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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 �,
Name: JOSEPH M.PERKO File No: `1
a/Va: (Assigned by Register)
a/k/a:
a/k/a: Social Security No: 191-46-4739
Date of Death: March 7,2013 Age at death: 55
Decedent was domiciled at death in Cumberland County, Pennsylvania (state)with his/her last
principal residence at 807 Allenview Drive,Mechanicsburg,PA 17055 Upper Allen Township Cumberland
Street address,Post Office and Zip Code City,Township or Borough County
Decedent died at 807 Allenview Drive,Mechanicsburg,PA 17055 Upper Allen 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 $ 50,000.00
If not domiciled in Pennsylvania. ....................... Personal property in Pennsylvania $
If not domiciled in Pennsylvania. ....................... Personal property in County $
Value of real estate in Pennsyl vania......................................................... $ 112,000-00
TOTAL ESTIMATED VALUE. ... $ 162.000.00
Real estate in Pennsylvania situated at: 807 Allenview Drive,Mechanicsburg,PA 17055 Upper Allen Township Cumberland
(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 o d=1dicil(s)
thereto dated e-•=
M G> n
State relevant circumstances(e.g.renunciation,death ofexecutor,etc.) W� 7
f►1 C7 .; t
Except as follows: after the execution of the instrument(s)offered for probate Decedent did not marry,was nq�aivt�cq jwas a pate offending
divorce proceeding wherein the grounds for divorce had been established as defined in 23 Pa.C.S. §332�)�n8�id not have aei6,born or
adopted;and Decedent was neither the victim of a killing nor ever adjudicated an incapacitated person. - ;;-,
Q NO EXCEPTIONS Q EXCEPTIONS ro�
:;0 r tom' Pit
B. Petition for Grant of Letters of Administration (If applicable) --- 0
c.t.a.,d.b.n.,d.b.n.c.t.a.,pendente lite,;:rante absentzlurante mPoritate
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.
NO EXCEPTIONS (D 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
Jessica M.Moore Daughter 75 Kenmar Drive,Shermans Dale,PA 17090
Joseph L.Perko Son 75 Kenmar Drive,Shermans Dale,PA 17090
(Valerie M.Perko has renounced her right to serve in favor of Jessica M.Moore and Joseph L.Perko)
Form RW-02 rev.1011112011 Page 1 of 2
Ni
Oath of Personal Representative Official Use Only
COMMONWEALTH OF PENNSYLVANIA }
} SS:
COUNTY OF CUMBERLAND }
Petitioner(s)Printed Name Petitioner(s)Printed Address
Jessica M.Moore 75 Kenmar Drive Shermans Dale PA.17090
Joseph L.Perko 75 Kenmar Drive,Shermans Dale,PA 17090
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 Petitioner(s)will well and truly administer the estate according to law.
Sworn to or affirmed and subscribed before Date
me i 4L day of k-PI"ke 0 o/ Date r, Ei4
By C Date rn wmo
For the Register Date=-a 2 O
ei t
BOND Required: ® YES ® NO To the Register of Wills:
FEES: Please enter my appearance by m3CZ[g#pt�e betOM:
-,p �.-
o = c7
Letters . . . . . .. . . . . .. . . . . . .. . . $ 260.00 Attorney gnature: ;: rr't
�7 s
( 3)Short Certificate(s).. . . . . 15.00 —!
( 1 )Renunciation(s).. . . . . . . . 5.00 O 'O»
( )Codicil(s). . . . . . . . . . . . .
( )Affidavit(s).. . . . . . . . . . .
Bond.. . . . . . . . . . . . . .. . . . . . . . . Printed Name: Marlin R.McCaleb,Esq.
Commission. . .. . . . . . . . . . . . . . . Supreme Court
Other . . .. .. . . ID Number: 06353
Inventory . . . . . . . . 15.00
Appraisement . . . . . . . . 15.00 Firm Name: Law Offices-Marlin R.McCaleb
. . . . . . . Address: 219 East Main Street
. . . . . . . . P.O_Box 230
. . . .. . . . Mechanicsburg,PA 17055-0230
. . . . . Phone: 717-691-7770
Automation Fee. .. . . . . . . . . . . . . 5.00 Fax: 717-691-7772
JCS Fee. . . ... .. . . . . . . . . . . . . . 23.50 Email: marlinmcealeh(a4mcn_cnm
0
TOTAL. . . . . . . . . . . . . . . . . .. . . $ 338.50
DECREE OF THE REGISTER
Estate of JOSEPH M.PERKO File No:
a/Va:
AND NOW, �'1 e Y► I ,in consideration of the foregoing Petition,
satisfactory proof having been presented before me,IT IS DECREED that Letters of Administration
are hereby granted to Jessica M.Moore and Joseph L.Perko
in the above estate and(if applicable)that
the instrument(s)dated N/A
described in the Petition be admitted to probate and filed of record as the last Will(and Codicil(s))of Decedent..
Ella k, 1)aA'gCj) j 11 � A '
U-1jba -
egister of Wills r
U ' -
Form RW-02 rev.1011112011 Pa e 2 of 2
H105.805 REV(9/11)
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $61K C 0 R D E D 0 F F I C E 0 F This is to certify that the information here given is
REGISTER OF W ILLS OFpfNyf_ correctly copied from an original Certificate of Death
duly filed with me as Local Registrar. The original
3 RPR 5 PM 4 03 ?o
certificate will be forwarded to the State Vital
M
t, a� Records Office ermanent filing.
P 19398941CLERK of 9 _ a����` M 13/2013
AN .0 COURT 9lMENT,oF,?``,`I
Certification Number Local-Registrar Date Issued
° CUMBERLAND Co., PA
Type/Print In COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF HEALTH-VITAL RECORDS
Permanent CERTIFICATE OF DEATH
Black Ink State File Number:
1.Decedent's Legal Name(First,Middle,Last,Suffix) 2.Sex 3.Social Security Number 4.Date of Death(MI/Day/Y,)(Spell Ma)
Joseph M_ Perko M. 191-46-4739 March 7 2013
Sa.Age-Last Birthday(Yrs) 5b.Under 1 Y 15c.Under 1 Day 6.Date of Birth(MO/Day/Year)(Spell Month) 7a.Birthplace(City and State or Foreign Country)
Months Days Hours Minutes Scranton PA
55 October 3 1957 17b.Birthplace(County) Lackawana
Be.Residence(State or Foreign Country) Bb.Residence(Street and Number-Include Apt No.) Sc.Did Decedent Live in a T nship7
XJ� Penns lvania s,decedent lived in Upper Allen
80.Residence(County) 807 Allenviaw Dr.
Cumberland ea.Residence(Zip Code) 17055 Q No,decedent lived within limits of _city/born.
9.Ever In US Armed Fo=nl 30:Marital Status at Tlme of Death 0 Married 0 Widowed 11.Surviving Spouse's Name(If wife,give name prior to first marriage)
/es �No 0 Unkno Divorced 0 Never Married ED Unknow
12.Father's Name(First,Middle,Last,Suffix) 13.Mother's Name Prlor to First Marriage(First,Middle,Last)
Jose h Perko Mar aret Moetell
14a.Informant's Name 14b.Relationship to Decedent 14c.Informant's Mailing Address(Street and Number,City,State,Zip Code)
g Jessica M. Moore Da hter 75 Kenmar Dr. Shermansdale, PA 17090
G ......................................................°" ..............."..."............'..".'.... isa.a ace o eat _____
..-- .. ......_h....ec,_on_ one........... --------- _ _____ _
If Death Occurred In a Hospital: �` Inpatient If Death Occurred Somewhere Other Than a Hos Ital '' ;Ww .....
p Hospice Fa Ility }Decedent's Home
Emergency Room/Outpatient Q Dead on Arrival 0 Nursing Home/long-Term Care Facility Other(Specify)
e� 15b_Facility Name(If not institution,give street and number; •15c.City or Town,State,and Zip Code 15d.County of Death
907 Alle-ny-lew Dr-,z e sb 17055 Cumberland
16a.Method of DlsposlSion EX Burial Cremation 166.Date of Disposition 161.Place of Disposition(Name of cemetery,crematory,or other place)
.$ Q Removal from State 0 Donation
other(speclfy 03/14/2013 Indiantown Rgg National Cemeter
16d.Location of Disposition(City or Town,State,and Zip) 17a. ture of Funera Servic son to ge of Interment 1]b.License Number
4 Annvi.11e PA 17003 014819
E 17c.Name and Complete Address of Funeral Facility
s Myers-Harney Funeral Home Inc. 1903 Market St. CaMP Hill PA 17011
.� 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
-2 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.
Q 8th grade or less - is Spanish/Hispanic/Latino. Check She"NO" hit, 0 Korean
0 No diploma,9th-12th grade box If decedent is not Spanish/Hispanic/Latino. Q Black or African American EJ Vietnamese
High school graduate or GED completed �S�I not Spanish/Hispanic/Latino 0 American Indian or Alaska Native Q Other Asian
Some college credit,but no degree Was,s,Mexican,Mexican American,Chicano 0 Asian Indian 0 Native Hawaiian
0 Associate degree(e.g.AA,AS) 0 Yes,Puerto Rican
0 Yes,Cuban Bachelor's degree(e.g.BA,AB,BS) Q Chinese Q Guamanian or Chamorro
<] 0 Filipino 0 Samoan
Master's degree(e.g.AMA,M5,MEng,MEd,MSW,MBA) Q Yes,other Spanish/Hispanic/Latino L]Japanese 0 Other Pacific Islander
Q Doctorate(e.g.PhD,EdD)or Professional degree (Specify) Other(Specify)
.MD DOS DVM L B JD
21.Decedent's Single Race Self-besignation-Check ONLY ONE to indicate what the decedent considered himself or herself to be 22a.Decedent's Usual Occupation-Indicate type of work
]j hit or African American Q Japanese Q Samoan done during most of workfng life. DO NOT USE RETIRED.
Q 0 Korean 0 Other Pacific Islander
p Q American Indian or Alaska Native Q Vietnamese 0 Don't Know/Not Sure SU Yv1SOr
.7S Q Asian Indian Q Other Asian Q Refused 22b.Kind of Business/Industry
Q Chinese 0 Native Hawaiian 0 Other(Specify)
Q Filipino Q Guamanian or Chamorro Arm De t.
ITEMS 23a-23d MUST BE COMPLETED 23a.Date Pronounced Dead(MO Day r) 23b.Signature of Person Pronouncing Death(Only when applicable) 23c.License Num e
BY PERSON WHO PRONOUNCES OR r
CERTIFIES DEATH
23d.Date Signed(Mo/Day/Yr) 24.Time of Death
Unknown A.M. f25.Was Medical Examiner or Coroner Contacted? Ys O No
CAUSE OF DEATH Approximate
26.Part 1. 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,or ventricular fibrillation/�i,th�o)ut showing�She etiology.JDO�NOT ABBREVIATE. Enter!(o/n�lly done cau se on a It,,. Add additional lines if necessary Onset to DeatHh�
IMMEDIATE CAUSE ------------> `Ir���/�(L O r7Slf�-'�vI 1V� 0K f'L
(Final disease or condition a s Due o(or as a consequence of): i
resulting In death) b 1W&i+y 1?/11/ A l N-t Gti'1
Sequentially list conditions, Due to(or as a consequence of):
if any,leading to the cause
listed on line a. Enter the
UNDERLYING CAUSE Due to(or as a c,nse
(disease or Injury that quence of):
F Initiated the events resulting d.
y In death)LAST. Due to(or as a consequence of):
p 26.Part 11. Enter other/s�lficant conditions contrib tl a t1,d t nth but not/,rresssulttiingg In the underlying/�cause given In Part 1 27.Was an autopsy pert med7
a_/LJ�� VL 4 .V Iv- Gciv (//� Q.Ves �No
28.Were autopsy findings available
to complete the caul¢�n ath7
O Yes vivo e
29.If Female: 30.Did T co Use Contribute tp Death? 31.Ma!� �of Death
E Q Not pregnant within past year 0 Probably ®Natural 1] Homicide
s Q Pregnant at time of death 0 No c 0 Unknown 0 Accident 0 Pending Investigation
Q Not pregnant,but pregnant within 42 days of death
0 Not pregnant,but pregnant 43 days to 1 year before death 32.Date of Injury(Mo In j u Da )(Spell 5 Month) 0 Suicide 0 Could not be determined
/ Y/Vr
Q 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:
Q Yes Q Driver/Operator 0 Pedestrian
0 No 0 Passenger 0 Other(Specify)
39a. t- Check Only on.):
���rtifying physician-To the best of my knowledge,death occurred due to the c se(s)and manner stated
O7 Pronouncing✓><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
0 Medical Examiner/Coroner O basis of ex inatlon,and/or investigation,in my opinion,death occurred at the time,date,and place,and due to the causes)and annq stated
Signature of certifier: Title of certifier: Jioo` License Number: '�_�""n�(7/^71' .r7-�07 7-
39 Name,Address and Zip Code of
/L/+ FDU�I�✓L M P n CoFIeytig Cr a4 u se oj,�q;1 h(Item ) Data Signal QMO/Day/Yr)�- it_L F�
S�YUNr(r �vi�SBI�R6 70c-& 1nAA1-" 1z, 3
40.Registrar's District Number 41.Registrar's Slgn 42.Registrar Flle Date(MO Day r)
3/ ��.
� 43.Amendments
rrEM# 3 yA
SHOULD READ �NLY e��T�Fy�,�U �i�ys;c;�}�✓ c � ��v