Loading...
HomeMy WebLinkAbout01-23-13 (4)PETITION FOR GRANT OF LETTERS REGISTER OF ~VII:LS OF C{,(OY1f~L~f'~.G ~"nl'~ COUNTY, PENNSYLVANIA Petitioner(s) named below, who is; are 18 years of age or older. apply(iesj for Letters as specified belotiz. and in support thereof aver(s) the following and respectfully request(s) the grant of Letters in the appropriate form: Decedent's nformation a,'k/a: a/k/a: a/kJa: Date of Death• o !~,%~,;yy ,,~~- ~ t ~ Decedent was domiciled at death in _~t~t~S.:~tiLfi~J~ County, principal residence at _ ~/ ~{ ~,2 ~4~ ~,~~~ C File iaio• ~ ~ ' ~ 3 °- C~Gr~`~ (assigned by Register) Social Security No: __,~ 7s'~ _ i~- ~~ 7 Age at death• R ,;L ~ (store) with his/her last Street address, Post Office and Zip Code City, Township or Borough County` Decedent died at C'~i~~-ts~c~ ~•-~,f(,~~~,//}~ /~(~`"D( t9~- CTS ~~''.,L-~S(.~c~ ~~.~f`~./~ ~~ Street address, Post Office and Zip Code CUy, Township or Borough County State Estimate of value of decedent's properly at death: 1Jdomiciled in Pennsylvania ............................ All personal Property IJnot domiciled in Pennsylvania ........................ Personal property in Pennsylvania If not domiciled in Pennsylvania.......... .... Personal property in County ........... Value ajreal estate in Pennsylvania .................................. . ...................... TOTAL ESTIMATED VALUE... . Real estate in Pennsylvania situated at: /{~~,~ (.lttach additional sheen, ifnecessary.) Street address, Post Office and Zip Code City, Township or s 9y~0. ao S S S ~ t~~~- ~: C7 rti~ e'"? m __, ^ A. Petition for Probate and Grant of Letters Testameniarv `` c~' "~ ~~' Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated _ ~ °°~d ~ ~~ and tddi~r s thereto dated r... 3:~T j--~-r, b ,, w ,~ ) ,,-a _., State relevant circumstances lag. renunciation, death ojexecutor, etc.) t .a H ~ --~ ' ., a f .' ._y ;7 Except as follows: after the execution of the instrument(s) offered for probate Decedent did not marry, was not drvbrted, was not a parry t©apertftling < r divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa. C.S. 3323 ~ `" § {g), auc~ did not have a child boar or adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. 1 r~~ ~~ ~ ^ NO EXCEPTIONS ^ EXCEPTIONS y ~--~ _."~ (~ B. Petition for Grant of Letters of Administration (If applicable) ` c.t.a., d.b.n., d.b.n.c.t.a., pendente lice, durartte absentia, durante minoritate If Administration, c.t.a. or d.b.n.c.~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 rn 2 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 Will and was survived by the following spouse (ifany) and heirs (attach udclitiona! sheets, ijnecessary): Fong RW-02 rev. 10/i'l/1011 Page 1 of 2 Oath of Personal Representative o~r~ ~ ~ ~.o~iy ~ C0~(\(Q~',L'E.aLTH CF P~~tiS`r Lb',~tiLi } a o- Id .t' 3 ~ is - ..~.~, v, ^~, ~ '~ r1J Ji~ir Ift The Petitioner(s) above-named stivear(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 drat, as Personal Representative(s) of dte edent, the Petitioner will well and truly administer the estate according m law. Sworn to or affirmed a d subscribed before ~~~ Ine t ~ day o , ~0 Da:e _ ~1'~"fl.~_. By: Date Date or the Regis[er Date BOND Required: AYES NO FEES: Letters ...................... S (~ )Short Certificate(s)..... . ( )Renunciation(s)........ . ( )Codicil(s)............ . ( ) Aftidavit(s)........... . Bond.......... .............. Commission ................. . Other nvon~rm ...... lfi. Automation Fee ............. . . ~L• _ JCS Fee . ............. TOTAL ..................... S , To the Register ojWi!!s: 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 ~~CIY(~~ ;t.~ ~. `f+ ~Y-~-~ File No: ~, - ~'7 -' (~0$y a/k/a: AND NOtiV, ~ ~ I ~(, ~3 ,~_~ in consideration of the foregoing Petition, satisfactory proof having been pr a ted before me, IT I DECREED that Letters ~Ci th,~) ~~ n ~~r~r~ ---._.._ are hereby granted to • in th above estate and (if applicable) that the instrument(s) dated ~ ~~ described iii the Petition be admitted to probate and filed of record as the last ~Vill (and Codicil(s)) of Decedent. G°Cc iY ~~ Register of Wills ~ r l).~'~((, ~~~ LOCAL REGISTRAR'S CERTIFICATION OF DEATNi WARNING: It is illegal to duplicate this copy by photostat or photograph. Fee fur this certificate, $6.00 ~ ~ ~ ~ ~ ~ _ ';~ ~ 1_ ~~~ ?~i3 ~~~~ 23 ~ 4~ 2 3 This is to certify that the information here given is correctly copied from an original Certificate of Death duly filed with me as Local Registrar. The original certificate will he forwarded to the State Vital Records Office for permanent tiling. CL~~~ ` - ~` .~ ~ ~.: e.. ~ ~~ ;:ORPHANS' ~.~ ~~ ~~~ JA 2 2013 Certification Number ~ h~ ~ ^'~ ~° s - ~ U M B E R L ~ ~ c ; .. ; , , - • Local Registrar Date Issued 1 Type/Print In Permanent COMMONWEALTH OF PENNSYLVANIA .DEPARTMENT OF HEALTH ~ VITAL RECORDS Black ink CERTIFICATE OF DEATH 1. Decedent's Legal Name (First, Middla, last Suffix) Stale Flle Number: ~l O `\a .~ f , ~~ 2- Sayx~ 3. Social S~c-u~rity Nul~~~ q, pat„ f/Day/Yr) (Sp'a~l iCtM~i°) Sa. `Age`-Last Birthday (Ves) Sb. Under 1 Year Sc. Under 1 Da 6. pate of Birth (MO/Day/Year) (Spell Mon-'a Birthplace CI '~~7Q_° ~~ w-` ~~ ~~ Months Days Hours MtnuTes ( ty end State or Foreign Country) `lO ~ `~-?-~ 7b. Birthplace (County) PA Sa. Residence (State or Foreign Country) 8b. Reside a (Street and Number- Include Apt Nv.) 8c. Dld Decedent Liye in a Towns hlp7 PA n` 8d. Residence (cpnnty) 61 4 Forge Rd_ es, decedent eyed in South Middleton LM,p C-~mll~erland ge. Residence (Zip Code) 1 701 5 Q N°, decedent Iiyed within limits of 9. Ever in VS Armed FOrces7 10. Marital Status at Time of Death [~ Married )® Widowed city/boro. Q Yes { No Q Unknown Q Divorced 0 Never Married 11. Surviving Spouse's Name (If wife, give name prior to firs[ marriage) ~ Unknvw _ 12. Father's Name (First. Middla, Last Suffix) 13. Mother's Name Prior to Firs[ Marriage (First, Middle, Last) ~ C_ Mc D~1da Elmira - tailor 14a. Informant's Name yob. Relationship to Decedent 14c. Informs is Melling Address (Street and Number, CI o DaF'na M - F~lgle Dau hter ty, state, Zip code) g 6l4 Forge Rd_ Carlisle, PA 17015 _ If Death Occurred in a Hospital ~[~ - - - - - - -, - - ~ 15 a_ see o Daat ec on Z. Ono npatlent Ilf Death Occurred Somewhere Other Than a Hospital ~ Hospice Fe <IIiTy O Q Emergenry Room/Outpatient Q Dead on Arrival I 0 Nursing Home/long-Term Care Facill 1~ Decedent's Home eW~2 15 b. Facility Name (If not institution, give street and nurnbe r) 15c. Cit tY Q Other (S pacify) ~ ~'-c1r11S12 F2e 1i~ilal Mi=di.cal Y or Town, State, and Zlp Code 15d. County of Death Center Carlisle, PA 17013 ~~.anberland m 16a. Method of Disposition Q Burial Q Cremation 16b. Date Of Disposition 16c. Place Of Dls v Q Removal from State $Kponatlon Position (Name of cemetery, crematory, or other place) _` Q orner (sPe<Iry) 1/2/201 3 Humaazit Gifts R v 16d. Location of Disposition (City or Town, State, and ZI a 1St P) 17a. Signature of F era) Service Lice Pe rspyy Charge of Interment 17b. License Number ~ Philadelphia , PA CS ' E 17c. Name antl Complete Address of Funeral Faclli FD O 1 2633 L 8 Ekvin Brothers Funeral ~ic~ne, Snc_ 630 S_ Hanover St_ Carlisle, PA 17013 ~' 19. Decedent's Ed uca[IOn -Check the box that best describes the 19. Decedent of Hispanic Origin -Check the 20. Decedent's Race -Check ONE OR MORE races fo indicate what 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 fo be. Q 8th grade or less is Spanish/His pe nic/Latino. Check the "NO" Q No dlplo ma, 9th - 12th grade box if decadent is no[ 5 fish HIS ~ White Q Korean .~ Nigh school graduate or GED completed Pan / Panic/Latino. Q Black or African American Q Vietnamese Q Some college credit, but no de ~ No, not Spanish/Hispanic/Latino Q American Indian yr Alaska Native Q Other Asian ~ Associate de gran Q Yes, Mexican, Mexican American, Chlca n° ~ Asian Indian gree (e.g. AA, q5) ~ Yes, Puerto Rican Q Na[Iye Hawaiian Q Bachelor's degree (e.g. 9A, A9, BS) Q Ves, Cuban Q Chinese Q Guamanian or Chamorro ~ Master's degree (e. g. MA, MS, MEng, MEd, MSW, MBA) ~ Ves, other 5 Q Filipino ~ Samoan ~ Doctorate (e.g. PhD, Ed D) or Professional de Panls h/Hispanic/Latino Q lope Hasa Q Other Pacific Islander gree (Specify) O Other 5 . MO DDS, DV M, LLB JD ( pacify) 21. ^ecede nT's Single Race Self-Designation -Check ONLY ONE tv indicate what the decedent considered himself or herself t0 be. 22a. Decade Ht's Usual Occu White Q Japanese Q Samoan Patton -Indicate type of Work Q Blacek or African American Q Korean Q Other Pacific Islander done during most of working 1(fe. DO NOT USE RETIRED. o Q Am clean Indian or Ala ~:ka Native Q Vletna mere Q Don't Know/Not Sure ~~p~y~y~Y- •~i Q Asian Indian 0 Other Asian ~7 Refused /Operator Q Chinese Q Native Hawaiian Q Other (Specify) 22b. Kind of Business/Industry ~ FIIl pino Q Guamanian or Cha mo no ITEMS 23a - 23d MUST BE COMPLETED 23a. Oete P O c d Oead (MO/Day/Vr) 23 Slgnatu re of Per;on PrO noun<in Death OnIOOt r gY PERSON WHO PRONOVNCES OR nOV !/yV/\,-r~X~'J B ( y when applicable) 23c. License Number CERTIFIES DEATH / Z 3 u n Z c~ j Z - 23d. Date 5 ne (MO/Day/Vrl 24. Time of Death CI~V'~-s--CAL /rte/J ~ ~ y & S~~ /z 3/ so/z /d 3 oQ.-,,, ~-l 25. Was Medical Examiner or Coroner Contacted? ~ Yes CAUSE OF DEATH N° 26. Part 1. Enter the Spain of e t --diseases, Injuries, ar complications--that direct) I respiratory arrest, or ventricular fibrillation without showing the etlolo Y caused the tleath. 00 NOT enter terminal events suet. as ca rd lac arrest ~ APnTe Nl amlate / gy. DO NOT ABBREVIATE. Enter only one cause on a Tine. Add additi0 Hal lines if necessary, I Onset to Death IMMEDIATE CAUSE ------ -._______~ a. /~'e J R ~ CQ ~ ~` ~ yr ~iL,~ tt` 1 (Final disease or condiilon Due fo o v ) resulting In death) ~ ( r as a cons /qu ante f : Sequentla lly list c0 nditions, ; If any, leading to the c Due to (or as a consequence vf): IlsTed on line a. Enter then I UNDERLYING CAUSE 1 (disease Or injury that Due to (or as a consequence of): -- 1 I G Initiated the events resulting d. I ~ in death) LAST. '~ Due t° (Or as a con __ ~ sequence of): 26. Pan 1t1~.~ Enter other significant diti t Ib tl t de h but not resulting in the under) in I ~ ~JlG /1~1.f_, /'iCf 5:-C ti~'P vrG / S c!U {-sr. ~ Q Y g cause Biyen In Part 1. .,n / 27. Was an autopsy performed? ~~ l~ i~.Lc~.,~ 5 O Yes p ~ 28. Wares autopsy findings available ~ 29. If Female: tv complete the cause of deaths 30. Did Tobacco Vse Contribute to Death? Q Ves Q No E' ,~Alot pregnant within past year Q ,,es 31. M} Q Pregnant at time of death Q Probably ~B Natu calf Death m Q Not pregnant, but pregnant within 42 days of death ^B~NO Q Vnknvwn Q Accident Q pendl Hid Invests ~ Q Not pregnant, but pregnant 43 tlays to 1 year before death 32. Date of In u Q Suicide ~ Could not be deTerim fined Q Unknown if pregnant within the past year 1 ry (MO/Oay/V r) (Spell Month) 33. Time Of Injury 34. Place of Injury (e.g. home; c0 nstruction site; farm; school) 35. Location of Injury (Street antl Number, City, County, State, Zip Code) 36. Injury at Work 37. it Transportation Injury, Specify.: 38. pescribe Now In Q Ves ~ privet/Operator 0 Pedestrian Jury Occurred: Q No Q Passenger Q Other 5 ( Peclfy) 39 Certifier - physicla n, certified nurse practitioner, medical examiner/coroner (Check only one): Q Certifying only - T° the best of my knowledge, death occurred due tv the ea use(s) and m r stated. Pronouncing 8, Certifying - T e best of my owledge, tleath occurred at the time, datenand lace, and due to the cause O Medical Examiner/Coroner - the basis of min orlon and/or Investigation, in my opinion, death occurred at the time, date, and elate rand due to the cause Signa[u re of certlfie r~ xa p (s) and Mann stated. TiTle of certifier: I'f~/:/7 License Numbe rl/?!~ U ~ ~~~5~ 396.}}N~~a m~~~e, Ad~7dr /hand ZI/g~C~od of Person Completing /Cl pause f DeP~Jty~ (Item 26) t L.X7/!4 a/'-) /~r_-" ~~ ~ U 5 //• ~/T~h?7!/~C. /T/i@ f L~ y!/L~ ~ j~~, 39c. Data 51 ned ( a,/DaY/Yr) ~j 40. Registrar's District Number ~y'7 s //y- /7 6 ~Z ~ / GO~L~ - - 41. Registrar a+u re y~~ 42. Re Istrar FII Date (MO Day r) .~ 43. Amendments ~ ry^ ~ - ~n , Disposition Permit No. O 1, 9 ~ p~ 1 H105-143 REV 07/2012