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HomeMy WebLinkAbout03-14-13REGISTER OF WILLS CUMBERLAND COUNTY PENNSYLVANIA . SMALL ESTATES AFFIDAVIT ~ ,, For Insurance Proceeds c~ ~ ~ rn © ~ ~ ~ ca ~~ ~„ ~_~ ~-~ (Original Death Certificate Must Accompany this Form) ~ ~ --~ C!~ =~~ ~ r'~ Deceased ~ ~ ~ l~- C~- ~ Case No. ~ ~~ - =~ ;~ ~ .:Ma ~ •~ also known as Social Security No. ,~ - ,~~.~- ~ .~ ~' Before the Register of Wills of said County personally came ~{ }{u ,~ . I j1S L~.(~lZ t~ 6"'~ ~~ who re~i~es -~- ~~~ '~~ °~ , ate 5 ~ $ ~ p.~-e ~~ ~~ ~~ ~Z, C ~~ )~-i LL ~C~ i -70 l i ,being duly sw rn, deposes and says that 1 0 ~ >2 ~- y , ~ l S 1-~ 2 i~ ,age _ , a resident of 35 y ~ Sep i-e_~he..ra.. ~~., Ch-~~ t~ ~t ~Pci l `t ~ ~ t in said County, departed this life, at I-~b tit f on the ~'~ ~ i 4 day of A.D. 20 ~_rj ~ 12 pm o'clock (~ M., possessed of personal property estimated to be of the value of $ . ~ ,and possessed of real estate, the estimated value and the location of which is as follows: Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of any testamentary writings whether or not offered for probate; was not the victim of a killing, was never adjudicated an incapacitated person, and was not a party to a pending divorce proceeding at the time of death wherein grounds for divorce had been established as defined in 23 PA C.S. section 3323(g): The total amount of insurance proceeds payable by ~.~ ~.?~-c., does not exceed $11,000 and 60 days have elapsed since the death of the insured. The undersigned agrees payment cannot be made under this Affidavit if a written claim for same has been made by a Personal Representative of the estate and no other heir(s) having preference exist or have released their benefits to the undersigned. ~` Tat said decedent left aspouse -whose name and residence is e ~ R ~ ~ ~"J ~~ tt A'~-~ ~5 ~g ~~P~emhL~- ~ i2.~vre C~~~ I~-~ ~-~ a d t ~ and the following as next of kin: NAMES RELATIONSHIP RESIDENCE ` . z a h~~ ~~~ S~R~-~~ R~~ ~2t~~ ab,e rz. ~- ~/' ~ 1 5 i +~- Q O .~ ~ Soh 18 ~ I 17 r ~ r v i l r ~ ~~c<< r ~ J~ ~ -S l~G~(Zc~ t ~ Q 35~ Se ~ 2 That the above named are the spouse & and all the known next of kin of said decedent, to the best of my knowledge and belief. _ Your Petitioner avers there are NO KNOWN PROBATABLE ASSETS that would require an estate proceeding. Therefore, NO ESTATE WILL BE RAISED, AND LETTERS ARE NOT NECESSARY. Signed .. By: ~ ~ Sworn and subscribed to l ~' day of r 0,~~ ~~ GC My me this 20 I I ~.~•C.~~ uss~on gncp~res ~,~ met, ~ ~~~~ P~- P~. P 1~ ~~ C~~ t-ro ~ i Register of Wills: 1 ~!~ Kindl a to appeara ce in t e bove case this _1/ da of ~"^' , 20 y Attorney I.D. No.