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PETITION FOR GRANT OF LETTERS
REGISTER OF 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) the following and respectfully request(s) the grant of Letters in the appropriate form:
Decedent's Information
~zz 1 J
Name: Walter Albert Cox File No: 3 _ CJ 1 Y l ti
a/k/a: (Assigned by Register)
a/k/a:
a/k/a: Social Security No: 194-24-9769
Date of Death: June 18, 2012 Age at death: 80
Decedent was domiciled at death in Cumberland County, pA (State) with his/her last
principal residence at 1000 Claremont Road Carlisle 17013 Middlesex Township Cumberland
Street address, Post Office and Zip Code City, Township or Borough County
Decedent died at 1000 Claremont Road Carlisle 17013 Middlesex Township 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 Pennsylvania All personal property $
If not 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.... $ 0.00
Real estate in Pennsylvania situated at: FOR LITIGATION PURPOSES ONLY
(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
Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Will of the Decedent, dated and Codicil(s)
thereto dated
State relevant circumstances (e.g. renunciation, death of executor, etc.)
Except as follows: after the execution of the instrument(s) offered for probate Decedent did not marry, 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.
0 NO EXCEPTIONS 0 EXCEPTIONS
® B. Petition for Grant of Letters of Administration (If applicable) pendente lite
c.t.a., d.b.n., d.b.n.c.t.a., pendente lite, durante absentia, durante minoritate
If Administration, e.t.a. or d.b.n.e.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 dice had been blished a44efined
in 23 Pa. C.S. § 3323(g) and was neither the victim of a killing nor ever adjudicated an incapacitated perso= < rn M
NO EXCEPTIONS 0 EXCEPTIONS C7o ran G7 O
M C'> Cn ;u
Petitioner(s), after a proper search has/have ascertained that Decedent left no Will and was survived by the folmVi speuse (i uy) ar"eto (attach
additional sheets, ifneeessary): CJ 1
Name Relationship A R, 699
Catherine Cramer Daughter 7 Pine Road, Apt. 502, V
Mount Holly Springs, PA 17065 --~U co Alfred C. Cox (see attached renunciation) Son 3101 Springs Road, Lot 14 'v _ O
Carlisle. PA 17013' '*t
Jeffrey A. Cox (see attached renunciation) Son 3101 Springs Road, Lot 14
Carlisle PA 17013
David L. Cox Son Whereabouts Unknown
Form aw-02 rev. 10/1112011 Page 1 of 2
Oath of Personal Representative
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
}
} SS:
}
Official Use Only
Petitioner(s) Printed Name Petitioner(s) Printed Address
John B. Zonarich Es 17 South Second Street Floor 6 Harrisbur PA 17101
The Petitioner(s) above-named swear(s) or affirm(s) the statements in the foreg ng Petition are true and correct to the best of the knowledge and belief
of Petitior..er(s) and that, as Personal Representative(s) of the Decede t, the Pet Toner(s) will well and truly administer the estate according law.
Sworn to or affirmed and subscribed before Date Z S 1
me this I S~ day o ~ rl, ,~~'~ /.3 Date
B ~- n/ Date
For the Register ~ j Date
BOND Required: ~ YES ~ NO
FEES:
Letters ...................... $ O?~,'
(3 2') Short Certificate(s)...... 1.~, (~j
( )Renunciation(s)........ .
( )Codicil(s) ............ .
( )Affidavit(s)........... .
Bond ........................
Commission ................. .
Other .... , , ,
Gf1 ....... C1~
-E V ~ ..... ~ l~~
..... 'f~
Automation Fee . .............. ~ ,~ ,~jG
JCS Fee . .................... ~'.~--
TOTAL ..................... $ I .~:A6'
To the Register of Wills:
Please enter my appearance by my signature below:
Attorney Signature:
Printed Nam: John B. Z`onarich
Supreme Court
ID Number: 79989
Firm Name: SkarlatosZonarich LLC
Address: 17 South Second S r
Floor E ~ Q ,~,,,
Harrisburg, PA 1'1-~~ w ~ m
Phone: (717) 233-1000 m ~ ~ ~ ~
Fax: _(717) 233-6740 r-- ~?"' r' }--~ rn m
Email: ~h~(~.Skarlatns~nr~.ri~lb~~h ~ ~
`
~ ~
~ C Q
~ G . ;.
DECREE OF THE REGISTER ~ ~ c~ ~,~ r`~n
~- --~ ~ ~
Estate of Walter Albert Cox File No: _ ~~ - ~ ~~~
a/k/a:
AND NOW, (~ C~~. , ~ G ~ , in consideration of the foregoing Petition,
satisfactory proof having been p sented before me, IT IS DECREED that Letters of Administration Pendente Lite
are hereby granted to John B. Zonarich, Esq.
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 Will (and Codicil(s)) of Decedent.
Register of Wills .~~ n
Form RW-02 rev. 10/11/201 / ~
Page 2 of 2
rnrs:;os jtev (vn u
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
/~V RECORDED OFFICE OF
Fee for this certificate. $6.1J i ill 1 I fh', 61i1t (Ili llllt3f111a!Oil !lE)C: PjYen is
REGISTER OF WILLS ~ti'lt I~~
y> i~ ~.~111~~m a❑ o)IRinal Certii)Ctnc (4 Death
zi _ r ly "l;i: 61h me as Loco i F.C ktrar. The or(tdlnal
rail? 11C tl)mrtrl_ied to the State Vital
1013 FEB 1S AM 8 -
91
herm~(,ie;(t
CLERK OF
P 18597686
` ^RPHkNS COURT
Certification Number CllMBERLAND CO. PA Date Issued
Print In 16MMONWEALTH OF PENNSYLVANIA -DEPARTMENT OF HEALTH - VITAL RECORDS
'Is Irkl CERTIFICATE OF DEATH Slate File Number:
1. Decedent's Legal Name (First, Middle, Las,,Sumx 2. Sex 3. Social Secunry Number 4. Date of Death (MO/Day/Y,) (Spell Mo)
fa I q 4-97(o J e- 18 9.00,
5a. Age-Last 81rthday (Yn) 5b. Under l Year 5c. Under 1 D 6. Date of Birth (MO/Day/Year) (Spell Month) ]a. Blrthpla (CI d Sate or Foreign CO m')
G Months Day Hou Minutes y~
IEK.l3'~d- tG'3,~. 7b. em Place(County)
Bill. ResldeF (State or Foreign C.untry) Bit. Res1I dente (Street and Number Inclluude (Apt ~Na.) 8c. Did Decedent Live Ina Township2 ~1 J
IDW 00re"C*t'•k K[~z nyas, de<eeent llvee in m;UC,l.~~ex twp.
ad. Rest ence (DOpnry)
VVA1114 11 Be. Residence (Zip Cade) -7 C> 13 ❑NO, decedent lived within limits of city/bore.
9. Ever In US Armed Forces? 10. Marital Status at Time of Death Married Widowed 11. Surviving Spouse's Name (If wife, line name prior to first marriage(
11d Yes []No ❑ Unknown ❑ DNOrced Never Married ❑ Unknown
12. Father's Name IFIrst, Middle, Last, SufKr) 33. Mother's Name Prior to First Marriage (First, Middle, Last)
P_
CLY'Esw~.e_ Emx, 5y-. vex
=a_ 146. elationzhip to Decedent 111c. Informant's Mailing Address (S[ree[and NU r, Ciry, Stale, Zip Code]
`r 17 i X015
.Paceo Deal Check
........................................................................................°".Y..."8..............................slww
If Death Occurred in a Hospital: I~ Inpatient :I/Death Occurred Somewhere Other Than a Hospital: LJ Hospice Faclllty Decetlen['s Hame
[]Emergenct Room/Outpatlem ❑ Deadon Arrival Nursing Home/Long Term [are Faclllty Other (Specify)
i 15b. t Ili not InstHUtion, Si street and number; • 15c. Ciry Z Town, State, and ZIP Code 15d. County of Death
i Ii51ePA 1'7o13 p
I6a. Method of Disposition IR EN&W ❑ Cremation 166.°{1. of Disposition 16c. Place of Disposition INameof cemetery, crematory , or other place)
m Removal In 5Staite []Donation I _ladIapI'~ Rot {141 y?.-" Mevytuvii'l P"
1 Dec N) tP Il l~7
v 16d. LacationofDis`pStion(City or Town. State, and Zip) 17a. Slgna Fun Ise Ice Licensee. rsonin Chargeoflnterment 1]b.lkense Number
4 C&uw l~ill P~ t~Utl OI
E 1]c. Name and Complete A~dress of Funeral Facility
8 r. 705E5
38. cedem's Education-C ck the box that best describes the 19. Decedent of His cOrigin-Check the 2.Deceden['s Race-Check ONE ORE racosto Indicate what
2 highest degree or level of school completed at the time of death. box that best describes whether the decedenl the decadent considered himself or herself to be.
❑ gth grade or less Is Spanish/Hispanic/Latino. Checkthe"NO' White ❑ Korean
❑ No diploma, 9th 12th grade box If decedent Is not Spanish/Hntutric/Onno. ❑ Black or African American ❑ Vietnamese
❑ High school graduate or GED completed No, not Spanish/Hispanic/Latino ❑ American Indian or Alaska Native Other Aslan
❑ Some college aedlL but no degree Yes, Mexican, Mexican American, Chicano ❑ Asian Indian ❑ Naive Hawaiian
Associate degree le.g. AA, AS) Yes, Puerto Rican Chinese Guamanian or Chamorro
❑ Bachelor's degree (e.& BA, A8, BS) ❑ Yes, Cuban Filipino Samoan
❑ Master's degree (e.g. MA, MS, MEn& MEd, M5W, MBA) ❑ Yes, other Spanish/Hilpi nlc/Latino Japanese Other Pacific Islander
❑ Doctorate (e.g. PhO, Edo) or Professional degree ISpecity) ❑ Other (Specity)
e.. MD, DOS DVM LLB, ID
21. Decedent's Single Pace 1,11-Designation Check ONLY ONE[. indicate what the decedent Cansitlered himself or hersel/to be . 22a. Decedent's Usual occupation - Intllcate type at work
,White Japanese []Samoan done during most of working life. DO NOT USE RETIRED.
❑ Black or African American ❑ Korean Other Pacific Islander
❑ American Indian or Alaska Native ❑ Vietnamese ❑ Don't Know/Not Sure d,ey
❑ Aslan Indian ❑ Olher ASlan ❑ Refused 22b. Kind of Business/Industry
Chinese ❑ Native Hawaiian ❑ Other (Specify) Filipino ❑ Guamanian or Chamorro L f r g 111 ('TQYL
ITEMS 23a"23d MUST BE COMPLETED 23a.IDate Pronounced Dead (MO Day ) 23b. Signature of Person Pronoun ng Death (Only when applicable 23c. License Number
BY PERSON WHO PRONOUNCES OR LJ(Jl / C}/(/) ~j )
CERTINES DEATH
23d. ..,a Signed (M oay/Yrl z4. Time I Death lll~~~ t-
U~.1 2S. Was Medical Examiner or CO er [o ac[ed] ❑ Yes ❑ Na
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 Interval:
respiratory arrest, m ventricular fibrillation without showingthh etio/lsogy. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary Onset Ia Death
IMMEDIATE CAUSE ----------x a. Y1A GI t,
(Final disease or condition ue to Ior as a consequence of):
resulting In death) o
It.
eiV'U't,61~a
Senuenrally list conditions, Due to tar as a consequence of):
if any, leading to the cause
listed on line a. Enter the
UNDERLYING CAUSE Due to (or as a consequence oo:
leisease ar Injury That
F initiated the events resulting d.
In death) IAST, Due to for as a consequence of):
s 26. Part H. Enter that significant conditions contributing to death but not resuting In the underlying ,use given in Panl 27 . Wasan auto
ee]
❑ yes No
P' no
f 28. Werc autopsy findings available
to complete the cause of death]
[]Y []No
29. If Female: 30. Did Tobacco Use Contribute to Death] 31. er -l Da E ❑ Not Pregnant with in past year ❑ yes ❑ Probably Natural ❑ Homicide
❑ Pregnant at time of death ❑ No ❑ Unknown ❑ Accident ❑ Pending Investigation
❑ Not Pregmu,L but pregnant wlthin 42 days of deatf ❑ Suicide ❑ Could not be determined
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 yea, 33. Time of Injury
34. Place of Injury (e.g. home; construction site; farm; school) 35. Location of Injury (Street and Number, City, State, Zip Code)
36. Injury at Work 137. If Transportation Injury, Specify: 38. Describe How Injury Occurred:
❑ Yea, ❑ On-/Operator Pedestrian
❑ No Passenger ❑ Other (Specify)
39a. ~C}yrrttiZ (Check only one)'.
; C ru ng physician . To the best of my knowledge, death occurred due to the cause(s) and manner stated
❑ Pronouncing & Certifying physlclan - To the best of my knowledge, death occurred at the time, date, and place, and due to the cauze(sl and manner stated
O Medical Examiner/Coroner-On jhe bb^asis of ex'a'minit/ion, and/or Investisgattion, In my opinion, d,,th occurred at the time, date, and place, and due to thecau/se(s) andm'annner statetl
Signature of certifier: ~ el Title of arbiter I C License Number: 0 OX- VJ 3 - e
3IA) 9b. Name; Address and Zip Code of Person Completing Cauu of Death (Item 26) 39c. ..tell gn (Ma/ ay/Yr) ,
_urft
. o ar/~sU I "io ZOIz-
40. Registrar's District Number 41. Regi Ign t 42. Peg trar lle Dat (Ma/Day r)
1, I • ~ 4 h ~ • 6 ~t H l
43. Amendments
Disposition Permit No. ri 7,29H I9 REHV 105-143
0]/2011