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HomeMy WebLinkAbout02-04-13r-~,; ~ ° :L7 w ~ M c o rn ~ PETITION FOR GRA\1T OF LETTERS via ~ REGISTER OF WILLS OF t.~L~.n~t,b~.~r ~~-t`x~ COUNTI~~~fI~YLVANIAt~~~ r~, Petitioner(s) named below, who isiare 18 years of age or older, appl~~(ies) for Lctte~ a~spec~ed b~elo~~ and in su ort thereof aver ~ the followin and res ectfully re nest 5~ the grant of Letters in~~e ., aria -~t Pp ~') g p Q ~' ln' p t~e-tfori~x:.° ~._ Decedent's Information = ~,..~ k..-.._ ~--- r`'~ Name: ~,~~v, r1 ~Ch~ i~-,~C:b1 J~ ~ , Filero: ,~~~.~r~~.~~~ a/k/a: (Assigned by Register) a/kla: a/k/a: Social Security No: ~ ~7J --~C~ - ~1 ~~ ~/ Date of Death: 1 , c,Z Gi - ~C-~_~ Age at death: tc3 3 Decedent was domiciled at death in ~;,utir ,~;,.,~~ County, ~~ (State) with his/her last principal residence at ~'7:~ C A~~j' 1~1C~; y~ '~s[- CCu`i51,,,~~. ~'~-='^~~_)r_•~'t Street address, Post Office and Zip Code City, Township or Borough County Decedent died at ~ac`, •;ysr• 1~c-r,t~,~ ~:~, (~ ~~,; ~ , c~ ,~ ~.~~~:-~ ~ ] '}`~~}. Street address, Post Office and Zip Code City, Township or Borough County State Estimate of value of decedent's property at death: IJdomiciled in Pennsylvania ............................ All personal property $ If not domiciled in Pennsylvania ........................ Personal property in Pennsylvania $ If trot domiciled in Pennsylvania ........................ Personal property in County $ Value of real estate in Pennsylvania ......................................................... $ TOTAL ESTIMATED VALUE.... $ 5 ~~, Real estate in Pennsylvania situated at: (Atlncl~ additional sheets, if necessary.) Street address, Post Office and Zip Code City, Township or Borough A. Petition for Probate and Grant of Letters Testamentary Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in tl~e last Will of the Decedent, dated thereto dated County and Codicil(s) State relevant circumstances (e.g. renunciation:, deat/r ojexecutor, etc.) Except as follows: after the execution of the instrument(s) offered for probate Decedent did not many, 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.u., d. b. n., d.b.n.c.t.a., pendente life, durunte 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) a~ld 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 survivedby tl~e following spouse (if any) and heirs (attach udditionul sheets, if necessary): Name Relationshi Address ~ 1 ' 1Q`~~ i 1 ~.,j''lC,~ t ` Jt.%e1. ~~~~ ~J%(C~i' ' ~~ ~ r' ~Nl`~ ~~.~v ~ ~'1'1RC~tL~ ~. l~ vl u~-11c:, ~t ~O J I `~ ~ p J,+~.l Cw ~ ~ ~ ~~ u ~~ ~~ 17 ~~ ~. -~~e..r~, I~~ ~ ~ to ~ ~ ~ ~ , ~ ~ Ca`~ ~~% Fo,-,~t ~w-nz rev. 10/!1/1011 Page 1 of 2 Oath of Personal Representative CO~(~(OV'~.'v'E.~LTr{ CF Pc~'~S`: LV,~~lI.-~ } J ~ :~-~; ~ ~ C c~ w m ~ ~ a t:TJ . ~ r n ~ rn ~ rn ~ ~ t... ~- oificiat ~.~. ,"~ _~ ~'' ~ ~°~- i° -w~; ~~. _~ The Petitioner(s) above-named swear(s) or affirm(s) the statements in the foregoing Petition are tnie and correct to the best of the knowledge and belief of Petitioner(s) and that, as Personal Representative(s) ofthe Decedent, the Petition r(s) will well aild truly administer the estate according to law. Sworn to .o affirmed and ~bscribed before Dated -~ ~j me this th day of ~~----~~n//i.n ~' ~ ` - ° °7 .° ° ~ BY~ o~~ f`~7• / u'tne Register Date Date Date BOND Required: ~~'~S ~NO FEES: Letters ...................... $ L~ . i ~. ( ~ )Short Certificate(s)...... ~~• 4'~ ( )Renunciation(s)......... ~t'C ( )Codicil(s) ............ . ( )Affidavit(s)........... . Bond ........................ Commission ................. . Other 111 ~ /G~k° ~ /9 ~f'/I CG~1.~ .... c' ~ ~'C Automation Fee ............... °4~' JCS Fee . .................... TOTAL ..................... $ ~' To tl~e 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 ~ ~ ~~~ /I ~ File No: a/k/a: ,.... AND NO~V, ~ ~r ~ ~ ~ , in consideration of the foregoing Petition, satisfactory proof having been pr ented before me, IT IS D C ED t at L tters ~ , ` ,- ~ are hereby granted to ~ V~~ ~• ~~. in the above estate and (if applicable) that the instrument(s) dated described in the Petition be admitted to probate and filed of record as the last tiVil (and Codicil(s)) ,Decedent. Register of Wills al'1~~~ 1fiff~~19~C; ~~ s:~ il~~c~iG~~ ~ o~l.~~i~ ~§ ~x}1~° ~v.~a~,~Y ~~~ }~c~~e~~~ ~r ~~~~~~9~~~pf~. [ RECORO~D 0~~'ICE OF ~ ,3: i~ _;, L ~iai`~: t?,z)t t't;t` inf(jrtn~ttic~n 1~erc I~i~cn i t'CL Ft)r t}llti Ci?I'I1~~iC;liC, `~(~.O(1 ' ~-~ ~ _ . L. ~~ ~~ ~;~~~i •y-a~' €~ ~~= t i r{ t l_~ I (~`~:I~t, ll <?1:~ X111 C)ri'~ ij d~ ~~E`rCi~IC~t~f: O~~ ~~t'i .,'' ~, . ~~ ~• t ~ ~ ~ h ~ ~ R i1 ;~', y,., ., ~t ~ ., ~ot_ ~1~~: ~j._ ~_(jtit). Rc~~)str~3r_ ~-he c~r)~)nui (~~ ~ t ~ ~ ~ ~ '~ ~ r +ll ll ~ k ~'~ I~~ ~~3i t~ ~UII`1~ tU the ~I~lff_' ~'1~7~ i i ~1 ~~-~- --~ ~~~ ~' '! ~~.,=t.,. i.)'1+I_c.~ ~,); ;``C'?~s")i.lt?~'11r i~ilin'~T. ~- .,~~'f:~~a, .v _ ;,_ ~, - CLERK GF -~~ ;:~ , ±~- , _, ORP~A~ s ca ~ RT '~~~ ~~ 4 -- ___ - --- il p ~+(/~~( A k1 /~ I. ~O t_~(t:i.)Citi()n .'~ltit~~?t': OUMBERL~~D 1.s{;//~} j(L~~~} ~... _,,~_.I.~ '..I, ..s 4~ _,`i ..! ~?i1lC' I.`,`~itt"i~ Type/Print In COMMONWEALTH dF PESYLVANIA • DEPARTMENT OF HEALTH VITAL RECORDS Permanent CERTIFICATE OF DEATH Black Ink W W V D O_ 1. Decedent's Legal Name (First, Middle, Last, Suffix) 2. Sex 3. Social Security Number 4. Date of Death (MO/Day/V r) (Spell Mo) MELV IN J . HENCH JR . Male January 29, 2013 Sa. Age-Last Birthday (Vrs) Sb. Under 1 Year Sc. Under 1 Da 6. Date of Birth (Mo/D ay/Year) (Spel l Month) 7a. Birthpla e,(Ci and S tate or Foreign Country) 63 Months Days Hours Minutes Jul 17 1949 Car~is~e, PA y , 76. Birthplace (County) r an 8a. Residence (State or Foreign Country) 86. Residence (Street and Number -Include Apt No-) 8c. Dld Decedent Live in a Township? 172 E N h S Q Yes, decedent lived in twp 8d. Residence (County) . ort . t . , C>~berl-and 8e. Residence (Zip Code) 170 No, decedent lived witl-Iin limits of C: l i ~~ city/boro. 9. Ever in US Armed Forces? 10. Marital Status at Time of Death ~ Married Q Widowed il. Surviving Spouse's Name (If wife, give name prior to first marriage) Yes Q No Q Unknown ~{Divorced Q Never Married Q Unknown NOt Applicable 12. Father's Name (First, Middle, Last, Suffix) 13- Mother's Name Prior to First Marriage (First, Middle, Last) Melvin J _ HencY1 Sr _ Ma Jane Hollowa 14a. Informant's Name 14 b. Relationship to Decedent 14c. Informant's Mailing Address (Street and Number, City, State, Zip Code) 0 Melvin L_ Henctl Son 3552 Roxbury Rd_ Apt C Shippensburg PA 17257 C ac _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1_Sa. Place o oeathl _C h_e c_ o_n ly one_ _ _ _ _ _ _ _ _ If Death Occurred in a Hospital: ~) Inpatient - IIf Death Occurred Somewhere Other Than a Hospital ~ Hospice Facility 1~ Decedent's Home ° Q Emer enc Room/Out atient ~ Dead on Arrival 1 g Y P Q Nursing Home/Long-Term Care Facility Q Other (Specify) w 15b. Facil(ty Name (If not institution, give street and number) lSc. City or Town, State, and Zip Code 15d. County of Death LL Carlisle Re i.onal Medical Center Carlisle, PA 17015 CLi~berland -- 16a. Method of Disposition Q Burial ?~. Cremation 166. Date of Disposition 16c. Place of Disposition (Name of cemetery, crematory, or other place) .mo Q Removal from State Q Donation D other (specify) Jan 31 , 2013 Rr7r-iaTt Funeral Home (Crematory) 16d. Location of Disposition (City or Town, State, and Zip) 17a. Signa of Funera rvice nsee or Person in Charge of Interment 17b. License Number Carlisle, PA 17013 ~~~~_~~~ FII;~012909-L ~ 17c. Name and Complete Address of Funeral Facility Ronan Funeral Hoale 255 York Road Carlisle, PA 17013 m ° 18. Decedent's Education -Check the box that best describes the 19. Decedent of His anic Ori p gin -Check the 20. Decedent's Race -Check ONE OR MORE races to 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 to be. D 8th grade or less is Spanish/Hispanic/Latino. Check the "N O" ~-White Q Korean Q No diploma, 9th - 12th grade box if decedent is not Spanish/Hispanic/Latino. Q Black or African American Q Vietnamese ~~ High school graduate or GED completed ®-N O, not Spanish/Hispanic/Latino Q American Indian or Alaska Native ~ Other Asian Q Some college credit, but no degree Q Yes, Mexican, Mexican American, Chicano Q Asian Indian Q Native Hawaiian Q Associate degree (e.g. AA, AS) ~ Yes, Puerto Rican Q Chinese Q Guamanian or Chamorro Q Bachelor's degree (e.g. BA, AB, BS) Q Yes, Cuban Q Filipino Q Samoan ~ Master's degree (e.g. MA, MS, MEng, MEd, MSW, MBA) Q Yes, other Spanish/Hispanic/Latino 0 Japanese ~ Other Pacific Islander Q Doctorate (e. g. PhD, EdD) or Professional degree (Specify) Q Other (Specify) e. MD DDS, DVM, 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 Usual Occupation -Indicate type of work ~-iR/hite Q Japanese 0 Samoan done during most of working life. DO NOT USE RETIRED. Q Black or African American Q Korean Q O[her Pacific Islander Q American Indian or Alaska Native Q Vietnamese Q Don't Know/Not Sure Bi1t.C17i?r Q Asian Indian ~ Other Asian ~ Refused 226. Kind of Business/Industry Q Chinese Q Native Hawaiian Q Other (Specify) Q Filipino ~ Guamanian or Chamorro U S ~-.C1Ver"trmnt ITEMS 23a - 23d MUST BE COMPLETED 23a. Date Pronounced Dead (Mo/Day/Yr) 23b. Signature of Person Pronouncing Death (Only when applicable) 23c. License Number BY PERSON WHO PRONOUNCES OR CERTIFIES DEATH ~ a~ ~ ~ f 3 23d. Date Signed (MO/Day/Y r) 24. Time of Death ^^ O~ (.~ ~" +~~ 25. Was Medical Examiner or Coroner Contacted? Q Yes No CAUSE OF DEATH ' ~ Approximate 26. Part I. Enter the chain of events--diseases, injuries, or complications--that directly caused the death. DO NOT enter terminal events such as cardiac arrest, 1 Interval: respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. 1 Onset to Death rr~ i 1~~ IMMEDIATE CAUSE > a. G ~ \ ~~ ~ n O G ~ 1 ~ CI -~` (Final disease or condition Due to (or as a consequence of): ~ 1 resulting in death) _ O i dZ 64 -~- T-~ n~ ~ N -Q v n., .~ N ~ A ~ b. ~S- I Sequentially list conditions, Due to (or a a consequence of): 1 if any, leading to the cause /~ -y~ ~ listed on line a. Enter the c- 1- ~ !-S G PG ~ ~+ ~C ~~ ti--S / 1 UNDERLYING CAUSE Due to (or as a consequence of): 1 w - (disease or injury that /~ 1 ~- r ..~t.(.tin 1 initiated the events resulting d. tSC ~ V In death) LAST. ue to (or as a consequence of): 1 I 26. Part 11. Enter other sienifica nt conditions co ntributin¢ to death but not resulting in the underlying cause given in Part I. 27. Was an autopsy performed? 0 Q Yes ~ No ~ 28. Were autopsy findings available to complete the cause of death? O Yes No 29. If Female: 30. Did Tobacco Use Contribute to Death? 31. Manner of Death E Q Not pregnant within past year Q Yes ~' Probably ~ Natural Q Homicide v Q Pregnant at time of death Q No O Unknown Q Accident Q Pending Investigation m Q Not pregnant, but pregnant within 42 days of death Q Suicide p Could not be determined I-° Q Not pregnant, but pregnant 43 days to 1 year before death 32. Date of Injury (Mo/Day/Yr) (Spell Month) ~ Unknown if pregnant within the past year 33. Time of Injury 34. Place of Injury (e.g. home; construction site; farm; school) 35. Location of Injury (Street and Number, Ciiy, County, State, Zip Code) 36. Injury at Work 37, If Transportation Injury, Specify: 38- Describe How Injury Occurred: Q Ves Q Driver/Operator Q Pedestrian Q No Q Passenger Q Other (Specify) 39a. Certifier -physician, certified nurse practitioner, medical examiner/coroner (Check only one): D Certifying only - To the best of my knowledge, death occurred due to the cause(s) and manner stated. '.Pronouncing 8+ Certifying - To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner stated. D Medical Examiner/Coroner - On the basis of exa ina 'on and/or investigation, in my opinion, death ccurred at the time, date, and place, and due to the ca use o ( s) an d manner stated. ,~ yy G ~ 2 /"~ O ~ ~~ 7 Signature of certifier: i Title of ce rtifie r: License Number: / 396. ame, Address and Zip Code of Per o Completi Cause of Death (Item 26) ' ~ ~ 39c. Da Signe (Mo/Day/Yr) ~~ton/ O ~ i ~ Lj p ~~ ~ / /-~(Lt t s (e )-~o s _ Cotsz 1. s re f~ 1 fit, I S~ ~ a 9 ,~2 0l 3 40. Registrar's District Number 41. Registrar's Signature 42. Registrar File Date (Mo/Day/Yr) 43. Amendments 0 ~~3 ~ ~-/ H105-143 Disposition Permit No. REV 07/2012 ~i-13 -33 ~ © t" a:: ~ ~ ~ ~~ REl~iU~'~tCIATI~~+T m ~ ~ ~ ~' ~ ~ ~~ ~ ' ~ - REGISTER OF WILLS o ~ ~r~~Jc~ I t~ ~~ ~ COUNTY, PENNSYLVAI~ -.`~ ;~ ~~ ~.;~ v~ F__j ~~= ; Estate of ~~'\~~ ~; ~ ~ J ~~ ~ ~~~~. ~~ ~ ,Deceased I, J ~ s s , c ~ \~ l~~c,. ~ c ~ _ , in my capacity/relationship as (Print Name) C,~.~~, Y. ~..~ of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to (Date) Executed in Register's Office Sworn to or affirme '~ and subscribed before e his ~ -/~ day ~_~ ~puty for Register of Wilis t! 1 - f (Signal e) (Street Address) c,~,~ }~, ~1~ ~~.~\ 1~~2y~ (City, State. Zrp) 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 purposes stated within on this day of , Notary Public My Commission Expires: (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission.) Form RW-06 rev. /0.!3.06 ~~-~3~~~ rv ~~i RED L~~tCIATIO~,' ~ © w -~ ~ ~ m --~.~ ~ ~ rn `r' ~.' .M~ ~..~ REGISTER OF WILLS `~ rn ~ ~ ~ -~ ~''~ `~°~' .~' ;~ n-, ~ -- . i~< ~ Wit' COUNTY PENNSYLVANIA ~- ~ ~` ~ ~J ~ ^7"} .,"~ ` j ~ ~ II ~ / ~ C/~ Q . 3~" ~ C.~ Estate of ~~ e ~ v , ~~ ~;> >~\ ~ ~. ~_ ~~ ~ ~ ,Deceased I, ~~iS o.m~ 1; ~ 1--% ~ ~a, ~, __ , in my capacity/relationship as (Print Name) 5~-> y~ of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to ~~i r'~'iri~ C ~~~1~ L / ~~~ ~ ~ ~ ___.. (Date) (Signature) Executed in Register's Office Sworn to or affirmed and subscribed befor m this t ~' day of _ 2v _ u %~~- uty for Register of Wills ~ .~ (Street Address) (City, State. Zip) 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 purposes stated within on this day of , Notary Public My Commission Expires: (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission.) Form RW-06 rev. 10.13.06