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HomeMy WebLinkAbout10-19-12c~ cu 4 •t' Z 0 0 Register of Wills of Cumberland County PETITION FOR GRANT OF LETTERS OF ADMINISTRATION Estate of ~~~~ ~~/2!// S'E~~ ~~ also known as Deceased. ~ 5, Social Security No. '- No. ~1 ~~ ~i~\~~~ To: Register of Wills for the County of Cumberland in the Commonwealth of Pennsylvania The petition of the undersigned respectfully represents that: Your petitioner(s), who is/~e`'18 years of age or older, appl ~ ~~ for letters of administration on the estate of (d.b.n.; pendente liter durante absentia; durante minoritate) the above decedent. ~R L ~N ~ C~c ~! /3 r Decedent was domicilNOat death in County, Pennsylvania, with h ~Q last family or principal residence a~~ ~ •~ S %R ~"~'C T ~~ G / , f G ~'~ /dam l-YO/~ (list street, number and municipality) '~` ' 3 / ears of a e diedS ~~ ~ °2 °~ , 20~, at 9' ? ~' M• /~-"~ Decedent, then 6 ( y ~ g ', ps'~T ~b~GNSo ~y /mil//GSaN ~l~I~! ~.//~ ,~ ~ ~ Decedent at death owned property with estimated values as follows: (If domiciled in Pa.) All personal property (If not domiciled in Pa.) Personal property in Pennsylvania (If not domiciled in Pa.) Personal property in County Value of real estate in Pennsylvania situated as follows: Petitioner- after a proper search haS following spouse (if any) and heirs: Name Rela >E F~.t Dliv E' R v SSE c u TY~U ~~•~ t/~ SEA/' i i'.q C.F`~~f i c ascertained that decedent left no will and was survived by the phi Residence ~ re~c / ~_ s' c . S ~e.e.F.~- ~~e ~-~`J'c ems. i~oi-3 THEREFORE, petitioner(s) respectfully request(s) the grant of letters of administration in the appropriate form to the undersigned. Signature(s) of Petitioner(s) n ~~ Residence(s) of Petitioner(s) J~.3 O a~ ~ ~`~`~G~~ C~Q-~ L iSLEi ~~ /~~D I_3 ~ tt/ l .^. ! ! !t ,~' s ~ ~~ ~~ ~ .~ `! ...~..I~ 1 .. ~',..i , . ~~. .' i r~~ 9 atJ` ~'v'v ~~~~ ~ .~ DOH-1961 (10/2005) RESIDENCE RECORD DI~S7 T NEW YORK STATE ~ (,~ DEPARTMENT OF HEALTH REGISTER NUMBER CERTIFICATE OF DEATH a~- ~~~-o~~°~ STATE FILE NUA9BER 1. NAME: FIRST MIDDLE LAST 2. SEX: MALE FEMALE 3A. DATE OF DEATH: 13B. HOUR: MONTH DAY YEAR NCHS Saha Dervisevic ^1 ~2 09 26 2006 ' 9:34 P. m 4A. PLACE OF DEATH: HOSPITAL HOSPITAL HOSPITAL NURSING PRIVATE HOSPICE OTHER 14B. IF FACILITY, DATE ADMITTED: (Check one) DOA ER OUTPATIENT INPATIENT HOME RESIDENCE FACILITY (Specify): I MONTH DAY YEAR 4C 4C. NAME OF FACILITY: (If not facility, give address) 14D. LOCALITY: (Check one and specify) 14E. COUNTY OF DEATH: I CITY VILLAGE TOWN ~ I Wilson Memorial Hospital I^ ~ ^ Johnson City I Broome 4G 4F. MEDICAL RECORD N0. 14G. WAS DECEDENT TRANSFERRED FROM ANOTHER INSTITUTION? (It yes, specify institution name, city or town, county and state) Y D 4848158 ~ ~ 5. DATE OF BIRTH: 6A. AGE IN 66. IF UNDER 1 YEAR 6C. IF UNDER 1 DAY 7A. CITY AND STATE OF BIRTH: (It not USA, Country and 76. IF AGE UNDER 1 YEAR, NAME OF HOSPITAL OF BIRTH: ~ I I ~ MONTH DAY YEAR Region/Province) i ENTER: ENTER: YEARS: ~ months days ~ hou_rs minutes I I H 10 11 1945 60yrs. ~ ~ ~ ~ I I I Bosnia I ~ U ~ 8. SERVED IN U.S. ARMED 9. DECEDENT OF HISPANIC ORIGIN? Check the boxes that best describe whether the decedent is Spanish/Hispanidlatino. 10. DECEDENTS RACE: Check one or more races to rndicate.wbat the decedent considere@elf or herself to be: C) p Z N ~ FORCES? (Specifyyears) A~J' No, not S anish/His rGlatino B ^ Yes, Mexican, Mexican American, Chicano p ~ ,.e-~] ~ .,p~] ~ J Asian Indian w Chinese , ~ ! ; A ®White/Caucasian B ^ Black or African Ameriianl_ pp ~ NO YES I~0 ^ 1 C ^ Yes, PuertD Rican D ^ Yes, Cuban 4 -T E ^ Filipino F ^ Japanese ; = Korean Vietnaptese =~ j N ~ a/ ~ E ^ Yes, Other SpanishlHispaniGLatino (Specify) - _ J ^ Native Hawaiian K ^ Guamanian or Chamorro ~ oan °---1 _ , • W Q 11. DECEDENTS EDUCATION: Check the box that best describes the highestdegree or level of school completed at the time of death. ~ ` 1 "t -- _ t N ^ American Indian or Kaska Native (specify) f - :'; ~~ --- "' 1 ~ <_ 3Gh Brae 2 ^ 9th-12th grade; no diploma 3 ^ High school graduate or GED ::~ , c,~ - (s. (~ Q 4 r j S,~mt college c,eriri, bat no degree 5 ^ Associate's degree 6 ^ Bachelor's degree p ^ Other Asian (specify) `r R ~ Other Pacific Islander (specify) , ~ `) ~ ' c -~ - t --, _-- ~ 1 r. 7 [~ iulasters degree 8 ^ DoctoratelProfessional degree S ^ Other (specify) `-:~% ~ ' ~~ +~ _I C._.. ~ ~ ?t. SC~CIi+I SECURITY N~tAB[R: 13. MARITAL STATUS: NEVERMARRIEO MARRIED WIDOWED DIVORCED SEPARATED 14. SURVNING SPOUSE: fnternameif '- ~ - married or separated. It surviving spouse is t "~'~ ++ ~ a ,~ ~ ~ ~' Iv4-80-1 r4-~ ^ 1 ^ 2 ~ ^ 4 ^ 5 wife, enter maiden name. ' - i5A. USUAL aCCUPATIDN: (gin rot enterrstired) 115B. KIND OF BUSINESS OR INDUSTRY: 115C. NAME AND LOCALITY OF COMPANY M: U ~~ ~ Ht~mer~a'.~er ~ Own Home I W ~ 16p: RESn?5f~~;E: ~ 16B. County or RegioNProvince 16C. LOCALITY: (Checkone and specify) 116F. IF CITY OR VILLAGE, IS RESIDENCE WITHIN CITY OR VILLAGE LIMITS? WN ~ ~ I S a e orCDUn+r rf not USA: CITY VILLAGE TO (`~~ S ^ NO IF NO, SPECIFY TOWN: rt~~tusA) '~ p~, Cumberland ~ ^ ^ Carlisle ~ ~ 160. STP.FET AND N!JA!GLR OF RESIDENCE: 116E. ZIP CODE: ~ w ~ U 530 2nd Street ~ 17013 17. NAME OF FIRST MI LAST 18. MAIDEN NAME FIRST MI LAST - ~~ FATHER: Ba j ro Ba j ric OF MOTHER: Malca Korkotovic 19A. NAME OF INFORMANT: t 196. MAILING ADDRESS: (include zip code) 17 0 5 5 31 - Savit Sisic 010 Lenker St.Birch Bldg. Mechanicsburg, Pa. 20A. t~ BURIAL 2 ^ CREMATION 3 ^ REMOVAL 4 ^ HOLD 5 ^ DONATION t 208. PLACE OF BURIAL, CREMATION, REMOVAL OR OTHER DISPOSITION. t 20C. LOCATION: (City or town and state) MONTH DAY YEAR 6^ENTOMBMENT I Shellsville Cemetery- ~ Grantville, Pa • 31 • 09 29 2006 7 316 21A. NAME AND ADDRESS OF FUNERAL HOME: 121 B. REGISTRATION NUMBER: .'Coble-Reber Funeral Home 208 N nion St.Middletown a. ' 22A. NAME OF FUNERAL DIRECTOR: 122 IGNATU E OF FUNERAL DIRECT ~ 22C. REGISTRATION NUMBER: _ °R Jose h L. Hubik ~ ~ ~ ~ 01900 D BY: 24B. DATE ISSUED: 23A. NA RE OF REGIS ~ 236. DA1E FI 4A. IAL OR REM P RMIT R I I MONTH DAY YEAR I MONTH ~ AY Y ~' , /t'' ~~r ~~ ~i I ~ ~ I ' ~ ~ ~ ~ ~ ~~~~~~ DS V ~ ITEMS 2 HRU 33 COMP ETED BY CERTIFYING PHYSICIAN -- OR -- CORONER/ RONER'S PHYSICIA OR MED CAL EXAMINER 25A. CERTIFICATION: To the best of my knowledge, death occurred at the time, date and place and due to the causes stated. OCOD CeRitier's Name: License No.: Signature: Month Da Year CANCER • Certifier's Title: 0 ^ Attending Physician 0 ^ Physician acting on behalf of Attending Physician Address: ~•,- J ~ ` ,~" "~ ~ ~ ~~ ~ ~ ~ "" ~~ ~ 1 rover 2 ^ Medical Examiner /Deputy Medical Examiner L! "' C ` ~ ~~ G ~~ c r! ~ 258. If coroner is not a physician, enter Coroner's Physician's name & title: License No.: Sig Month Da Year 25C. If certifier is not attending physician, enter Attending Physician's name & title: license No.: Address: 26A. Attending physician Month Da Year Month D Year 266. Deceased last seen alive Month Da Year by attending physician: 26C. Prounounced Month D Year me Dead ~ © AT ~ M attended deceased: FROM TD ON 27. MANNER OF DEATH: UNDETERMINED PENDING 28. WAS CASE REFERRED TO CORONER OR MEDICAL EXAMINER? 29A. AUTOPSY? 1298 IF YES, WERE FINDINGS USED TO DETERMINE NO YES REFUSED t CAUSE DF DEATH? ''~ f '~ NATURAL CAUSE AC (DENT HOMICIDE SUICIDE CIRCUMSTANCES INVESTIGATION ^1 ^3 ^4 ^5 ^6 O^NO 1 ^0 2 I O^NO ]1~Jr~~~ FOR COMPLETING CAUSE OF DEATH CONFIDENTIAL CONFIDENTIAL SEE INSTRUCTION SHEET APPROXIMATE INTERVAL 30. DEATH WAS CAUSED BY: (ENTER ONLY ONE CAUSE PER LINE FOR (A), (B), AND (C).) BETWEEN ONSET AND DEATH t PART LJMMEDIATE CAUSE: `" ~ ~ L _ v DUE TO OR AS A CONSEQUENCE OF: ~, I r ~ 0 0 . DUE TO OR A5 A CONSEQUENCE OF: t ~ ~ ~ I V' ? ~ ~ PART IL OTHER SIGNIfICAN7 CONDITIONS CONTRIBUTING TO DID TOBACCO USE CONTRIBUTE TO DEATH? o ~ ~ DEATH BUT NOT RELATED TO CAUSE GIVEN IN PART I (A): 1 [] YES 2 ^ PROBABLY 3 ^ UNKNOWN ~ n p1 p INJURY AT WORK? OW INJURY OCCUR 31 C OF 1 Y; 31 E A ~,`~„ o ~ . - 31A. IF INJURY, DATE: HOUR: 31 B Y C TY: Ci ar town d nd 31 DESCR BE H ~ g ~• MONTH DAY YEAR ~ j ~ ~ r ~ ~~j~jt G' ~ ~ I ,.;~`~( ~ I NO YES " '"J""` ~ G~ I ~~? } ' ~~ i ,~°°~" ! V..i,~A~E7U H ,,, '~g'1'a~fF TFt~19~1R'TA~; SPECIFY: 32. WAS DECEDENT 33A. IF FEMALE: 338. DATE OF DELIVERY: MONTH DAY YEAR ~ ~+-~ a 1^ DrivertOperdtor 2 assenger 3^ Pedestrian HOSPITALIZED IN NO YES 0 of re ant vnthin last ear t ^ Pre naM at time of death 2 ^ Not re nant, but pregnant within 42 da s of death ~P 9n Y 9 P 9 Y ~^ o .__, LAST 2 MONTHS? rn ,, v-i n -. . n „_,._ _ _ .. - of tuM •f, > > o = V O i Register of Wills of Cumberland County RENUNCIATION Estate of ~/¢~ ~~ 2v~f ~~ v~ C Also known as deceased To the Register of Wills of Cumberland County, Pennsylvania The undersigned ~ ~~ ~~~~~ `S ~ v f G (Name) (Relationship) (Capacity) of the above decedent, hereby renounce(s) the right to administer the estate and respectfully request(s) that Letters D ~ /~ ~l ~~ 5 ~~'~~~~~~~.,~ be issued to S~~~`'u ''J ~~ ~~~ ,S ~ v ~ C Witness my/our hand(s) this day of Affirmed and subscribe before me this day of ~~~-~~ /~ ~cx~Co Notary Public My Commission Expires: Or Affirmed and subs il~ed before me this ~ day of ~~ ~"'~ ~t~(t~ ~~ ster o i , I Deput ~ (Signature and seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's commission) No ~~ - o ~ ~ ~~~~~ ~~o N ) 20 _~ ~- • ~~ ~ ~A J - fy ~Signature) ~~/ (Addre (Signature) (Address) (Signature) (Address) -~~ ~ ',~ ~l <1, v:f ii~~ ~~,C jj ' ' , ~,> ~ o ~ c u,y i •F ~° 0 V -.-_ Register of Wills of Cumberland County RENUNCIATION Estate of .~~~~~ ~~~12f//SEv~C No. ~\ -- V ~' Cvl ~~ Also known as ,deceased To the Register of Wills of Cumberland County, Pennsylvania / ~ (~~G1~i4 ~ C 1~.~u l~ ~ f~ J The undersigned L- >~v~ ~ `~' (Name) elationship) (Capacity) of the above decedent, hereby renounce(s) the right to administer the estate and respectfully request(s) that Letters d /~ ~/~//r' fs /~G' ~ /T/,O/U be issued to ~~ ~ "'~'~ ~ 1 N ~~~' v ~ ~ ~ `~ ~ Witness my/our hand(s) this day of Affirmed and subscribed before me this day of Notary Public My Commission Expires: Or Affirmed and subs i e ~ fore me this day of aG~~' Co ~ster W ~ s Deputy (Signature and seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's commission) 20 ,Q LC. (Signature) ~ ~ "~, `,` `J G, C" / (Addr~,e s~ l T V l (Signature) (Address) (Signature) (Address) ~y ' ~~~~J i~J ~ ff J ~r+ !'~ ~ ~` ,_ . L. .;` O< [p ~ , I o = o Register of Wills of Cumberland County CERTIFICATION OF NOTICE UNDER RULE 5.6(A} Date of Death: ~/°~~ Name of Decedent: t iS ~-~~ Estate No.: ~ ~~J " od ~.1~" 1 g To the Register: 1 certify that notice of (beneficial interest) estate administration required by Rule S.b(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on ~I~Y~PA2 ~3~ CPC . Name Address L~;v~ ~ " ~~ 'r'te - ,13.E ~' . ~~~e.~-- ~~ ~~°~ ~ ~'~ ~~~/~.3 Lam,-y,~ ~~~v~f ~~ Yr~ - S"~z~ .~ '~~'~ ~~~-~~- e , /~~- f~'~ ~.~ r --wrj /i+y ~e%C`~~/~J ~' I f~ C. " ~~ C7 ~ ~~ ~ li t~ ~•Q- ~~`t~ Notice has now been given to all persons entitled thereto under Rule 5.6(a} except Name~/'~ p,~'/f-~c~tr/G/~ Z ~~!'~~t./f~-J`,/R,~ G.L-~'. Address ,L,~t-!t/C~~j'r „e,~C'/ ~,~- ~~ Q 2 02' ~ - ~ D o Telep one Capacity: ^ Personal Representative '~ Counsel for personal representative