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` REGISTER OF WILLS
CUMBERLAND COUNTY PENNSYLVATTFAn '
SMALL ESTATES AFFIDAVIT L "'
For Insurance Proceeds
N r to be used for Sett lement of Small Estates under 2Q N.C,SA::631l12
(Original Death Certificate Must Accompany this Form) -9
Deceased Rofil°RY F LEFIIt�Q SR Case No.
also known as Social Security No. tat-to-1-I(A _
Before the Register of Wills of said County personally came 'ZONALZt, E. LHI'1ER, who resides
at 713 ??JAL 3otufAIr-bA. w4 im'TON�fJG, 4.$408 being duly sworn,
deposes and says that ROQART r,,tj�S R _ ,age 61? ,a resident of
Act -1c %/E. LEAOyNEQ�j .tOti3
in said County,departea this life,at ` i on the 61" �2i G" day f
�IGeEA%AQ _ A.D.2*1 ISs ii o'clock _ M,possessed of personal
persoynal
property estimated to be of the value of$ j 068 ,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(8):
The total amount of insurance proceeds payable by PIk%X0JLNTIA L 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.
That said decedent left a spouse-whose name and
y t ;t71dg nce is Tif-LF ASP-b - t.ATMiNklikif At.&MA
-ENAER 90.7 &%-&% K9 t-FA0YNE I
and the following as next of kin:
NAMES RELATIONSHIP RESIDENCE
'DotvAL:D E. L&HfIEA soa Z', RaynL 30141terR- wiLh ,u6IMIA .
_ 05
,Dm.@d46 oaks F &Elvnek JR con) r o �vr4;t7roRp"�R.rgoaSC cAF- F4c- 29rg5
That the above named are the spouse&and ail 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 RA] D L TERS ARE NOT NECESSARY.
Signed
By:
Sworn and subscribed to before me this
i-``day of•�O` ,20 i`3``spu1 I o �//#egister of Wills:
Zl4 dly enter appearance in the above case this
_ day of >20
N°p'y r° '6tory Pu01iC
My Commissrgn fy�#jjH6 Bt Coin:!Y_.i I.D.No.
Attorney
as
Sri y 1
''% rh C P,
' BE IT REMEMBERED,that as of the3 yday of A.D.20 �3
There has been NO ESTATE PROCEEDING RAISED FO HIS DECEDENT AND NO LETTERS HAVE
BEEN ISSUED BY THIS COURT.
egister
Glenda Farner Strasbaugh
Register of Wills&Clerk of Orphans'Court
My Commission Expires First Monday,January,2014
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