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Home My WebLink About03-25-13 Q M t'r7 X �a ca o -0 rn C> PETITION FOR GRANT OF LETTERS � Cn � � REGISTER OF WILLS OF n wy'tn6cy COUN ', ERNSY�.VANlA Petitioner(s) named below. who is/are 18 years of age or older, apply(ies) for ers ass citied btfiow. and in rL- support thereof aver(s)the following and respectfully request(s) the grant of Letters~ili M-6 approp r,7te fdrm. Decedent's Information �j- 3 "r1 Name:_,lo(rn� dc-. "r ?®�,ovc. File No: 4 a/k/a: (Assigned by Register) a/k/a: a/k/a: Social Security No: OXC, - 1 Z- 11-to 2.. Date of Death: l X6 ti 3 Age at death: Decedent was domiciled at death in AC. County, PrA (state)with his/her last principal residence at v--C�,n _� wc.- ,Q V-,t, V,-06c,ti4�.Q Street address,Post Office and Zip Code City,Township or Borough County Decedent died at_ c, _ L ew e G Street address,Post Office and Zip Cog City,Township or BdWugh County State Estimate of value of decedent's property at death: If domiciled in Pennsyl vania............................ All personal property $ If not domiciled in Pennsy lvania. ....................... Personal property in Pennsylvania $ If not domiciled in Pennsy lvania. ....................... Personal property in County $ �-- Value of real estate in Pennsyl vania......................................................... $ TOTAL ESTIMATED VALUE.... $ 60 000, Real estate in Pennsylvania situated at: (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 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.a.,d.b.n.,d.b.n.c.t.a.,pendente lite,durante absentia,durante minoritate If Administration,c.t.a.or d.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)and was neither the victim of a killing nor ever adjudicated an incapacitated person. 12 0 EXCEPTIONS E]EXCEPTIONS Petitioner(s),after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse(if any)and heirs(attach additional sheets,if necessary): Name Relationship Address t��w�l otn ogee acs cr1 I �-tS` v�t•.�.s5 IMe�l..a ws 6u r� 'V-N 7 o S-C-) Form R w--02 rev.1011111011 Page 1 of 2 A" 1'.'.--: a 3 Ix -ID IT C, _ 3' v r Offi Vllse Only, �t Oath of Personal Representative :.4- rn cr COMMONWEALTH OF PENNSYLVANIA } c _ COUNTY OF 011�011U nl.{ } SS: ` c...-. F_ :1,• e c:7 'd Petitioner(s)Printed Name Petitioner(s)Printed Address 1e e l )Ofr1DU cA✓1 /5`/.5 Tr tvc,;-)cs 5 Dt Olez,4c,.„ t_s /76.5-6 The Petitioner(s)above-named swear(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 that,as Personal Representative(s)of the Decedent the Petitio (s •11 well and truly administer the estate according to law. Sworn to •r affirmed a d ubscrib-d to-for ,,!i�' ?-- Date j-0•25-37-5 me t is 05. y of /�/*��L_� ,' 0 Date By: _ Date . th Register Date BOND Required: 0 YES Q NO To the Register of Wills: FEES: Please enter my appearance by my signature below: Lette d t ,ys $ � Attorney Signature: ( , ) Short Certificate(s) �'` ( )Renunciation(s). ( )Codicil(s) ( )Affidavit(s) Bond. Printed Name: Commission Supreme Court Other ID Number: Firm Name: MUM. Address: ra7M7of.�/ 3v.too , Phone: Automation Fee , D d Fax: JCS Fee. 7 Email: TOTAL $ °9613' /tV.\/7) k` DECREE OF THE REGISTER 1 Estate of (-\n n k 2 (L �Z)YY/lIC)I File No: 71 -13 2,J 9 a/k/a: AND NOW, (-t(Ch 2 Lp , 2 C , in consideration of the foregoing Petition, satisfactory proof having been presented before me,IT IS DECREED that Letters art f14 ) 14,( (y(t (J) ) are hereby granted to if (Le_1 C(ThOV/CV:_1l in the above estate and(if applicable)that the instrument(s)dated IVIM described in the Petition be admitted to probate and filed of record as the last Will(and Codicil(s))of Decedent. • •l 1 ,J ) iv A � t ■ :.i Register of Wills ) ( D C1(Le/Si/� CUP Form RW-02 rev. 10/11/201; Page 2 of 2 H105.805 REV(9/11) LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARPIl • It is illegal to duplicate this copy by photostat or photograph. DE'D 'op ICE or REGIS TER � � Fee for this certificate, $6.00 ..,�,� ,r This is to certify that the information here given is k. > 13 r r +,tt��p�jH OF pE - correctly copied from an original Certificate of Death J � v q `�,�� _ l9` duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital CLERK '� rJ yam' a Records Office for permanent filing. ORPHANS � 19 7 9 5 3meE RLAr -.9rM ��;,,,(t� 1 C Certification Number Co.� , P,� '-"'ENT��'"Ffl Local Registrar Date Issued r !/Print In COMMONWEALTH OF PENNSYLVANIA•DEPARTMENT OF HEALTH•VITAL RECORDS manent ack Ink CERTIFICATE OF DEATH State File Number: 1.Oece1(e�t's t.egu Nam First,Mkidk,Last,Suffix) 2.Sex 3.Social Security Number 4.Date of Death(Mo/Day/Yr)(Spell Mo) �IOl1I1 li male 1 029-12-1402 5a.Age-Last Birthday(Yrs)ISb.Under I Year 15c.Under 1 Day 16,Date of Birth(Mo/Day/Year)(Spell Month) 7a,,alrthRlace IC1ty�3M State or Foreign Country Months Days Hours Minutes , S. t 93 June 10, 1920 7b.Birthplace(County) Suffolk 8a.Residgj�e(State or Foreign Country) 8b.Residence(Street and Number-Include Apt No.) Sc.Did Decedent Live in a Township? YA 1100 Grandm way es,decedent lived in Hampden n twp. 8d.ReurldY)Id Be.Residence(71p Code) 17050 []No,decedent lived within limits of tlty/boro. 9.Ever in US Armed Forces? 10.Marital Status at Time of Death []Married 2(X Wklowed 11.Surviving Spouse's Name(If wife,give name prior to first marriage) f0 Yes ❑No ❑Unknown ❑Divorced ❑Never Married ❑Unknown - 12.Father's Name(First,Middle,Last,Suffix) 13.Mother's Name Prior to First Marriage(First,Middle,Last) f. 14a.I�rma�nt'ss Nam 14b.Relationship to Decedent 14c.Infomant's Mailing Address(Street and Number,City,State,Zip Code) 1545 Inverness Dr., Mechaicsburg, PA 17050 ............ ........................................ ,........1.�:.......5....��.............?!!.ale................. a If Death Occurred In a Hospital: D�Inpatient ;If Death Occurred Somewhere Other Then a Hospital: �'(Hospice Facility D Oecedent's Home ❑Emergency Room/Outpatient ❑Dead on Arrival Nunirlg Home/Long-Term Care Facility Other(Specify) C I15b.Facility Name(If not institution,give street and number; .15c.City or Town,State,and Zip Code 15d.County of Death Emeritus at creekview Mechanic PA 17050 Cumberland 3 16a.Method of Disposition ❑Burial XR Cremation 16b.Date of Dispel n3 16c.Place of Disposition(Name of cemetery,crematory,or other place) - ° ❑Removal from State ❑Donation Jan�y 21, Hollinger Crematory i ' other(Specify) . Z16d.Location of Disposition(City or Town,State,and ZIP) 17s.Signature of Fune Service Ucensee or Person in Charge of Interment 17b.License Number i Mt. Holly Springs, PA FD 011667 L 17c.Na and Com ete Address of Funeral Fadllry Ma pezz FW_1eral Hare, 8 Market Plaza Way/-, Mechanicsburg, PA 17055 -1 18.Decedent's Education-Check the box that best describes the 19.Decedent of Hispanic Origin-Check the 20.Decedent's Race-Check ONE OR MORE races to Indicate what 12 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. ❑8th grade or less is Spanish/Hispank/Latmo.Check the"No" 15 White Q Korean ❑No diploma,9th-12th grade box if decedent is not Spanish/FOspank/Latino. ❑Black or African American ❑Vietnamese ❑High school graduate or GED completed 91 No,not Spanish/Hispanic/Latino ❑American Indian or Alaska Native ❑Other Asian ❑Some college credit,but no degree ❑Yes,Mexican,Mexican American,Chicano Q Asian Indian Q Native Hawaiian ❑Associate degree(e.g.AA,AS) ❑Yes,Puerto Rican ❑Chinese ❑Guamanian or Chamorro a Bachelor's degree(e.g.as AB,BS) ❑Yes,Cuban Q Filipino ❑Samoan ❑Master's degree(e.g.MA,MS,MEng,MEd,MSW,MBA) ❑Yes,other Spanish/Hispanic/Latino Q Japanese ❑Other Pacific Islander ❑Doctorate(e.g.PhD,EdD)or Professional degree (Specify) ❑Other(Specify) e..MD DOS 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 :M White ❑Japanese ❑Samoan done during most of working life.DO NOT USE RETIRED. Q Black or African American ❑Korean ❑Other Pacific Islander Major - registered nurse Q American Indian or Alaska Native ❑Vietnamese ❑Don't Know/Not Sure ❑Asian Indian C]Other Asian ❑Refused 22b.Kind of Business/industry ❑Chinese ❑Native Hawaiian ❑Other(Specftyjy C]Filipino ❑Guamanian or Chamorro US ITEMS 23a-23d MUST BE COMPLETED 23a.Date Pronounced Dead(Mo/Day r) 23b.Signature of Person Pr no axing Death O��nly w/h/en applicable 23c.Ucense Number CE PERSON 1A DEATH PRONOUNCES OR /-/f-/3 �`-,I^^" ` CERTIFIES DEATH 23d.Date Signed Mo/Da/Yrj 24.Time of Dea1b� I_ �CCltlf 25.Was M ical miner or Coroner Contacted? ❑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, Interval: f respiratory arrest,or ventricular fibrillation without showing the etiology.DO NOT ABBREVIATE.Enter only one cause on a line.Add additional Ones if necessary i Onset to Death / IMMEDIATE CAUSE -------------> a. L',fa rcl 1 n c- A c(-P c;,+ (Final disease or condition Due to(or as a consequence of): s resulting)n death) b. Sequentially list conditions, Duet(or as a consequence of): it any,leading to the cause (� r listed on line a.Enter the C. I"c U,� UNDERLYING CAUSE Due to(or as a consequence oft: W (disease or Injury that I n Mated the events resulting d. .>l�Y'�+ \Q +J Q MO r, Gam. W in death)LAST. Due to(or as a con 3 sequence of): u 26.Part 11.Enter other sitndkant conditions contribuUne to death but not resulting in the underlying pose given in Part 1 27.Was an autopsy 7 h Q�Q n-Z-44t(a S 1 S Yes No 29.Were autopsy finding available (: pe-r k rN c.to- to complete the cause of death? 5 ❑Yes ❑No 29.If Female: 30,Did Tobacco Use Contribute to Death? 31. ner of Death [3 Not pregnant within past year Q Yes ❑Probably Natural Q Homicide ❑Pregnant at time of death ❑No rKnknown ❑Accident Q Pending investigation , Q Not pregnant,but pregnant within 42 days of death ❑Suicide Q Could not be determined •°_ [3 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,City,State,Zip Code) 36.Injury at Work 37.If Transportation Injury,Specify: 38.Describe How Injury Occurred: ❑Yes ❑Driver/Operator ❑Pedestrian - ❑No ❑Passenger ❑Other(Specify) 39a.CSertifler(Check only one): $Certifying physician-To the best of my knowledge,death occurred due to the cause(s)and manner stated ❑Pronouncing 6 Certifying physician-To the best of my knowledge,death occurred at the time,date,and place,and due to the cause(s)and manner stated ❑Medical Examiner/Coroner.On the bask of examination,and/or investigation,In my opinion,death occurred at the time,date,and place,and due to the cause(s)and manner stated Signature of certifier: Title of certifier: n h License Number: 0-50111,2J.950 39b.Name,Address and ZtWode of Person Completing Cause of Death(Item 261 i-{t7L((s sbu�s PR 39c.Date Signed(Mo/Day/Yr) 40.Registre sD strict Nu i r� 41.ReRistpr Sy{naturi � 42.Regislfrrar File to(Mo r) 174 E/A//.f•/v��a gl7]` 43.Amendments Qa '7 H105.143 Disposition Permit No. ! ' RFV n7/7011