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PETITION FOR GRANT OF LETTERS
REGISTER OF WILLS OF,' 11 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 Information n
Name: File No: -,2Z L,o Vy
a/k/a: J (Assigned by Register)
a/k/a:
a/k/a: Social Security No: ~~(o /gyp 6,q7
Date of Death: )>il= 7 iqi --a-- Age at death: Cl
/
i
Decedent was domiciled at death in County, t~
(Stare) with his/her last
principal residence at /"IV u) J ; 1142 Z/) )21,? li )0
Street address, Post Office aid Zip Code - -f-' J7~G~i it Township or Borough County
Decedent died at C-~ J -e-e-4 f i H i u, y7jl~Jef^r~t'/:b' rT
Street address, Post Office and tip Cit , Township or Borough County State
N%11~t71~°i7f9
Estimate of value of decedent's property at death:
If domiciled in Pennsylvania All personal property $ ' ~n r C? 0
If trot 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'0
Real estate in Pennsylvania situated at:
(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 n ( = rn
Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated _ O .a d Cgilcz~
thereto dated C->
State relevant circumstances (e g. renunciation, death of executor, etc.) t ' i" 't fR 1
r- :z M C:) w s 4z:q
Except as follows: after the execution of the instrument(s) offered for probate Decedent did not marry, was not dived Naifmt a paq to a dizd
divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. § 3323(g), and Hot hav~hild rr-or
adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. a C
❑ NO EXCEPTIONS ❑ EXCEPTIONS
~ L.J -r1
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.
IKNO EXCEPTIONS ❑ EXCEPTIONS
Petitioner(s), after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (ifany) and heirs (attach
additional sheets, if necessary):
Name Relationship Address
Form nw-02 rev. 1011112011 Page 1 of 2
Oath of Personal Representative Official use only
COMMONWEALTH OF PENNSYLVANIA
SS
r' ` OF
r'f l` Y) 4111 Ci 't 22 i C
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 rfgfirmed subscribed before ht~~;"' ~`>?11 Date rn ~~day o 1 cv t Date
B I Date
For the Register Date
BOND Required: Q YES NO To the Register of Wills:
FEES: Please enter my appearance by ignature bed:
Letters $ Attorney Signature: W C-- C,
( 2) Short Certificate(s)...... M n y
( ) Renunciation(s)......... M O x`t r'Y
( ) Codicil(s) (A
( ) Affidavit(s)............ C7 -Y1 -sy -.tip
Bond Printed Name:
_W
Commission Supreme Court ~ q~-•. rn
Other ID Number: i r.._
Firm Name:
Address:
Phone:
Automation Fee L'( Fax:
JCS Fee Email:
TOTAL $ it
DECREE OF THE REGISTER
Estate of C S File No:
I-, f L)
a/k/a:
AND NOW, L'T ft L& V _ in consideration of th fore Bing Petition,
satisfactory proof having been presented before me, I IS DECREE hat L ters AALM I n l ~ LL 6111
are hereby granted to _ \-LL(P l
in the above estate and (if applicable) that
the instrument(s) dated
described in the Petition be admitted to probate and filed of record ao AL'~ s the last rW^~il~~l (and Codicil(s)) of (Decedent.
rp
Register of Wills l ilty) ~
ff
Fnrm RW_n)
M0111 NBA 0"1 1)
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
RECORD,`- C 0 771 0'
Fee for this certi[7cate, $6.0REG ER, OF I-h i,, to certify that the information here given is
~~NOFp
cojleetly copied from an original Certificate of Death
10 t9 J~ 111,~~/ duk filial «rth me as Local Registrar. The original
t i z cerffic.nc v. ill be forwarded to the State Vital
i:Ccorck Office for lie]manent filing.
CLERK C
\q9T P~III N0 2 9/2012
P 188839,W T R,
PHAN5' CCCRI
MfNT 0~,
Certification Numbs LANQ CO., A Local Registrar Date Issued
Type/Print In COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH - VITAL RECORDS
Permanent
Black CERTIFICATE OF DEATH
Ink State File Number:
1. Decedent's Legal Name (First, Middle, Last, Suffix) - 2. Sex 3. Social Security Number 4. Date of Death (Mo/Day/Yr) (Spell M.)
Stanley Benjamin Yancis Male 166-16-6249 ovember 27, 2012
t^ Sa. Age-Last Birthday (Yr.) Sb. Under 1 Year Sc. Under 1 Da 6. Date of Birth (MO/Day/Year) (Spell Month) 7 Y 1h lace $a y p d Stag pF Foreign Country)
_ J 91 ~ Months Days Hours Minutes M(D Lit , YH
November 21, 1921 7b. Birthplace (County) Luzerne Coun y
\ Be. Resldence (State or Foreign Country) 8b. Residence (Street and Number - Include Apt No.) Sc. Dld Decedent Live In a Township?
PA 210 Big Spring Rd_Yga,deledentuyealn West Pennsboro
Bd. Resldence (County)
tV
Cumberland Be. Resldence (Zip Code) ONo, decedent lived within limits of city/bor
9. Ever in US Armed Forces? 10. Marital Status at Time of Death E3 Mauled Wldowed 11. Surviving Spouse's Name (If wife, give name prior to first marriage)
W yes ID No E3Unknown 0 Dlvorred EJ Never Married Q Unknown
12. Father's Name (First, Middle, Last, Suffix) L_; Mother's Middle, Last)
Jose h Yancis Mar '
14a. Informant's Name 14b. Relatlonsh(p to Decedent nformaAddress (Street and Number, Clty, State, 21p Cotle)
Karen Anne Middleton Dau I-I 1 Tamanin Mach an ic burg PA
I Karen
w ace o Deat c ec on y one
If Death Occurred In a Hospital: tJ Inpatient :If DeathOccurred Somewhere Other Than a Hospital:1 WtaHOSpIce Facility Decedent .1 7--a-S5....
Room/OUtpatient p Dead on Arrival Nursing Home/Long-Term Care Facility Other (Specify)
<d 15b. Facility Name (if not Institution, give street and number; IS.. City or Town, State, and Zip Code 15 d. County of Death
Green Rid e vi11a e umberl nd
16a. Method of Disposition E3 Burial Cremation 166. Date of Dls position 16c. Place of Disposition (Name of cemetery, crematory, or other place)
p Removal from state p Donauon
her 11/30/201 2
ot(Speclfy) Ho111nger Funeral Home & Crematory
16d. Location of Dlsposlilon (Clay or Town, State, and ZIp) 17a. Signature of Funeral Service LI a or Person in Charge of Interment 176. License Number
Mt_ Ho11 S n FO 138812
E 17c. Name and Complete Address of Funerai Facllfty Ho l l i n
8 501 N. er ' Fu eral Homa & ator
Baltimore Ave., 1 nrin s Y. 2nc.
18. Decedent's Educatlon - Check the box that best describes the 19. Decetle nC of Hlspanlc Orlgln -Check She 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 that best describes whether the decedent the decedent considered himself or herself to be.
Ej 8th grademor less Is Spanish/Hlspanlc/Latin. Check the "No" t.'Vhlte C:j Korean
0 No diploa, 9th - 12th grade box If decedent Is not Spanish/Hlspanlc/Latino. E3 Black or African American Vietnamese
E3 High school graduate or GED completed No, not Spanish/Hlspanlc/Latino 0 American Indian or Alaska Native 0 Other Asian
Some college credit, but no degree 0 Yes, Mexican, rAexlcan American, Chicano M Asian Indian Q Native Hawallan
0 Associate degree (e.g. AA, AS) E3 Yes, Puerto Rican
0 Bachelor's degree (e.g. BA, AB, BS) E3 Yes, Cuban C Filipino Guamanian or Chamorro
P Samoan
Ej Master's degree (e.g. MA, MS, MEng, MEd, MSW, MBA) Yes, Other 5 Fill i
parish/Hlspanlc/Latino 0 Japanese Q Other Pacific Islander
Doctorate (e.g. PhD, Edo) or Professional degree (Specify) Other (Specify)
MD DDS OVM LLB
21. Decedent's Single Race Self-De.
s lgnatlon -Check ONLY ONE to Indicate what the decedent considered himself or herself to be. 2Z.. Decedent's Usual Occupation - Indicate type of work
15whlte Japanese Ej Samoan _ done during most of working life. DO NOT USE RETIRED.
Black or African American E3 Korean Other Pacific Islander
American Indian or Alaska Native 0 Vietnamese E3 Don't Know/Not Sure Suparvi sor
'W^ Cj Asian Indian Q Other Asian 0 Refused 226. Kind of Business/Industry
E-3 Chinese 0 Native Hawallan 0 Other (Specify)
E3 Filipino Guam. nlan or Chamorro
ITEMS 23. - 23d MUST BE COMPLETED 23a. Date Pron° n d D d (MO/Oay/V r) 23 b. Signature of Person Pronouncing Death (Only when applicable) 23c. Llcer,se Number
BY PERSON WHO PRONOUNCES
CERTIFIES DEATH I t
23d. Dare 5 gned ( o/Day/Yr) 24. Time of Death
7/ ' 25. Was Medical Exam or Coroner Contacted? Yes N_,
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. Interval:
respiratory arrest, or ventricular fibrillation without showing the etlal,gy. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional (Ines If necessary
Onset to Death
t
IMMEDIATECAUSE
(Final disease or contlltton Due to (or as a consequence of):
re..I I..[. deatM1)
b.
Sequentially list conditions, o.. to (or as a consequence of):
If any, leading to the cause -
Ilsted on Itne a. Enter the
UNDERLYING CAUSE Due to (or as a consequence of):
[disease or Injury that
in plated the events resulting d-
In death) LAST. Due to (o as a consequence of):
Z5 26. Part 11. Enter other significant conditions contributing t death but not resulting In the underlying cause given In part I 27. Was an autopsy performed?
Yes Q No
128. Were autopsy `In dings available
to complete the cause of death?
29. If Female: 30. Did Tobacco Use Contribute to Death? 31 10 Yes )3 No
. Manneralr of Death
E 0 N of pregnantwlthln past year \"es Probably
2 E3 Pregnant at time of death 0 No Q Unknown Natu M Homicide
m Not pregnant, but pregnant within 42 days of death Q Accident E3 Pending Investigation
Not pregnant, but Pregnant 43 days to 1 year before death 32. Date of Injury (MO/Day/Yr) (Spell Month) Suicide 0 Could not be determined
E3 Unknown if pregnant within the past year 33. Time of Injury
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 3?. If Tra nsportatlo n Injury, Specify: 38. Describe HOW Injury Occurred:
Yes Driver/Operator 0 Pedestrian
E3 No Passenger 0 Other (Sp,clfy)
39a. C ler (Check only one
Ce nosing physician - To the best of my knowledge, death occurred due to ,Cur,, haus and manner stated
ED - c er Pronouncing & Certifying p clan - To th best of my knowledge, death o d at at the time, date, a d place, and due to the se(s) and mann stated
O Medical Examiner/Coroner O sls of examination, and/or Investgation, in my opinion, death rred at the time, date, and place, and due to the cause(s) and manner stated
Signature of cer[Ifler: "rlTle of certifier: ( License Number: ~n l f S L
39b. Name, Address and Zip C Person Com pleting Cause of Death (Item 26) 39c. Date a 5 necl /Day/Yr)
56 Asht n StCarlisle, PA 17015 Ifz /z
40. Registrar's District Number 41. Registrar's Sig 42. R glstrar File Date (MO Day/Y,)
It 0
43. Amendments
O
Disposition Permit Nn. V f-( ~~j ~J / V REV 07/2011