OR p•
CERTIFIES DEATH c
23d. Date Signed (MO/Day/Vr) 24. Time of Death
9li 3 /2611 7 - C ^ r f 25. Was Medical Examiner or Coroner Contacted? 0 Yes ~No
CAUSE OF DEATH
26. Part 1. Enter the chain of event diseases, injuries, or complications--that direct) Approximate
s irato directly caused the death. DO NOT enter terminal events such as cardiac arrest Interval:
re p ry arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines If necessary Onset to Death
IMMEDIATE CAVSE a. _ S S /HOC LG
(Final disease or condition Due to (or as a consequence of):
resulting in death)
b. Pw~ v~to~v/,e
Sequentially list conditions, Due to (o as a co nsequ nce of):
if any, leading to the cause
tilled Zr, line a. Enter the -T2 7-
U--- e/~,~-~ r iGiC~
RLYING CAUSE
(disease or injury that Due to (or as a consequence of):
F initiated the events resulting d.
in death) LAST. Due to (or as a consequence of):
aZ5 26. Part It. Enter other significant tiqU, contributing t death but not resulting in the underlying cause given in Part 1 27. Was an autopsy performed?
M O ves
m n l ~9-S Ti9-- i i ~ ~i /3/20.S;d-/L Cni°i.S- 28. Were autopsy flnd~ s a arable
e to complete the cause of death?
u 29. If Female: 0 Yes 0 No
30. Did Tobacco Use Contribute to Death? 31. Manner of Death
E 0 Not pregnant within past year 0 Yes 0 Probably 0 Natural Homicide
E Pregnant at time of death 0 No E:3 Unknown
0 Not pregnant, but pregnant within 42 days of death 0 Accident 0 Pending Investigation
<N 1 t- 0 Not pregnant, but pregnant 43 days to 1 year before death 32. Data of in"u 0 Suicide 0 Could not be determined
cl- 0 Unknown If pregnant within the past year 1 ry (MO/Day/V r) (Spell Month)
33. Time of Injury
sv 34. Place of Injury (e.g. home; construction site; farm; school) S. Location of Injury (Street and Number, City, State, Zip Code)
36. Injury at Work 137. If Transportation Injury, Specify: 38. Describe How Injury Occurred:
0 Yes 0 Driver/Operator 0 Pedestrian
0 No 0 Passenger 0 Other (Specify)
39a. Certifler (Check only one):
0 rtifying physician - To the best of my knowledge, death occurred due to the cause(s) and manner stated
~B Pronouncing g. Certifying physician - To the best of my knowledge, death occurred at the time, date, and place, and due to the --(s) and manner stated
0 Medical Examiner/Coroner - 0, the basis of a in and/or investigation, In my opinion, death occurred at the time, date, and place, and due to the se(s) and manner stated
Signature of certifier- /f Title of certifier- License Number::0 O 7y3L2- -L
39b. Name, Address and Zip Cude of Person Completing Cause of Death (Ite 26) 39c. Data
51 d ( /Day/Vr)
,vim/ u sL rvi rEcc~/~ t~~ 3~j a<EX s~vL~YL_ ~i12i jL. ~V c s,PG /scF 6'e / 70/S-
`3 / 3 20/ Z
40. Registrar's District Number 41. Registra nar- ~ 42. Registrar File Data Day r)
k _ O l~!
43. Amendments
_O
Disposition Permit No. c> a REV V 0 077/20
/2011