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HomeMy WebLinkAbout01-15-13PETITION FOR GRANT OF LETTERS REGISTER C1F WILLS OF CUMBERLAND 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) tl following and respectfully requests the grant of Letters in the appropriate form: Marge Kaye Sentiwany Decedent's Information Name: Roger E. Sentiwany a/k/a: a/k/a: a/k/a: Date of Death: 01/0312013 File No: 21 - 13 - ,_ ~'" -r (Assigned by Register) Social Security No: Age at Death: 50 Decedent was domiciled 2~t death in Cumberland County, pA (State) with his/her last principal residence at 10511 Allendale Road, Apt. L, Mechanicsburg 17055 Upper Allen Township Cumberland Street address, Post Office and Zip Code City, Township or Borough County Decedent died at Holy Spirit Hospital Camp Hill Cumberland 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 Penns;ylvania ....................... All personal property $ If not domiciled in Pelnnsylvania ................ Personal property in Pennsylvania $ If not domiciled in PE!nnsy/vania ................ Personal property in County $ Value of rea! estate in Pennsylvania.......... $ 10,000.00 TOTAL ESTIMATED VALU6S_ 10,000.00 Real estate in Pennsylvania situated at _ - (Attach additional sheets, if necessary.) ~ © -^ ~ Street address, Post Office and Zip Code City, Township or Borough ~ ~ - - Co ^ A. Petition for Probate and Grant of Letters ~estamentarv ~ ~~;;: ~ ,~ `j.~ s a ~y~ Petitioner(s) aver(s) that he,lshe/they is/are the Executor(s) named in the Last Will of the Decedent, dated C~'~ ~ ~ ° ~ and Codicil(s) _"~' ," thereto dated -~ ~'~"? ••~; i ~ . 'd ., __- (State relevant circumstances, e.g., renunciation, death of executor, etc.) ~ ~ ..'q Except as follows: after the execution of the instrument(s) offered for probate, Decedent did not mar ,was not divorced, wasnot a Party to a pending `~ ,-t divorce proceeding wherein I:he 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. ^X NO EXCEPTIONS ^ EXCEPTIONS ^X B. Petition for Grant of Letters of Administration (If applicable) c..a.; .n.; .n.c.t.a.; pe en a rte; urante a sen ra; urante mmonta e If Administration, c.ta 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 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. ^X NO EXCEPTIONS ^ EXCEPTIONS Petitioner(s), after a proper :>earch has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs (att.ech additional sheets, if necesss~ry): Name Relationship Address Marge Kaye Sentiwany Wife 207 Bosler Avenue Lemoyne, PA 17043 Form RUV U2 rev. 10-11-2011 Copyright (c) 2011 form software only The Lackner Group, Inc. A~ +a Page 1 0 Oath of Personal Representative COMMONWEALTH OF PEIVNSYLVANIA } } ss: COUNTY OF CumberNand } Official Uses Only Petitioner(s) Printed Name Petitioner(s) Printed Addre,~g? I ~. ~ ~ - Marge Kaye Sentiwany 207 Bosler Avenue ~ ~ -- Lemoyne, PA 17043 _ v~~~... ~l Ij I t Th ~ v 5„ -. I ne retltloner(s) above-names 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, Petiti Her(s) will well and truly administer the estate according to law. ~• Sworn to or affirmed and subscribed hefore '~ Date - ~-~ me this J~~ day of ~- o?i`[:3 i Date BY~ :2'=~,y~~ Date For the R ister // /,~yL~ pate BOND Required? ~ Yes ~ o To the Register o ills: ~ `) FEES Please enter y appearance si ature b w: Letters ......................................... .. $ ~-~'.) `, (-~~ Attorney Sign re: j '~ (., " ~. )Short Certificates O........ ~ ~ ~ `' . ~ 1..~ ( )Renunciation(s) .............. . ~ ( )Codicil(s) ....................... . ( )Affidavit(s) ..................... . Printed Name: Robert G Radebach Bond ............................................ . Supreme Court Commission ................................ .. ID Number: 19255 Other ') ~`' ~~~.I ~`~ ~' ' ~~ ~ ~ `~ ~~` ~_ - Firm Name: Law Office of Robert G. Radebach i `' ~ ~ ~ '~ ~ ~' ' i~' '1 ~ ~ ~ , - r 912 North River Road Address: Halifax, PA 17032 Phone: 7171896-2666 Automation Fee ........................... . _- ! ' JCS Fee ....................................... . ` . . - , ,y~ - ' Fax: 7171896-2754 TOTAL ......................................... ~' ~ `; `, . $ ,~ E-mail: missyswartz5l@aol.com DECREE OF THE REGISTER Date of Death: 01103/2013 Social Security No: 207-54-0435 Estate of Roger E. Sentiwany File No: 21 - 13 a/k/a: AND NOW, ~(' -~, ~ \'~ _ r .- ~ ~ ~ , in consideration of the foregoing Petition, satisfactory proof havtfig been pr es nt before me, IT IS DECREE D that Letters of Administration are hereby granted to Marge K aye entiwany in the above estate and (if applicable) that the instruments}dated ~, / ~'~ described in the Petition be admitted to probate and filed of record as the last ill (and Codicil(s)) of '~ gister of Wills -- Copyright (c) 2011 form software only The Lackner Group, Inc.`;-~^ :) ~ ~ ~~. ~ ((~ ' ~ ~ ~ ~ 1 ~%\,~ '~J " ~~9e 2 of 2 1.~.~~ ~ ~~ ~ ~ , .~ "~3 ~ - ,~ 1 ~ ~-,_~j ? ~, ~3 n ( ~ / - `~ V ~ E. l~' :~ t. i (~; yr ~ ;~ ~ _ , a I ' ~ '-'~~ e..~ ~ ~~~ JAf~ 0 8 213 ~~~ Type/Print In COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF HEALTH VITAL RE CORDS Permanent #20'13-09-D04 CERTIFICATE ~F ~EATI-1 J"~ U( "d 3. Decedent's Legal Name (First, Middle, Last, Suffix) 3. Sex 3. Social Security Number bare of Deatfi (MO/Oay/Yr) (Spell Mot Roger E= Santiwany Males January 3, 20'13 Sa. Age--Last Birthday (Vrs) Sb. Under 1 Year Sc. Under 1 Da 6. Date vT Birth (MO/Day/Vear) (Spell Month) Ja. Birthplace (City and State yr Fvrelgn Country) Mnntha bays Hours Mlnut¢s 50 Junes 29, ~ 962 Jb. Birthplace (County) D8 Ba. Refidence (State Or Foreign Country) Sb. Residetnce (Street and Number -Include Apt No.) 8c. Did Decedent Liy¢ in a Township? Pan ]- QYes, decedent lived in iJoDer Allan na' aa. Resmen<¢ (cpuntyj 1051 Allendale Rd _ A t D. Cumberland a¢. Readen<e (zip epee) 1705 QNO, decedent eyed within limits of city/ttorv. 9. Ever in VS Armed forces? 10. Marital Status a<Tlme of Death Married Q Widowed 11. Surviving Spouse's Name (IT wife, give name prior tv first marriage) Q Yes ~ No Q Unknown Q Olvorc¢d Q Never Married Q Unknow 12. father's Name. (first, Middle, L.asl, Suffix) 13- Mother's Name Prior iv First Marriage (nrs<, Middle, last) Eu ane Sentiwany o a e 14 a. Informant's Name 34 b. Relationship to Decedent 14c. Informant's Mailing Addrezz (Street antl Number, City, State, Zip Cpde ar Mar a Ka a ,>antiwanv 1 a. P a<e p ¢at G eck pn y pn¢ ...................... ... ~l._..-. - .. _ _ _ _ _ __ _ __ ___ _ __ _ _ -..........._ .. If Deatfi Occurretl Ina Hospltal~ ~ paTlent ilT Death Occurred Somewhere ~O[her Than a Hospital: wrayt Hvs Ice Faclll ~ ~~ ~~~~ yy' ~ ~ ~ ~ -~~i ~-~ ~ -~-~~~ ~~~~ LJ p ty y DGCr!dent' Home ° Emsrgenry Room/OUtpatlent 0 Dead on Arrival Nursing Home/Long-Term Care Facility - Other (Specify) - ~ SSb. Facility Name (If not Institution, give street and number; i5c. City or Town, Stag., and 21p Cotle 15d- County of OeatA Hol S iris Hos ital Cam Hill PA ~70'I1 Cumberland 16a- Method Of Dispose ion (~ Burial ~ Cremallon 16b. Date of Dispositiv 16c- Place of Disposition (Name of cemetery, crematory, or other place) Q Removal (rvm Sta t¢ Q Donation otner (spe<Iry.). 2 (J 1 3 anu r 7 Evans Cremator 16tl. Loption of DlsposlUVn (City or Town, State, and Zip) 1Ja. Signs of F 1 Service Licensee or Person 'rn Charge of Interment. SJb. Ut-enx Number Sctleaff'erst_own PA 17088 p1,.~- ~S OI:Z-`/ yQ ~ L-- IJC. Name and Complete Address of Funeral Facility m 18. Decedent's Education -Check the box these best dexribes the 19- Decedent of Hispanic Origin - Check the 20. Decedent's Race -Check ONE OR MCIRE rxes to indicate what highest degree or level of school completed at the time of death. box that best describes whether <he deeedenl the decedent considered himself or herseN to be. Q gth grade or less Is Spanish/Hlspanic/LH[ino. Check the "N O" ~ White [] Korean Q No Diploma, 9th - 12th grade box if decedent is not Spanish/H ispanic/Latinv. Q Black or African American [] Vietnamese ® High school graduate or GE O Completed ~( No, not Spanish/Hispanic/Latino 0 American Indian or Alaska NatNe [] Other Alien Q Some college credit but n0 de ree , g [] Yes, Mexlca n, Mexican American, Chlca no Q Asian Indian [] Native Hawaiian Q Associate de gree (e.g. AA, AS) Yes, Puerto Rican Q Chinese [] Guamanian or Chamvrro ' g Q Bachelor s d Brae (e. R. BA, AB, BSj ~ Yes, Cuban Q n11Pin0 [] Samoan ' Q Master s degree (e.g. MA, MS, MEng, MEd, MSW, MBA) Q Yes, ocher Spanish/Hispanic/Latino Q Japanese [] Other Pacific Islander Q Doctorate (e.g. PhD, E:dD) or Prvfesstvnal degree (Sp¢<Jfy) Q Other (Specify) D5, DVfvl LLB, JD 21. Decedent's Single Race Self-Oesigna[lon -Check ONILY ONE tv Indies to what the decedent Considered himself or herself [n be. 22a. Decedent's Vsual Occupatin -Indicate type of work n White 0 Japanese - Q Samoan done during most of working file DO NOT USE Rt-TREO. Black yr African A i mer can Q Korean Q Ocher Pacific Islander (~ American Indian or Alaska Nativ¢ Q Vietnamese Q Dvn't Know/Nat Sure Q Asfsn Indian Q Other Allan Q R¢fused 22b. Kind vT Holiness/Indushy Q Chinese Q Native Haweilin Q Other (Speelfy) Q Filipino Q Guamanian or Chemorre ITEMS 23a - 23d MUST BE COMPLf?TED BY PERSON WHO PRONOV NOES OR 23a. Date Pronounced Oead (MO Oay/Vr) 23b. Signature of P¢rspn Pronouncing Death (Only when applica htej 13c. Uc¢nze Number CERTIFIES DEATH 23d. Date Signed (MO/Day/Yr) 24- Time of Death 2:50 P-M. zs. was Medical Examiner or Cvrvner Cvntacted7 m Yes Q No CAUSE OF DEATH Approximate 26. Part 1. Enter the ttiain of ev_ents--dtseasez, InJurl¢s, or cpmpllcaTlpns--that directly Caused [he death. 00 NOT enter Lerminal events such as cardiac arr¢sr i [erval: respiratory arrest, or ventricular fibrillation without showing the eflolpgy- 00 NOT ABBREVIATE. Enter only one ravse On a line. Add additional Ilnt-z if nr-ccssary Onset to DeMfi IMMEDIATE CAUSE --~~---------~~-> a. Pending Investigation € (Final dizeas¢ or condltlc'^ Due cp to as a consequence - - off' resulHng In death) b. Sequentially list conditions. Du¢ Lo (or as a consequence vf) - --- - - _ If any, leading to [he cause listed pn one a. Enrer the _ UNDERtY1NG CAUSE Oue to (or az a consequence pT): (d lsease pr InJury that Jnitisted the ants resulting d. in de.eth) IAST. Due to (O as a consequence of): O 26. Pert 11. Enter other si ng fifes nt conditions t ib ulna to death but not resu hang in the underlying cause RNen in Part 1 2J. Was an autppsyrpcrformld7 ~ m Yes (~ No 28. Were autopsy findings available y to c piste Me c uu of dcxhJ a m Np Q Ycs 29. if Femal¢~ 30. Old Tobacco Vse Contribute to Death? 31. Mannar of Death 0 Not pregnant within past vest Yes Probabl Q 0 y 0 Natural HpmicMe (] Pregnant at time oi' death ~' 0 No 0 Unknown 0 Accident © Pen.iing Investigatfen Q Not pregnant, but pregnant within 42 days of dealt ~ 0 Sufcitle Q Could not tx- determinetl 0 Not pregnant, but pregnant 43 days to 1 year before deatt 32. Date of InJury (MO/Oay/Vr) (Spell Month) Q Vnknown if pregnant within the DaSt year 33. Tim¢ of Injury 34. Place of Injury (e.g. home, consiruc[fon site; farm; school) 35. Location of Injury (Street and Number, CFty, State, Zip Code) 36. InJury at Work 3J. If Transportation InJury, SpetlfY~ 3B. Describ¢ How Injury Occurred: 0 Y¢s 0 Orlver/Operator ~ Pedes[rlan 0 NO Q Passenger [] Other (Specify) 39a. Certi/i¢r (Check only vnc)~ 1] Certifying physician - lb the best of my knowletlge. death occurred due [o the cause(s) and manner stated Q Pronouncing ffi Certify" g physician --TO the ben of y knowledge, death occurred at the time, date, and place, and due [o the c us¢(s} and manner stated m M di l e ca Exa miner/~gnner- qp ~he basis vI ¢x in lien, anF1/or investigation, in my opinion, death occurred at th¢ [Ime, date, and places, and du¢ to th¢ <aus¢(s) and manrt<r stM¢C rr ``YY ( ] ~ \\ L~ Signature pf certifi¢r ]C - Q_`~i Q n<ie of c¢rtlfiar: Coroner Llcens¢ Number;_ 39b. Name, Addrezs and Zip Code of Person Completing Cau a Of DeaUt (Item 26) 5 39c. bate Slgnetf (MO/Day/Yr) Charles E. Hall Coroner 6375 Basahora Road Suites 1 M h i b PA , , ec an cs urg, 17050 January 4, 2013 40. Registrar's District Number 41 Re istrar' Sl ~ ] - g s g yy~e q1. Registrar File Dafe Mp ay 43. Amendments ~g 1 542-7 HIOS-143 Disposition Permit No. _ REV OJ/2011