HomeMy WebLinkAbout05-28-13 I3 -5qR
REGISTER OF WILLS
CUMBERLAND COUNTY PENNSYLVAN�1 �;
SMALL ESTATES AFFIDAVIT � o �-' m rn
ForInsurance Proceeds m a �; � �
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NOT to be used for Settlement of Small Fctatr und r 20 Pa C�# �1�7 � � �_}
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(Original Death Certificate Must Accompany this Form) C� n �� - � -''
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Deceased _�� �yt� � • �J I (.J-f} N �� Case NopC.�fc�;�Q1� 'v '� •-' ri�
also known as `'"' !
�,.�^ Social Security No.�('� (�-� [��
6efore tlie Register of Wills of said County personally came }�-��/ E-�-f� J f lt1�A-(1� J� who resides
1r �'/O, /�• /�HRI«I S1 /rleCha71�'csGU7'T P-A--170S�Cne��ga��ysWa��,
deposes and says that S�c'{t- �.]�- f G.1 l�J � ,age� ,a resident of
�Wv...�e�JrCL+-�-o� ' �foul�N. n�, YYI�c 0.'hnc5 u--(J'r
in said County,depar[ed this ife,at � � < <j on the O V� '�a of
�A.D.20 �.3 0 p!y` dclock _ M.,possessed of personal
property estimated to be oTthe value of$ O DO. (7 D ,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
execuYion of any testamentary writings whether or not off'ered for probate;was not the victim of a killing,
was never ad,jodicated an incapacitated person,and was not a pnr[y to a peodiog divorce proceeding at the
time of dea�thf�herein ground for div rce had been established as defined in 23 PA C.S.section
3323(g): ✓" � lld7fr�Q f��
The total amount of insurance proceeds payable by O � does not exceed$11,000
and 60 days have elapsed since the death of the insured.The undersign d agrees paymen[cannot be made
under this AfGdavit if a written claim for same has been made by a Personal Representative of the estate and
no other heir(s)having preTerence exist or have released their beneflts to the undersigned.
That said decedent lef[a spouse- hose ame and re idence is � �fl'll� J�(.�7�-IJ t��
g`I o N r11 Gt..fc e.f-S�- ��'�c.c�i a-n-: cs � w+ 9 -r- i � o s-s-
and the followin as next of kin:
NAMES RELATIONSHIP RESIDENCE J
I �T VI �'�IV V C ( D � yYI (�.�aC�"S`I� GC�. n�l70..C�.(�
ct �+r��v :1� w J 1 IJ'1 !� -f-fti e� 1 o n'1 fl--�(�c-r S-t i�'1 e-�hr G� �� e s�
1FJSIy f�r T11.J ��) J J !S c'a' Si/✓e�S 7ra� M�
113 Lo S � Viel�7
e-s a,ce_ �o fl y
That[he above named are the spouse&and all thc knowi���ext of kin of said decedent,to[he best of my
_ knowJedge and belief.
Yonr Petitioner avers there are NO KNOWN PROBATABLE ASSETS that would require an estate
proceeding. Therefore,NO ESTATE WILL BE RA1S AND LETTERS ARE NOT NECESSARY.
Signed n �� �
By: -r/""„
�wChn and subscr'bed to before me thjs_
�day o1' ,20 %� Register of Wills:
.,. � /� Kindly enter appearance in the above case this
`� � �' day of ,20
N i
MyCommission zpire I.D.No.
Attorney
' BEIT REMEMBERED,that as of the!�day of ,A.D.20,�
There has been NO ESTATE PROCEEDING RAIS FO THIS DECEDENT AND NO LETTERS HAVE
BEEN I5SUED BY THJS COURT.
/ eg ter
Glenda Farner Strasbaug z
Rep,ister af Wills&Clerk of Orphans'Court
My Commission Expires Firs[MondaV,Januarg 2014
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