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HomeMy WebLinkAbout03-28-13 rn O PETITION FOR GRANT OF LETTERS w �.� '? Cn REGISTER OF WILLS OF� > COUNT�Pr YINANI Pia I>- C CO Petitioner(s) named below, who is/are 18 years of age or older, apply(ies) for Imttes as sp�fec w, and in support thereof aver(s)the following and respectfully request(s)the grant of Letters ii hiPappropri—atb fo n: Decedent's Information .�.� �"` C-> Name: File No: b► CJl cn C> 21 l�"UUJv� a/k/a: (Assigned by Register) a/k/a: alk/a: Social Security No: Date of Death: Age at death: ?.2_ Decedent was domiciled at death in _County, fiWV--VYe-V,4&e1,4 (State)with hi /her last principal residence at M. Street address,Post Office and Zip Code City,Township or Borough County Decedent died at 2,,tPI. / G,JS' 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 Pennsyl vania............................ All personal property $ If not domiciled in Pennsylvania. ....................... Personal property in Pennsylvania $ If not domiciled in Pennsy lvania. ....................... Personal property in County $ Value of real estate in Pennsyl vania......................................................... $ TOTAL ESTIMATED VALUE. ... $ oyo 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 ofthe 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. ❑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. MNO EXCEPTIONS ❑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 Form RW-02 rev.10/11/2011 Page 1 of 2 Oath of Personal Representative ba fficial Use- nly � rnzC-> Z7.1:) Cn M COMMONWEALTH OF PENNSYLVANIA } m N M M } S S: z Cl1 CO COUNTY OF } o —� C> C. Petitioner(s)Printed Name Petitioner(s)Printed Addr 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 affirmed and ubscribed b for Date -3--2:e-/-3 me th' hd� D� - y Date ByRy Date Re gister Date BOND Required: Q YES d NO To the Register of Wills: FEES: Please enter my appearance by my signature below: Letters . .. . .. . . ... . . . ... . .. . . $ Attorney Signature: ( )Short Certificate(s).. .. .. ( )Renunciation(s).... . .. . . ( )Codicil(s). . . . . .. . . .. . . ( )Affidavit(s).. . . .. . ... . . Bond.. . .. . .. . . .. . . . . . . . . .. . . Printed Name: Commission. . .. .. .. . . . . . . .. . . Supreme Court Other . . . .. . . ID Number: �12i3 . . .. . . Firm Name: .. . .. . . Address: . . . .. . . Phone: /'_ 2)792 Z2.S10t—Automation Fee. . . . . . . . . . . .. . . Fax: JCS Fee. . . .. . .. .. . . . .. . . .. .. Email: TOTAL. . . ... . . .. . .. . . . . .. .. $ 0.00 DECREE OF THE REGISTER Estate of t� File No: (l�O a/k/a: AND NOW in consideration of the foregoing Petition satisfactory proof having been presented before me,IT IS ECREED t t Lett rs dG�/ i/? are hereby granted to e19r l�% in the above estate and(if applicable)that the instrument(s)dated described in the Petition be admitted to probate and filed of rec rd s the last Will nd Codicil(s))of De ee nt. Register of Wills Form RW-02 rev. 10/11/2011 Page C> c"ti' rri DD ;� z rn cagy f"n rn RENU CIATIO� © � � -� � C> C-> C-) C> C: REGISTER OF WILLS ~a _iw,„_ r COUNTY,PENNSYLVANIA Estate of ,Deceased in my capacity/relationship as (Print Name) of the above Decedent, hereby renounce the right to administer the Estate of the Decedent and respectfully request that Letters be issued to R (Date) Q(Signatu `J l (Street Address) (City,State,Zip) Executed in Register's Office Executed out of Register's Office Sworn to or affirmed and su sc ibed Before the undersigned personally appeared the before me th' day party executing this renunciation and certified of that he or she executed the renunciation for the purposes stated within on this day of , uty for Register of Wills Notary Public My Commission Expires: (Signature and Seal of Notary or other official qualified to administer oaths. Show date of expiration of Notary's Commission.) Form RW-06 rev.10.13.06 r GEORGIA DEATH CERTIFICATE A.BIRTH CERTIFICATE NUMBER Local #115 B.STATE FILE NUMBER 1.DECEDENTS LEGAL FULL NAME (FIRST,MIDDLE,LAST) 1a.LAST NAME AT BIRTH(IF FEMALE) 2.SEX 2a.DATE OF DEATH (MOIDAYIYR) Seth Danielson ZAISER Male February 2 ?2�J1� 3.SOCIAL SECURITY NUMBER 4a.AGE(YEARS) 4b.UNDER 1 YEAR 4c.UNDER 1 DAY 5.DATE OF BIRTH (MOIDAY/YR) MONTHS DAYS HOURS MINUTES 22 February 15 1991 y 6.BIRTHPLACE(CITY AND STATE OR FOREIGN COUNTRY) 7a.STREET AND NUMBER OF RESIDENCE 7b.ZIP CODE 7c.CITY OR TOWN OF RESIDENCE 'Harrisburg, P Mechanics bur 7d.COUNTY OF RESIDENCE 7e.STATE OF RESIDENCE 7f.COUNTRY 7g.INSIDE CITY LIMITS 8.ARMED FORCES Cumberland PA United States oYes]Q No o Unknown o Yes Q(No o Unknown 8a.OCCUPATION 8b.NATURE OF BUSINESS 8c.EMPLOYER Student Education Student o- 9.MARITAL STATUS 10.SPOUSE'S NAME 11.FATHER'S NAME(FIRST,MIDDLE,LAST) ~ ' p Married o Divorced (IF WIFE,GIVE NAME PRIOR TO FIRST MARRIAGE) ' p Married,but separated Never Married '? o Widowed o Unknown George Zaiser 0. 12.MOTHER'S NAME PRIOR TO FIRST MARRIAGE 13.DECEDENTS EDUCATION(HIGHEST LEVEL) 14a.INFORMANTS NAME Z (FIRST.MIDDLE,LAST) 0 8th grade or less a Bachelor's degree(e.g.,BA,AB,BS) (FIRST,MIDDLE,LAST) 0 9th-12th grade;no diploma o Master's degree(e.g.,MA,MS,MEng,Med,MSW) High school graduate or GED completed o Doctorate(e.g.,PhD,EdD)or Professional degree o Some college credit,but no degree (e.g.,MD,DDS,DVM,LLB,JD) ' o Associate degree(e.g.,AA,AS) o Unknown W Pamela Kribbs Geor a Zaiser ' 14b.RELATIONSHIP TO DECEDENT 14c.MAILING ADDRESS(STREETAND NUMBER,CITY,COUNTY,STATE,ZIP CODE) Father 1744 S. York Street /Mechanicsburg, 0 15b.HISPANIC ORIGIN 16.DECEDENTS RACE $No not Spanish/HispanictLatino o Yes,Puerto Rican CKWhite o Black/African American o Samoan p Yes,Mexican,Mexican American,Chicano o Japanese o Korean o American Indian/Alaska Native p Yes,Cuban o Asian Indian o Vietnamese - o Other Asian a Chinese o Native Hawaiian o Other Pacific Islander p Yes,other Spanish/Hispanic/Latino(specify) o Filipino o Guamanian/Chamorro o Other 0Unkown o Unknown 17a. IF DEATH OCCURRED IN HOSPITAL 17b. IF DEATH OCCURRED OTHER THAN HOSPITAL o Inpatient )Q Emergency Room/Outpatient o Dead on Arrival o Hospice Facility o Nursing Home/Long Term Care Facility o Decedent's Home D Other o Unknown = 18,FACILITY NAM 19.FA ILITY ADDR (sTREET AND NUMBER,CI T ATATE,ZIP CODE) 20.COUNTY OF DEATH :Fairview Park Hospital 200 Industrial BLVD Dublin GA 31021 Laurens 21.METHOD OF DISPOSITION 22.PLACE OF DISPOSITION(NAME AND COMPLETE ADDRESS) 23.DATE OF DISPOSITION (MO/DAY/YR) r o Burial o Donation o Removal from State Stanley Funeral Home and Crematory 3102 'RXCremation o Entombment o other 1320 North Jefferson Street/Dublin GA 'February 26,2013-, 24a.EMBALMER'S NAME&CERTIFIED INTIALS 24b.LICENSE NUMBER Unembalmed Cremation ' 25.FUNERAL HOME NAME 25a.FUNERAL HOME ADDRESS(STREET AND NUMBER,CITY,COUNTY,STATE,ZIP CODE) S F. H. &Cisr>rt 1320 North Jeffers /Dublim, CA -31 21 (Taurens) 26�FUNERAL DIRECTOR'S NAME(PRItJT) 2 A RE F FU IRECTO 26b.LICENSE NUMBER 27.DATE PRONOUNCED DEAD 28.TIME PRONOUNC906EATH 29a.PRONOUNCER'S NAME AND T E(PRINT) `MFe� 23 2013 21:50 Dr. Mai Ho M.D. O 29b.PRONOUNCER'S LICENSE NUMBER 30.ACTUAL OR PRESUMED TIME Z OF DEATH 21:50 061255 31.Part 1.Enter thechain of events-diseases,injuries,or complications-that directly caused the death. DO NOT enter terminal events Appro)dmate interval between such as cardiac arrest,respiratory arrest,or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. C'> onset and dea t IMMEDIATE CAUSE(Final A Massive Blount Force Trama C `-"' m m disease or condition resulting in death) Due to,or as a consequence of Q, Sequentially list conditions,if any,leading to the B l"T1 =0 Cn cause listed on line a.Enter the UNDERLYING Due to,or as a consequence of CAUSE(disease or injury that initiated the events m Iv M M resulting in death)LAST. C O� D Due to,or as a consequence of Q Q • "> "f 1 Z art II.Enter other significant conditions contributing to death but not resulting in the underlying cause given in Part I WAS AUTOPSY PE F"D Q • I'"` )"1i") W "`a Yes o o[Unkn 0 33.WERE AUTOPSY FINDINGS AVAILABLE 33a.WAS AN INJURY OF ANY KIND INDICATED IN THE CAUSE OF DEATH 34.WAS COE REFERRED T DICA ER OF TO COMPLETE THE CAUSE OF DEATH? FOR PART I OR PART 11 WITH THE DECEDENT OR CORONER o Yes o No o Unknown p Yes o No o Unknown Yes o No o Unknown 35.TOBACCO USE CONTRIBUTE TO DEATH 36.IF FEMALE 37.MANNER OF DEATH {o Yes ■ Not Applicable XAccident o Natural No o Not pregnant within past year o Unknown Not pregnant,but pregnant within 42 days Of death- o Could not be determined p o Pending Investigation o Probably o Not pregnant,but pregnant 43 days to 1 year before death o Homicide o Suicide o Pregnant at the time of death o Unknown if pregnant within the past year ' r 38.DATE OF INJURY(MO/DAY/YR)139.TIME OF INJURY 40.PLACE OF INJURY(e.g.,Decedenra home,construction site,restuarantwoodedar�) 41.INJURY AT WORK Feb. 23, 2013 ?0::;43 116 W. Bound MM-57. Intersta �es c p Unknown 42.LOCATION OF INJURY ST T. D CITY STATE COUNTY ZIP CO I Dublin GA Laurens MM 43.DESCRIBE HOW INJURY OCCURRED 44.IF TRANSPORTATION INJURY Cg MO brc - �e':' aNDriver/Operator a Passenger a Pedestrian D Other 45. To the best of my knowledge death occurred at the time,date,place,and due to the 46.On the basis of exqnnation and/or'nvestigation,in my opinion death occurred at the time cause(s)stated.Medical Certifier(Name.Title.License date,place,and due caujks) Z (PRINT AND SIGN) (PRINT AND SIGN) Q Richard . Stanldv III Coroner 004456 45a.DATE SIGNED (MO/DAY/YR) 45b.HOUR OF DEATH 403a.DATE S J ED(MQt�T 46b.MOUt3 @6�DEATH 4 P.E ON C MP TI CAUS .OFD AdDRESS,Co IPC Lvia 1e, L111 J Ll JV 7Ricar� 1 Manley rover ` :�. �)ox 1999 Dublin, GA W 49.DATE FILED(REGISTRAR) (Mo/DAY/YR) U ;48.REGISTRAR SIGNATURE{pRIN D SIGN) J11 X1 Ali fifibe kA March 19 2013 Form 3903(Rev.09/2009) This certificate does not constitute a certified copy without the appropriate certification on the back. CERTIFICATE OF RECORD This is an exact copy of the death certificate received for fling in LAURENS c nty, Georgia. Signed Local Custodian ,vocal Custodian Office h)o J County of _ Laure;as Date