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Home My WebLink About07-23-13 REGISTER OF WILLS : CUMBERLAND COUNTY PENNSYLVANIA SMALL ESTATES AFFIDAVIT c � `=� ��:�? 3�� :� .�� .._� :-� For Insurance Proceeds ry� ° ' = ��=---` � i,� � w .�,.,9 ,,. {�': ('\7 `_v NOT to be used for Settlement of Small Ectatec under 20 Pa.C.S.�.�3�f12 � � . x�� r _ : � �, � (Original Death Certificate Must Accompany this Form) �.� . _ ==� w�� :.� ._. �, : ;..� Deceased ��} �' - v. � ,� Q�(.C) Case No � � � _ E-., . �� ` 4 ...�............................................ ...................J.....y..,�..1.�...�..................................................................................... Z 3 ` ;.-. . .. ................_. �. _ • ............ � .........................�.............................................. also known as ............................ . cS,%g/I'�_:�.....�......:....................................................................................... Social Securit No. ...�.� �-- _..� y /._. .�'..................-- �� ...................... .... . ............. Before the Register of Wills of said Cou�ty personally came ./4/J,�� Q,��,.p.c� who resides at _�.?.....�.�.3.....__�S..-c',�D...o._...L................� � � .. .. .. �.....................��...2...�..V/�.L...�'f.....�..�� _�12...3�:...-. ��..Z..�. . ..._�being duly sworn, deposes a�d says that �,�' �' • ,....t...........L.��.1.................-....`�..�..�{?...�.2._0_U�'.................................................................................................................. �age �/,`2..... �a resident of ....�.�1,��S,�QLA�?.b...._C,�y..N...�.�_��N.....�..�'.....��m.E........_'..'....C��.�a..£�._a..N..7....�....................... � . ..........................................................................................................._..__...................... insaid County,departed this life,at .................................................�,�il�............................................................................................... on the ..............................�s�'............. day of /l7AQc..N_.._ ...._.__ A.D.20 J3 /.Z`2�IqW(o'clock � M.,possessed of personal .......................................... ...................... ...................................... . � . ................ property estimated to be of the value of$ �� 8(r,.�$ ,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 pe�ding divorce proceeding at the time of death wh rein grounds fo�divorce had been established as defined in 23 PA C.S.section 3323(g): /lJ � The total amount of insurance proceeds pay�ble by /� 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 th undersigned. That said decedent left a spouse—whose name and residence is /V � ................................................................................................................................................................................................................................................................................................................................................................................................................................. . ........................................................................................ and the followin as next of kin: NAMES RELATIONSHIP RESIDENCE ,��s �lo�ez�o�J S'o r� &`�i3 �c�ra�z R�, �aKV�u.� /h�, �CJ/1!A c. /�D�2 �.c� c5�/� .�C�S ��,, T. CAQ.L 1 sL � A�. LV!L L /YI� l�f�� L� �a +'� �Q �rQ 191-��4 d�. /��U11�lLLE I�R. �L N c��'it3 �' c�/4l,{�1-�T�',� '�c3��e1. ��1 rt1 c�7. CAQlI�"L E R . 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. ............ Xour Petitioner avers there are NO KNOWN PROBATABLE ASSETS that would require an estate proceeding. Therefore,NO ESTATE WILL BE RAISED A D LETTERS ARE NOT NECESSARY. Signed ay: 7 ,2� ��3 ......... Sworn and subscribed to before me this ......... ........... day of ...................................................................... �20 ................................. Register of Wills: � Kindly ente ppea ance in the above case this ................ ..................... .......................................................................................................................................................................................................... day ........... ,ZO .... ........ .. ........................... ........................................................ �. .............................. Notary Public .................................................................................................................................................................................. .._........ ........ ........ .... ............. .............._... ........ ..... ... .... ...... ..:..... . ................................. ............ ........... ..... My Commission Expires I. .No. Attorney BE IT REMEMBERED,that as of the day of ,A.D.20 There has been NO ESTATE PROCEEDING RAISED FOR THIS DECEDENT AND NO LETTERS HAVE BEEN ISSUED BY THIS COURT. ....................................... ........................................................................................................................................... ..................................... ..................................................................................................................................................................................................................................................... Register Glenda Farner Strasbaugh Register of Wills&Clerk of Orphans'Court My Commission Expires First Monday,January,2014 �, � �.