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HomeMy WebLinkAbout11-16-12r~ :. ~. ~ ~~ PETITION FOR GRANT OF LETTERS _~ -:'-: °~= REGISTER OF WILLS OF COUNTY, PENNSY~~~INIA ~' _,,-. `-,~ Ea Petitioner(s) mined below, who is~'are 18 years of age or older, apply(ies) for Letters as sec-used belo support thereof aver(s) the following and respectfully requests j the grant of Letters in the approp~te'form: •• Decedent's Information Name: `" t:.s~ L'li' ~~~~~~~~~I~ a/k/a: a/k/a: _ Date of Death: (?~`/--- ~~ - ~~ /,,~ Decedent was domiciled at death in _ (~ U M „~ ~~ ~. ~ to C~ County, principal residence at ~ ~ tJ vV ~ u ~ t~ S ~ ~ /~ ~ rv -R- t ; ~-~ -T-; ~r~ ~J .- . _. ... r ~ and ~i ~ `a t~.~;rr ~_~ C7 -rz / L" File No: ~~ ~~ ~ --~ (,~ '~-~- (Assigned by Register) Social Security No: _.~,;~~ °~ ~~ - C1 ~ ~~` Age at death: {~,,~ (stare) wit 1 her last _~~ m L ~ ~r~r~ol Street address, Post Offi and Zip Code City, Township or Borough County Decedent died at~,~.j~~~R ~1>~~f-. ~t-~rs. j7 ~ jq ~~-f~rs ~'~~~.~! ~/~ Street address, Post Office and Zip Code City, Township or Borough ~ ounty State Estimate of value of decedent's property at death: If domiciled in Pennsylvania ............................ All personal property $ ~~ C (; ~ (,; ., ~'C> If not domiciled in Pennsylvania ........................ Personal property in Pennsylvania $ If not domiciled in Pennsy!vania ........................ Personal property in County $ Value of real estate in Pennsylvania ......................................................... $ ;,~(~, .CCU`- . C~C• TOTAL ESTIMATED VALUE.... $~ C;~,(,~ , G Real estate in Pennsylvania situated at: / I - ' `' ~~ ~ U _ 'r r~ ~ r ~,~ L ~ ~ /~ l~~ (Attach additional sheets, i/'necessary.) Street address, Pos ffice and Zip Code City, Township or ough 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 relevant circumstances (e.g. renunciation, deat/t 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. ^ NO EXCEPTIONS ^ 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 minoritute If Administration, c.t.a. ord.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. ,~NO EXCEPTIONS ^ EXCEPTIONS Petitioner(s), after a proper search has/have ascertained that Decedent left no W ill and was survived by the following spouse (if any) and heirs (attach additional sheets, if necessary): Name Relationshi Address ~ i .L ~ ~. U. / ~ I -S' Fo,-n,nwnz ,~ev.lnill,znll `,~+ , . ~~~ -1) ,~ ;,~ Page 1 of ~ Oath of Personal Representative CONI~IONWEALTH OF PENNSYLVANIA COC'~T`,~ OF } SS. ,, Official list Only ~ `µ ~M' .z.'T i. .'...~ _ .. _+i..w I ~ l ..,... __. t -J ~ I t ~._ _. .~ _. ~; iti~_~ ~._.. ~ ?e:i.ion;:Isl ?r.nted dame a,r:- ~ _ t 1 .. <<~onerls} P,ii~te~ _~curess ._., .: "`T7 +:± N r! l~ - +rLC.~ 1 ~G, , ~ 1 tif: /~ - lG'S~" ~.~`.:.~ ~ U,S;~f' N ~~ ~; -~_°i ~, r...~ `~ 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 t11at, as Personal Representative(s) of the Dece eut, the Petitioner(s) will well and truly administer the estate according to law. . ." Sworn to or affirmed a subsc ibed before Date %- ~~ met is t~i~ of ~ ~~ ~~~ ~~ Y ~~4~G~~ Date By: ~-` Date o til,~ Register Date BOND Required: ~ YES ~ NO FEES: Letters ...................... $ ~,~1• C ,. ( r~) Short Certificate(s)...... ~ ~'~' ( f )Renunciation(s)......... • 4' ~' ( )Codicil(s) ............ . ( )Affidavit(s)........... . Bond ........................ Commission ................. . Other .....,., Automation Fee ............... ~.~:3 C~ JCS Fee . .................... ~" .C~` TOTAL ..................... $ ~_ To the Register of Wills: 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 ~ L~lCY7 (';~.. ~~). ~ (I 6 l /~,~~~ File No: ~. ~ ~ ~, a/lc/a: AND NOW, '~ ~ ~ ~ in consideration of the foregoing Petition, satisfactory proof having been presented before me, IT IS ECREED tha etters ~, are hereby granted to ~' j" in the above estate and (if applicable) that the instrument(s) dated described in the Petition be admitted to probate and filed of record the last W' 1(and Codicil(s)) f Decedent. gister of Wills Form RGt%-0? rev. !0/I1/201 / ~ ~~ H105.905 REV.(S/11) ~~ / _. _ ~ ~ ~~ This is to certi/fy tat this is a true copy of the record which is on file in the Pennsylvania Department of Health, in accordance with the Vital Statistics Law of 1953, as amended. ! i _ ,: (GARNtNC: It his !it~egal to duplicate this copy by photostat or photograph. . _ ;~~.; . t.~ ~ I. 9 .i Y S V # LIr f ~- ,.. r ' , ` ( . T J pp r U~~I'',•`. ~'~ ~ '~~,~r~ n. t ~~i , ~..'~ .~,. Y~ ~~6~~ ~~ Marina O'Reilly Matthew State Registrar ~~~' 1 1 ZD1.~ No. Type/Print In Permanent Black Ink =V\/ (~~ r 0 c c Q F n `a E n L u c C Date COMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF HEALTH ~ VI7AL RECORDS _..._. C'FRTIFICATE C7F [7EATH ~____ _.,_ _, _.___ ~C~ S~~c7 1. Decedent's Legai Name (First, Middle, La t, Suffix) 2. Sex 3_ Social Security Number 4. Date cf Death (MO/Day/Yr) (Spell Mo) ~- r/1 t/5 ) r , .; ©6 ~ '^f 5 c>, ~~a t_E _c~` -3 ~ - d ~ 9 .~ ~~(y s, 20~ 2 Sa. Age-Last Birthday (Yrs) Sb. Under 1 Year Sc. Under 1 Day 6. Date of Birth (Mo/Day/Year) (Spell Month) 7a~i77rthplace (City and Staie~or Foreign Country) / Months Days Hours Minutes S'C~ +~ G7~b , '~- / (~ ~!~ ~j ~~, ~~~ (-~ ~___~? I r,/~E"O 7b. Bi r[h place (County) ~..-L_~I rY'-~ Sa. Residence (State or Foreign Country) 86_ Residence (Street and Number- Include Apt No.) 8c_ D d Decedent Live in a Township? /~ ~ ESN ~ ~!' L_~/~ t __ /' Ves, decedent lived in ~---~~~ i~F~L_ ~ ~-i.L-.1-~ /~/ twp. Sd. Residence (County) ~ C__o ~J vY.~_~~ ~2r v F v ^1 ~ ~Q--c....~~N~ 8e. Residence (Zip Code) ~ ~l ° ~ ~ Q No, decedent lived within limits of city/boro. 9. Ever in US Armed Forces? 10. Marital Status at Time of Death ~ Married ~ Widowed 11. Surviving Spouse's Name (Ifi wife, give name prior io first marriage) 'Yes [] No ~ Unkn wn ~ Divorced [~, Never Married [] Unknow ast, Suffix) L 12. Father's Name (First, Midd e, 13- Mother's Name Prior to First Marriage (First, Middle, Last) ~ l ~ L • v \ _ ~ r T' ~l mil' ~.i ~~ ~ c~.'ZM P. ' 1 146. Relationship to Decedent 14 Informant's Name 14c. Informant's Mailing Address (S t re let and Number, City, State, Zip ^Co~de) 0 ,~ ~ ~`~/ ~. •v ! " \ t ~L--E2, r--\ P tis . ~ . ~ , ~' Co ~f w~~ ^ vY Ec_L- t~s~! < <,~13t 9 r i ~cs5_ G lSa. Place ofi Death Check onl one) __ _ _ _ _ - ----. - . . _ - - ... - ---..----- .. . ------ --------------------- ------ "' If Death Occurred In a Hospital: ~ Inpatient = P If Death Occurred Somewhere Other Than a Hospital: [~ F-los ice Fa cllity ~ Decedent's Home '° f Q Emergency Room/Outpatient ~ Dead on Arrival _ ~ Nursing Home/1_ong-Term Care Facility Other (Specify) Boat In_m_ arlna _ _ __ s 156. Facility Name (If not institution, give street and number) SSc. City or Town, State, and Zip Code ].Sd. County of Death 360 Water St Etters PA 17319 York - 16a. Method of Disposition '~ Burial ~ Cremation 16b. Date of Disposition 16c. Place of Disposition (Name of cemetery, crematory, or other place) CO <c ~ Removal from State ~ Donation ~ Other (Specify) _ /L~ ~~ 2312 - ~~ "~~--~-5~ i _ - ~l`~1~T~2 16d_ Location of Disposition (City or Town, State, and Zip) 17a. Signature of Funeral Service Licensee or Person in Charge of Interment 17b_ License Num r v r'/~ta2 ~ a .J t -.,~-~, ~1 ~ _ ~ L. 8 4 1 ~ "~~ o r •Z9 4-t - ~ ~ iv 17 Name and Com1pl ete Address of Funeral Facilit / _ _ ~fll~~}---+V E~-~ ~n~ E=2d L_ ~ r--.-SLlMR-. o,_,-~ 5CfL_lJ/ L/~r __L r~7 G ~ L-> n-j4~C 1 C~c: 1--10 w4^L.7 ~q_ L !e ofi ~-li m 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 r- highest degree or level of school completed at the time of death. box ihaC best describes whether the decedent the decedent considered himself or herself co be. r~ 8th grade or less is Spanish/Hispanic/Latino. Check the "No" ~ White CJ Korean No diploma, 9th - 12th grade box if decedent is not Spanish/Hispanic/Latino. ~ Black or African American ~ Vietnamese '® High school graduate or GED completed ~, No, not Spanish/Hispanic/Latino. Q American Indian or Alaska Native ~ Other As:an Q Some college credit, but no degree [] Yes, Mexican, Mexican American, Chicano ~ Asian Indian 0 Native Hawaiian ~ Associate degree (e.g. AA, AS) ~ Ves, Puerto Rican ~ Chinese Q Guamanian or Cham orro Bachelor's degree (e.g. BA, AB, BS) ~ Yes, Cuban ~ Filipino ~ Samoan 0 Master's degree (e. g. MA, MS, MEng, MEd, MSW, MBA) ~ Yes, other Spanish/Hispanic/Latino Q Japanese Q Other Pacific Islander ~ Doctorate (e. g. PhD, EdD) or Professional degree (Specify) ~ Other (Specify) (e. MD, DDS, DV M, 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 lJSUaI Occupation -Indicate type of work S White Q Japanese ~ Sarn oan done during most of working life. DO NO-1" USE RETIRED. ~ Black or African American Q Korean Q Other Pacific Islander 0 American Indian or Alaska Native ~ Vietnamese ~ Don't Know/Not Surer . ~-Q Q-r2-E LT•C] r~ 5 ~ ~ ~ ~ ~-~E ~- 0 Asian Indian ~ Other Asian ~ Refused 226. Kind of Business/Industry Chinese ~ Native Hawaiian [] O[her (Specify) ~ ,~ ~ I Q Filipino Q Guamanian or Cnamorro E ^ ~ ~ ~N :>=~~1~ ~T~ ~ E ITEMS 23a - 23d MUST BE COMPLETED 23a_ Date Pronounced Dead (Mo/Day/Yr) 236. Signature of Person Pronouncing Death (Gnly when applicable) 23c. License Number BY PERSON WHO PRONOUNCES OR CERTIFIES DEATH JUIy 5, 2012 23d_ Date Signed (Mo/Day/Yr) 24. Time of Death Approximately 2:12 PM 25. Was Medical Exarn in er or Coroner Contacted? ~ Yes ~ No CAUSE OF DEATH Approximate 26_ Part 1. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest, Incerval: respiratory arrest, or ventricular fibrillation without showing the etiology- DO NOT AB BRE VIA rE. Enter only one cause on a lino- Add additional lines if nec:essa ry Onset to Death IMMEDIATE CAUSE --------------> a. Hypertensive atherosclerotic cardiovascular disease 6 unknown (Final disease or condition Due to (or as a co nseq ue ncc of): resulting in death) b. Acute and chronic alcoOholism _ _ ___ Sequentially list conditions, Due to (or as a consequence of): if any, leading to the cause listed on line a. Enter the UNDERLYING CAUSE Due to (or as a consequence of): i th t di sease or njury a ( initiated the events resulting d. "~ in death) LAST. Due to (or as a consequence of): 26. Part 11. Enter other ss~nfficant conditions contributive to death but not resulting in the underlying cause give-n in Part I 27. Was an autopsy performed? p Yes Q No ~ 28. Were autopsy findings available m to complete the cause of death? ~( Ves ~] No 29_ If Female: 30. Did Tobacco LJSe Contribute to Death? 31. Manner of Death a E ~ Not pregnant within past year [~ Yes [] Probably ]g[ Natural [] Homicide v ~ Pregnant at time of death ~( No Q Unknown Q Accident Q Pending investigation Q1 ~ Not pregnant, but pregnant within 42 days of death Q Suicide ~ Could noC be determined ~ 0 Not pregnant, but pregnant 43 days to-1 year before death 32. Date ofi Injury (Mo/C ay/Vr) {Spell Month) _ ~ Unknown If pregnant wlchln the past year 33. Time of Injury 34. Place of Injury (e.g. home; construction site; fiarm; school) 35. Location of Injury (Street and Number, City, State, Zip Code) 36_ Injury at Work 37. If Transportation Injury, Specify: 38. Describe How Injury Occurred: ~ Yes ~ Driver/Operator ~ Pedestrian Q No ~ Passenger ~ Other (Specify) 39a. Certifier (Check only one): [] Certifying physician - To the best of my knowledge, death occurred due to the cause(s) and manner seated Pronouncing g. Certifying physician - To the best of my knowledge, death occurred at the time, date, and place, and duo to the cause(s) and manner stated ination, and/or investigation, in my opinion, death occurred at the time, date, and Glace, and due to the cause(s) and manner stated m $[ Medical Examiner/Corn r - On the basis of exa / /~j Signature of certifier: / C-L ~ Title of certifier: Deputy COrOner license Nurn ber: _ 396. Name, Address and Zip Code of Person Completing Ca of Death (Item 26) 39c. Date Signed (MO/Day/Yr) Stephen Cosey 118 Pleasant Acres Rd, York, A 17402 August 13, 2012 40. Registrar's District Number 4 istra is Signature 42. Registrar File Date (MO/D ay/Yr) / <f =/~ _ flu - ~! ~a~ ~~ 43. Amendments ~_ ~.1,' 11 ].US-145 D':sPUSltion 1'errn it l~: o.__~! ,~~~,l-f=__LL--_-__-_. _. ttEV 07/201.1 H105905 REV.(8/11) _ -- '~j ~' L' This is to certify tha'E th~s i~ rue copy of the record which is on file in the Pennsylvania Department of Health, in accordance with the Vital Statistics Law of 1953, as amended. WARNING: -~i~ i~fa~_ to 'tf#X{~I ,~cate this copy by photostat or photograph. ir.; _ ,,, , ~ ~ R ~ e f ~ .- C~~r 1 ~~~ ~ ~~'`~ No. Marina O'Reilly Matthew State Registrar NOV062012 Date H105.1t3Rev.O1106 COMMONWEALTH OF PENNSYLVANIA ~ DEPARTMENT OF HEALTH ~ VITAL RECORDS 030955 TYPIJPRINTIN PEFMANENT CERTIFICATE OF DEATH STATE FILE NUMBER RL4CK INK w Q C ~/ 6 T ` z w Y U -~ D ~ O w Q 1. Name of Decedent {First, middle, last) 2. Sez 3. Social Security Number 4. Dale of Death (Month, day, year) ~oara~5 t1~ f~a~~.15~r~ M,1~, 1 (~ - ©7 - `1521 M%a,~~K 29 2oaC, 5. Age (Last binhday) 6. Under 1 ear Under 1 da 7. Dale of Binh Month, da , ear 6. Birth lace C and slate or bre' n count 8a. Place of Death Check on one 9 ~ Yrs. Months Days Hours Minutes ~ ~T ~ 1 r t~~- E ~ ~ ~Z, Hospflal: ^ In anent ^ ERIOut client ^ DOA Other. II l~Nursin Home ^ Residence ^ Other • S a . - 8b. County of Death &. City, Boro, Twp. of Death 8d. Facility Name (II not ins dutbn, give street and number) 9. Was Decedent of Hispanic Origin? 10. Race: American Indian, Black, While, etc. ' ^ No C7~Yes (II yes, speciry Cuban, (Specify) ~~%.1T2F ~~0-1..~~G.J'TF ~~N~"2E ~2~~`T ~J~-1nJl ~Cr.w Mexican, Puerto Rican, etc.) ~1^1r~`C= ;, 11. Decedent'a Usual Occu alion Kind of work done Burin most of workin life; do not slate retired 12. Was Decedent ever in the US 13. Decedent's Educalron S eci on hi hest rode co feted 14. Martial Slalus: Married, Never married, 15. Surviving Spouse (If wife, give maiden name) Kind o(Work `` Kind of Businessnnduslry Armed Forces? Elementary/Seco dory (0-12) College (1-4 or 5+) ~2rrt %ez~ Cd'Yes ^ No `~. Widowed, Divorced (Specif17 ~4carL~~- p~ "'~A ~410H..i 1..0¢M~,J 16. Decedent's Mailing Address (Slreel cAyAown, stale, zip code) Decedent's Did Decedent ?,~ , ~J ~ L Q ~ Actual Residence t7a. Slate~~ ~J'J ~ ; Lv nwi0 Live in a 17c. ^ Yes, Decedent Lived in Twp. }--) p~ 7 (1~ ~ ~ Townshp? 17d. fd~ No, Decedent Lived wkhin 1 ~ 17b County ~ C-N~2t " G , . 1 ~ ~ . Actual Limits of _ Y t wq2~ ~ily/Boro I 16. Father's Na me (Firs(, middle, last) 19. Mother's Name (First, middle, maiden surname) / 20a. Informant's Name (fype/prinl) 20b. Informant's Mailing Pddress (Slreel, cityAown, state, zip erode) ~'~7 ~ 2 `'t' ~ ~ d ~ l ray S ~ ~r ~l O w~2'J ~, I, L ~ 4 I 21a. Method of Disposition ^ B i l ~C 21b. Dale of Daposflion (Month, day, year) 21c. Place of Daposil'an (Name o cemetery, crematory or other place) 21d. Location (CityAown, stale, zip code) ur a rematan ^ Renaval hom Stale ^ Danatbn ^ Olher•Specity: L ~'-•~QC../` 2..O~r,, ,~y~ ;` IOQ~~2~1'~'I~~JT~C~ iLl1 ~U~vK'~~ t-f0'~ ~...OGk ~--l4vE^v,~A,~~~1~{S 22a. Signature of Funeral Service Licensee (or person acting as such) 22b. License Nu er 22c. Name and Address of Facility ~f r ,, p 1 .~'17G119U"l-~ W~•~U3~~''VC~F ~N~~.'-l~ ~.O.PJp,CIa'~ +tow,ar~~lk l6 ~l1 M .. Compfele Items 23a-c only when certifying 23a. T the best of my knowledge, death o rred al the lime, dale and place staled. (Signature and title) 23b. License Number 23c. Dale Signed (Month, day, year) r phys~ ion a not available al lime of death to / ~ ~ ~ ~r 1 ~IL~ 1 ~ ~ ~ o Q cerli cause of death. ~ ~- 0 f ~ „ ! ~ '~/'1 ~ / ` ` • l v r l Items 24-26 must be completed by person who pronounces death. 24. Time of Death ^ 25. D e P al d (M rooounced DeQa onlh , day(,~year) `~ ^ U 26. y M s Case Referred to a Medical FxanunerlCoroner? 1!/~'~1 ` C ~ O M ~~`J IjJ ~ Y~G ~ ., ~ I Oc ~ O iYC.~C.v +, ~ ,,'l ~ , / Yes Jib No CAUSE OF DEATH (See Instructions and examples) ~ Approximate interval: Part II: Enter other significant conditions conlributine to death, 2B. DM Tobacco Use Contribute to Death? Item 27. Part I: Enter the chain of events -diseases, injuries, or compliatbns -that directty caused the death. DO NOT enter terminal events such as cardiac arrest, ~ onset to death but not resulting in the undertying cause given in Part I. ^ Yes '~,`Probabty respiratory arrest, or ventricular fibrillalbn without showing the eliobgy. DO NOT abbreviate. Enter Doty one cause on a line. ^ No ^ Unknown IMMEDIATE CAUSE (Final disease or ~` ~ ~ ~ ~ ~ /~(G!~(C ' `~--~ ^lW~° 29. I(Female: condilbnresullingindealh) --j a• l. ~ - ~ ~1 ^ N l t ithi t Due to (or as a consequence of): ~ year o pregnan w n pas Sequenlialry tat condltions, it any, b n l di t th li d Li ~ ~ C C~/ydlGh'~ ~ d~„d{ ^ Pregnant al time of death ithi 42 d ^ N l t b t t ea ng o e cause ste on ne a. Due to (or as a consequence off: c pregnan pregnan n o , u w ays Enter the UNDERLYING CAUSE ~ ~ ~ ~ l ~ ~ of death (disease or injury Ihal inltialed the c. ~ S r ~" ~ ~ ~ `~ but pregnant 43 days l01 year ^ Nol pregnant events resulting in death) LAST. Due to (or as a consequence oQ: ~ , before death d. • ^ Unknown if pregnant within the past year 30a. Was an Autopsy 30b. Were Autopsy Findings 31. Manner of Death 32a. Dale of Injury (Month, day, year) 32b. Describe how Injury Occurred: 32c. Place of Injury: Home, Farm, Slreel, Factory, Office Performed? Available Prar to Completion Natural ^ Hom~de Building, etc. (Specil~ ^ Yes ~No of Cause of Death? ^ Y ^ N ^ Accident ^ Pending Investigalbn es o ^ Suicide ^ Could Not Be Determined 32d. Tune of Injury 32e. Injury at Work? 32f. If TransporWl'an Injury (Specif}~ 32g. Location (SUeel, cityllown, slate) ^ Yes ^ No ^ DriverlOperator ^ Passenger M, ^ Pedestrian ^ Other-Spedly. 33a. Certifier (check only one) 33b. Sign ure nd T le of Certifier ' Certifying physician (Physician certiying cause of death when another physician has pronounced death and completed Item 23) , ~ i1~ V~'''~ To the best of my knowledge, death occurred due to the cause(s) and manner as stated......_.._..........._..............._........__..........._........._._........_.........._ ......................~ ' Pronouncing and certifying physician (Physician both pronouncing death and cerlitying to cause of death) To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner as stated .............._........._......._........_............_. _. ...^ 33c. License Number ~ n ~ D V7 ~ ~ L 33d. Date Signed (M nth, da , ear y y ) ' ~ ' Medical examinerlcoroner " - >~ On the basis of examination andlor fnvrsligation, fn my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner as stated.........^ 34. Name and Address of Pers~ ho Completed Cau;e o[D ap th (Item 27) Typ rin ~-- 35. gisUar's Signature and Dalrict Nu er ~ I ' ~ ~ ~ `~ ~ 36. Date Fled (Month, day, year) ' `''~'~ `T ~ ~ ~~ r k ~~ ~ p ~G~ I • I I - I I ~,,r.3o, apo6 I- ! - S (See instructions and examples on reverse) ~~ ~:~~ - ::~ ,~ .--. ~~' : - _ V ~., ~ . ~ . ~ .J ^ _. _ : ~ - . T3 ' h ~:.r? Q ? (era RENUNCIATION REGISTER OF WILLS CUMBERLAND COUNTY, PENNSYLVANIA __ , ~: {--~ _ rv -, .. r~.~ ~~ -.i_- -r--~ _a - : -, _. _~ _ ...__. -- ....._ ~°- :., ,- ,~: _. ~f, ._ ,, t ~.:~ _. L,: _J ~ _ ,, -_ .. ~ ~, J ~j ~ 4 ~~ G^' ~ Estate of JAMES WILLIAM ROBINSON aIk/a JAMES W. ROBINSON ,Deceased I, KATHRYN M. ROBINSON , in my capacity/relationship as (Print Name) the mother of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to GWEN D. MILLER ~ r ~~ r t e (Rte) (~ ) Executed in Register's Office Sworn to or affirmed and subscribed before me this day of , Deputy for Register of Wills 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 purposed stated within on this ~ ~~~ day Notary Public My Commission Expires: c~ ~~,~ S- (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission.) COMMONWEALTH OF PENNSYLVANIA Form RW-06 rev. 10.13.06 (Street Address) ^ / ~~,~ ~eol ~ ~~~~ (City, State, Zip) Not~a+ial Seal Dak Anr~esen, Notary Public Beech Creek 8oro, GHnton County My Commissbn Expires Sept. 26, 2015 MEMBER> PENNSYLVANIA ASSOCIATION OF NOTARIES