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HomeMy WebLinkAbout02-08-13PETITION FOR GRA\iT OF LETTERS REGISTER OF WILLS OF ~ ~)'I~~~~~ ~~ ,( j`~(~ COUNTY, PENNSYLVANIA Petitioner(s) named below. who isiare 18 years of age or older, apply(ies) for Letters as specified belo~~. and in support thereof aver(s) the following and respectfully request(sj the `rant of Letters in the appropriate form: Decedent's Information Name: _ Tc~Sc-',~"~t L ~~ lG a/k/a: a/k/a: a/k/a: Date of Death:. (- ~ -- ~ ~ File No• °~~ t _ 4 , _; i l~-~ (Assigned by Register) Social Security IV'o: l~ d - ~~~ ~ ,5~7,~ti ~ Age at death: ~ ;~ Decedent was domiciled at death in Ur~;~'c~~ 5~~4`~~s County, ~. y;a~. ~,^ f~,,,r principal residence at f,;t ~ ~~ C ~ j ~ ~ / ~ (State) with his/her last ' ,s•~ ~ 1 ~7 its ~=5,:'r~ 'tic-cT` '' ;fit Street address, Past Office and Zip Code City, Township or Borough Count Y Decedent died at. /~> ~y ~~r~ 7~`' ~os ~; `f~4 j ~'d.yr y~~~., ' l~ ~ yni ~ /~ ~f c r ~` Street a dress, Post Office and Zrp Cane City, Township or Borough Count • } State Estimate of value of decedent's property at death: IJdon:iciled in Pennsylvania ....... . .................... All personal property $ ~ .•~r_~C:'e . ,C-»~~ If trot 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.... $ _ Real estate in Penns}~Ivania situated at: ------~ (Attnch additional sheets, ijnecessary.) Street address, Post Office and Zip Code City, Township or Borough Count Y ^ A. Petition for Probate and Grant of Letters Testamentar Petitioner(s) aver(s) he/she/they is/are the Executor(s) named in the last Wili of the Decedent, dated thereto dated and Codicil(s) State relevant circumstances (e.g. renunciation, death ojexecutor, etc.) Except as follows: after the execution ofthe 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 Dave a child born or adopted; and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. ^ NO EXCEPTIONS ^ EXCEPTIONS Petition for Grant of Letters of Administration (ifap licable P ) c. t. u., d. b. n., d.b.n.c.t.u., pendentelite, durunteubsentia, duranteminoritute If Administration, c.t.a. or d.b.n.c.t.a., enter date of Will in Section A above and com lete list of heirs. Except as follows: Decedent was not a party to a pending divorce proceeding wherei~i the grounds for divorce had been established as defined iil 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 ;eft no Will and was survived by the following spouser3ny) a~ } (attach uclditionul s•heets~, i~ necessary): ~ ~~~ ~~ ~ G ~+ --r G~ t'? Form RW-OZ rev. I tL'I i'/1011 Page 1 of 2 / ~7ci The Petitioner(:;) above-named swear(s) or affirm(s) the statements in the foregoing Petitior. ar° tnle and correct to the best of the knowledge and belief of Petitioner(s) and that, as Personal Representatives} ofthe Decedent, the Petitioner(s) will well and truly administer the estate according to law. Sworn to or affirmed a subscribed before me th day of ,~~ ~ .~~~ Date ~y: t ~ ~~ I l~' ~ ,~ _ Date ~~~ ~'°- -~ ~ ~ Cate Fa- the Re, ister Date BOND Required: []YES ©'~10 FEES: Letters ...... . ( { )Short Certificate(s)..... . ( )Renunciation(s)........ . ( )Codicil(s) ............ . ( )Affidavit(s)........... . Solid....... ................. Colll lil l5s1o11 . ... ......... .... . Other ~' ~ ....... ~~ `~~ `7-~- l~ ()-L~ Automation F'ee . .............. _~ ~(.~~.' JCS Fee . .................... "~ tai _~; TOTAL ..................... $ , . _ A~ To tl:e Register ajWi!!s: Please enter my appearance by my signature below: Attorney Signature: Printed Name: Supreme Court ID Number: Firm Name: Address: Phone: Fax: Elnaii: DECREE OF THE REGISTEtZ Estate of `;' ~ (~ .~.~1 ~T- ~ File o: ,..~ ~ (, .:~ I~ ~ , .._, AND NOW, ~ '~ ^ ;, ~ , ~ „ o~L ~,) , in consideration of the foregoing Petition, satisfactory proof having been p>; sented before me, IT IS D CREED that Letters F//j11('~4 ',~~! ~~ ) '7d ( ; ,are hereby granted to ~~ ,;, ~~~ in the above estate and (if applicable) that the instrument(s) dated ~ J ~1 described in t:he Petition be admitted to probate and filed of record as the last 1~Vill (and Codicil(s)) of Decedent. r ~, Re tster of Wllls Y ~~y,~~~.,. >' .. ' i' Fncrn_R6V_N. ....., rnn ~nnt.r _ - ~ - .. ., Oath of Personal Representative RE C 0 R ~ ~ ~ ~ F f ~, ~ o rr ~: ;~~~ o~~y c~~,I~ro~~.~ ~ECs-S~'~'R G t,Ar~t '~.S E.\LTH CE PE~~;S`r LV:~~;I,-~ } _~~ .. ~;: ,;~r~1r ~~~=__ ..~ DEB 8 ~ ~ ~ 52 #~,!~.~~l~i~ i~~Q~ ~lir.~t~' ~f~i- + ;:'.;~~r ~t~t ~-:"It?~~s:.,t~~ ,,~ ~i-~1F~c:s(>. . REGISTER OE ~~'!I LS _. t, ,~ f ~~. ,, . I~t) :e![rt. i. i,; , ~3 FE8 8 P~ 5 , ., -- '~ ~ ~ ~ ~, t''t'fr~ [,. .. ilil,ilif`13 fit, 't~ !~ r. L ~~C~` /~~r-. ~}C~,~~ r _ ~ ~ It!;;7 (.tf111i_,11 1 ~~~~~ ~':~l~~l CLERK Qr ;~ti `"r _ ~~ i ~)^ ~~ ~,,,r,': ( ~ rl~ 1,; ,[ ~.~ ~ ~r~ ~~ If ti, ', ORPHANS' CCt1R i : ~~ +,~~. ,i (tit t It~ti~l_ IL .., rY:~ P 1917 91 ~~ 4 CUt~BERL~4ND C?., PA ~~~ •- - ~r .,.,,- '° n J ,~ nt In ~ -' " ~ ~ .„l COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH • VITAL RECORDS - - ent nk CERTIFICATE OF DEATH =~=~cn, , ~cgei name (rust, Mraoie, Last, Suttiz) 2. Sex 3. Social Security Number a~ Date o/ Death IMO/DaY/Vr( (Spell Mol Joseph C Bulo Male 161-22-5750 Jan 2 2013 6a. Age~Last Birthday (Yes) 6b. Untler 1 Year Sc. Under I Da 6. Date of Birth (MO/Da /Y S ll y ear) ( pe Month; 7a. Birthplace ICity and State or foreign Country) Months Days Hours Minutes ' 83 arPSltUm PA 1 August 27, 1929 7h. Birthplace (County) ell 8a. Residence (State or Foreign Country) Bh. Residence (Street and Number ~ Include Apt Nol 8c. Did Decedent Live in a Tow n s hi p? ~~ TT 77 ~~ r~ 427 Pawnee Dr •~Vez, decedent lived in "`""I••Pn Bd. Resid e CC (COU nt •w - _ ue • i ~d - P 1.u1~uJCi 1 8e. Residence (Zip Codel ^NO, decedent lived within limits of _ city/born. 9 Ever In US Armed Forces? 10. Marital Status at Time pf Death ^ Married ^ Widowed 11 Surviving Spouse's Name (If wife, Yes ^ No ^ Unknnw ~ Di give name prior to first mar lo ) ge vo ced ^ Never Married ^ Unknown 12 f th ' . a er s Name (First, Middle, Last, Sulfix) Jose h Bulo 13. Mother's Name Prior [o Frrs[ Marriage (First, Mitldie, Last) 14a. Informant's Name Amelia Chromik ]46. Relationship to Decedent Jeff Bulo lac In tormant's Marling Atldress IStreet and Number, City, State, Zip Code' Son 427 Pawnee Dr. Mechanicsburg, PA 1050 ~~~~ ~ .. „, t5 Place of Death Cneck only one! I(D th O c ed Mos [a L~~ kk++~a~~In anent ~ ~ ~ ~~ ~`~ - -~~ '"~ "" ""' "" ""' .. Pr P k~ Hos ... - ....... .... .. ..... ;If Death Occu ed Somewhere Other Than a Hpsp tai ~ ~~~" ^ E.mergency Room/Outpatient Dead on Arr I ^ P ce Fac tty ^ Decedent s Home ^ ^ Nursin H g ome/Long-Term Care Facility ^ Other (Specify) :6b Facility Name (If not institution, give street and number; ~16 Ci c. ty or Town, State, and Zip Code Hol S irit Hos 1ti31 15d County of Death Camp Hill PA 17011 i b p , un C erland 16a. Method of Disposition ^ Burial Af Cremation lbb. Date of Disposition 16c Plate of Disposition (Name of cemetery, cremator ^ Removal Irom State ^ Don y, or other place) ti a on other(spe~dy(____ 1/7/2013 t~nation Service 16d. Location of Disposition (City or Town, State, and Zipl 17a. Si naWEe Funeral 'tt ee erson in Charge of Interment 17b. License Number / Leola, PA 17540 / ~ ~ FD 013239 L 17c Name and Complete Address of Funeral Facility Neill F1~neral Home Inc 3401 Mark St Hill P 17 11 18 Decedent's Education -Check [he box that best describes the 19. D cedent of Hispanic Ori in -Check th ' g e ZO Decedent s Race -Check ONE OR MORE races to Inc icate wha! highest degree or level of school completed at [he time of death. bow that best describes whether the decedent th d e ecedent considered himself or herself to be. ^ 6th grade or less is Spanish/Hispanic/Latino. Check the "NO" White ^ vo diploma, 9th - 12th grade ~ ^ Korean box if decedent Is no[ 5 ^ High school graduate or GED completed panrsh/Hispanic/Latino. ^ Black or ghican American ^ Vietnamese No not S i h/H , pan s ispanic/Latino ^Amencan Indian or Alaska Native ~ Other Asian ® Some college credit, but no degree ^ Yes Mexican M A , , exuan merican, Chicano Asian Ind tan ^ Associate degree le.g. qA, q51 ^Ves Puerto Rican ^ ^ Native Hawa~ian , ^ 9achelor's degree le.g. BA, AB, BSI ^ Chinese ^ Guamanian nr Chamorre ^ Yes Cuban , 0 Filipino ^ Samoan Master's degree le.g. MA, M6, MEng, MEd, MSW, MBA) ^ Yes, other 6panlsh,~Hispanic/Latino ^ lapa nese ^ Doctorate (e.g. PhO, EdD) or Professional degree (J Other Pacific Islander (Specify) - ^ Other lSpecity( _ (e.. MD, DDS, DYM, LLB, 1D _-- -- _. 21. Oeredent's Single Race Self-Designation -Check ONLY ONE to indicate what the decedent considered him ll h lf se or erse to be. 22a. Decedent's Usual Occupation ~ Indicate type of work. W White ^ Japanese ^ Samoan done Burin ^ Black or Afncan American Korean g most of working hie. DO NOT USF RETIRED ^ ^ Other Paciilc Islander ^ Amencan Indian pt Alaska Native ^ Vietnamese ^ Don't Know/Not Sure PO11CPma71 Asian Indian ^ Other Asian ^ Refused 21b Klnd of Business/Industry ^ Chinese ^ native Hawaiian ^ Other (Specifv) _ __ ___ _ ^ Filipino [] Guamanian or Chamorro _---- LaW Enforcement I '.IB TEMS 23a - 23d MUST BE COMPLETED ::3a. Date Pronounced Dead (Mo/Day/Yrl 23b. Signature on Pronouncing Death (Only when appll<able 23c V PERSON WHO PRONOUNCES OR lirense Nuno iC ~ . er ERTIElES DEATH i 'Z ([5 2 , 3d. Date Si ed IMo/Day/Yr) 24. Time of Death _ ~rl:~ ((, tl 6E ~.Z a '` _ L ~l mss,.] ~µ? 25. Was Medical Examiner or Coroner Contacted? ~ Yes ^ No CAUSE OF DEATH 16. Part I. Enter the chain of events--diseases, injures, or complications--that direct) c Appro mate y aused the death DO NOT enter terminal events such as <a rhia res i p <arrest nterval. ratory arrest, or ventricular fibrillation without showing [he etiology. DO NOi ABBREVIATE Enter only one cause on a line. Atltl additional lines if necessary Onset to Death '~ IMMEDIA FE CAUSE ---~-----.--~ a. _ S ' F - ( inal disease or condition ---------- Due to (or as a consequence of) - ----- resuitmgit death) \ t / Sequ entra lly list conditions, - ------' Due to (or as a c q fl. ~~ - ---- I anv. ieadng to the cause 11 ?stea or Irne a Enter the c ~~1~- VNDERLYINGCAUSE ~u~ L,.~--~~L~.-~----.-..__ __- Due ro for as a con el quence of) -'- - -- 'disease or nlury that ni(ia ted the events •esultinp d _ _ - ~' ~n death) LAST. -_ _-.-.-._.---. _. .. .. _ I Due ro Ior as a con5e _ - _ - - quence oft - -- ------ 25 Part IL Enter other srgnlficant COnd'[itlnS [ontrlbUtlne to death but not resulting in the underlvin cause i n in Parl g q ve ~ 7- Was an autopsy performed> / ~C` ~r ^Ves e' No r~x~~vW1 ~~~~ ~~ `{1 ~ " 1 ' ~4" ~- 28 Were autopsy findings availahle t l o comp ete the cause or tleath? /9 If Female' ^ Yes ^ No ^ Not pregnam within t 30. Ord Tobacco Use Contribute to Death ~ pas year 31. Manner of Death ^ Pregnant al time or death ~ yes ^ prohably ~]~Natural ]Homicide U k ^ No n ^ nown ^ Accident ^ Pending Inves[igabon ^ Nor pregnant, but pregnant within 42 tlays of tlealh ^ Not pregnant, but pregnant 43 days to 1 year before death 32. Date of Injury (MO/Day/Vr( (Spell Month) ^ `'ulcide ~ Could not be deform red ^ Unknown if pregnant within [he past year 33 time of Injury la Pl l i . ace e nlury (e.g home; cons[ru<lion site; farm; school) 35. location of Injury (Street and Number, Cit Sra y.- te, Zip Code) 6. injury at Work 37. If Transportation Injury, Specify; 38. Describe How Injury Occurred ^ Yes ^ Driver/Operator (] Pedestrian ^ Np ^ Passenger [] Other (Specify) ?3a- Certifies ICheck only one). ^ Certifying physician - To the hest of my Inowledge, death occurred due to the cause(s) antl manner stated fi }-Pro t nouncing & Certifying physician ~ Id the best of my knowledge, death occurred at the time, date, antl place, antl tlue [o [he cause(s) and manner stated ^ Medical Examiner/Coroner - On t basis of examinati d t on, an /or investigation, in my opinion, death occurred at the time, date, and place, and due to the cause(s) and mane er statec s nat~r r r ( a~ g eo [ern er__r< , ~; nueort.ruRer "yb1(> - License Numbers '/~ ~ s(~ 6 j 396 name, Atldress a d Zip Code of Person [nmpleti g Cause o/ Death (Item 26) ' ,r ( ~ ~~ ~ 39c. Dare Signed (MO/Day/Yr) Cc~-r't` it }~ ~7o ( i ~- ~l- 4'i Registrar's District Nu tier 41 R i ' I . eg s(r r Signature e (MO/Day/Vr r ~ ~ ,'~ .slr•Y17' ~ 42. Registra/r File Dar , J 47 Amendments ~ G }~ Disposition Permit Nn `~ ~ ` <j ~ ~. ~ _ _ REV 07/2011